Concussions in Athletes and The Role of ComputerBased Neuropsychological Testing

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Concussions in Athletes andThe Role of
Computer-Based Neuropsychological Testing
2007 Sports Medicine Seminar for Coaches

• Sean T. Bryan, MD, FAAFP
• Clinical Assistant Professor of Family Medicine,
• Medical College of Georgia and
• Mercer University School of Medicine
• Program Director, SW GA FM Residency
• Fellowship Director, SW GA SM Program
• Phoebe Putney Memorial Hospital
• Albany, GA

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Overview

• Review concussions
• Definition
• Potential complications
• Scope of the problem
• Recognizing the symptoms
• Neuropsychological testing
• Traditional tests
• Computer-based testing programs
• Return to play decision making
• Prevention
• Answer questions

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What is a Concussion?

• Mild traumatic brain injury (MTBI)
• American Academy of Neurology (AAN) in 1997
• Defined as trauma induced alteration in mental
  status that may or may not involve loss of
  consciousness
• Confusion and amnesia are hallmark signs
• Can result from a direct blow to the head
• Can result form indirect forces acting on the
  head
• Linear acceleration, linear deceleration and/or
  rotational shear forces
• Pathophysiology
• Temporary trauma induced sodium channel
  dysfunction of injured neurons

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Potential Complications

• Second Impact Syndrome
• A second, even minor, head injury suffered while
  the symptoms of initial concussion are still
  present causes the brain to lose its ability to
  auto-regulate circulation of blood
• Leads to uncontrolled brain swelling and usually
  death
• Rare less than 20 cases reported since 1970
• Majority of cases reported in adolescents
• Post Concussion Syndrome
• Repeated concussions may have cumulative effects
  on brain function, especially when injuries occur
  close together in time

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Scope of the Problem

• Severe head injuries are rare in sports
• Concussions are very common!
• True incidence not known due to under reporting
• 2003 anonymous survey of high school varsity
  football players in WI
• 15.3 of 1,532 players sustained a concussion
  during the current season
• Only 43.7 of concussed players told anyone
• Concussions were most commonly reported to ATC
  (76.7)
• 1983 survey of high school football players in MN
• 19/100 players reported a concussion per season
• Estimated that 250,000 concussions occur in US
  high school football players per year

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Scope of the Problem

• One study estimates 62,000 concussions per year
  occur in 10 representative high school sports
• 60 of these occur in football players
• Other studies have estimated
• 10 of college football players will suffer a
  concussion per season
• 40 of all athletes will have at least one
  concussion in their high school and college
  careers combined
• Regardless of the exact numbers, experts agree
  the concussion rate in youth sports is a
  significant public health concern
• Recent CDC concussion education initiative
• http//www.bt.cdc.gov/masscasualties/braininjuries
  pro.asp

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Concussion Symptoms

• Headache
• Confusion
• Difficulty concentrating
• Disorientation
• Amnesia
• Probably the best marker of severity
• Slow thinking

• Dizziness
• Lightheadedness
• Irritability
• Fatigue
• Change in personality
• Loss of consciousness may or may not occur

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Neuropsychological Tests

• Tests designed to evaluate and measure various
  cognitive functions of the brain
• Studies show that tests measuring the following
  neurocognitive processes have clinical value in
  concussed athletes
• Attention
• Memory
• Reaction time
• Visual processing speed
• Post-concussive symptoms

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Neuropsychological Tests

• Traditional neuropsychological tests
• Face to face pen and paper tests
• Used in NFL and NHL concussion programs
• Limitations
• Time consuming and expensive
• Up to 5 or 6 test administrators needed
• Can take several days to complete a battery of
  tests
• Accuracy of results decrease as performance
  improves when athletes exposed to the same tests
  over time (practice effect)
• Accuracy of tests measuring processing speed and
  reaction time dependent on the skill of the
  individual administering tests

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Computer-Based Neuropsychological Testing Programs

• Advantages
• Studies show excellent correlation with
  previously validated pen and paper tests
• Test questions randomized to increase accuracy by
  decreasing practice effect
• Processing speed and reaction time accurately
  measured by computer
• Much less time to administer
• Much more affordable

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Computer-Based Neuropsychological Testing Programs

• Importance of baseline testing
• Wide variation in test performance among
  individuals
• Comparisons of post-injury test results to
  average norms adjusted for age have not been
  shown to be reliable
• Best available programs (my opinion)
• ImPACT
• http//www.impacttest.com/
• Cogsport
• http//cogstate.com/go/sport/concussion-management
  
• Headminder
• http//www.headminder.com/site/cri/home.html

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Program We Use

• Immediate Post-concussion Assessment and
  Cognitive Testing (ImPACT)
• Developed by experts at University of Pittsburgh
  who designed and implemented the NFL and NHL
  concussion testing programs
• Being used at the professional, Olympic,
  collegiate and high school levels
• Complete battery of computerized tests can be
  completed in 20 to 30 minutes
• Program graphs performance data and determines
  statistical significance of post-concussion
  results compared to baseline

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Return to Play Decisions

• Many different sets of concussion grading scales
  and return to play guidelines exist
• Based mostly on expert opinion, not scientific
  data
• Disagreement among experts
• Experts agree no athlete should return to play
  while symptoms/effects of a concussion are
  present!

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Return to Play Decisions

• Why do neuropsychological testing?
• 2003 WI high school football survey
• Reasons why concussions not reported
• Did not think it was serious enough (66.4)
• Did not want to leave the game (41.0)
• Did not know it was a concussion (36.1)
• Did not want to let teammates down (22.1)
• Physical exam is not always sensitive enough to
  detect subtle concussion effects

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Return to Play Decisions

• Concussion grading controversy
• Grade 1 Concussion (AAN 1997)
• No loss of consciousness
• All symptoms resolve completely and neurological
  exam is normal within 15 minutes of injury
• Athlete may return to contest that day
• Recent study demonstrated decline in ImPACT
  performance at 48 hours following Grade 1
  injuries similar to decline following Grade 2 and
  3 injuries
• LOC not a reliable indicator of severity
• LOC may depend on anatomic location of injury
• NFL statement discouraging return to play that day

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Return to Play Decisions

• Computer-based neuropsychological testing is a
  valuable tool that provides better objective data
  and helps us to decide if and when return to play
  is safe
• Physicians must consider all relevant clinical
  factors not just test results when making
  return to play decisions

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Preventing Concussions

• Appropriate and regular maintenance of headgear
  and helmets
• Proper fit
• Pneumatic compartments filled to correct pressure
• Frequent inspections for damage
• Mouth guards
• Teaching proper tackling technique in football
• Avoid head down position
• Rules changes and enforcement
• No spearing
• No head to head contact

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Conclusions

• Concussions are common in athletes
• Concussions can have severe consequences
• When evaluating athletes
• Have a high level of suspicion
• Know the symptoms
• Do a thorough neurological examination
• Neuropsychological testing is the best objective
  tool available to aid clinicians in concussion
  diagnosis and management
• Do not clear an athlete to return to play if
  he/she is still experiencing symptoms/effects of
  a concussion
• If you have questions, ask your sports medicine
  team

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Questions?

• Thank You!