Title:Oregon Concussion Awareness and Management Program: Makin
Description:
Oregon Concussion Awareness and Management Program: Making an Impact Michael C. Koester, MD, ATC, FAAP 6th Annual Pacific Northwest Conference on Brain Injury – PowerPoint PPT presentation
Title: Oregon Concussion Awareness and Management Program: Makin
1 Oregon Concussion Awareness and Management Program Making an Impact
Michael C. Koester MD ATC FAAP
6th Annual Pacific Northwest Conference on Brain Injury
February 29th 2008
Slocum Center for Orthopedics and Sports Medicine
Director Sports Concussion Program
Eugene Oregon
2 The Problem
We now realize that concussions occur more often than previously thought
Young athletes are at risk for serious short-term and long-term problems
3 The Problem
There is much variation in the knowledge of Health Care Providers managing concussed athletes
New and emerging technologies and research will lead to a continuing evolution of care
4 The Opportunity
Bill Bowers Executive Director of the OADA met with me last fall and expressed interest in developing a statewide concussion program similar to a program implemented in New York state last year.
I have envisioned a dream program for the past several years but needed buy-in from the involved parties.
We have willing participants OSAA OADA backing and multiple media stories trumpeting the problem--- the time is now!!!!
5 Extent of the Problem
Like all problems in sports- what is seen at the pro level is only a small part of the problem
Much more common in high school than any other level- due to large number of participants
6 Extent of the Problem
Estimated 300000 sports-related head injuries in high school athletes yearly
9 of all sports injuries
678 head-injuries in Oregon HS athletes in 2004-5 based on OSAA participation stats
7 The Goal
State-wide concussion management program involving all high schools
Establish state-wide physician network
Uniform evaluation and management protocol
Consultation service for coaches athletes parents and physicians
ImPACT neuropsychologic testing available for all contact and collision sport athletes
8 How do we achieve our goals
What happens when coaches and other members of the Sports Medicine Team work together to promote safety and injury prevention
9 Episodes of Permanent Paralysis in Football 1976 implementation of NCAA/High School rule changes and using coaching techniques eliminating the head as a battering ram 10 Episodes of Permanent Paralysis in Football 1987-1989 gradual increase in permanent quadriplegia 11 Episodes of Permanent Paralysis in Football 1991 distribution of video Prevent Paralysis Dont Hit with your Head and release of educational poster Play Heads-Up Football 12 The Plan
Three Tiers of Education
Medical Professionals
Physicians
Nurse Practioners/Physician Assitants
Athletic Trainers
Chiropractors
Paramedics/EMTs
Educators
Athletic Directors
Coaches
Principals/Administrators
Counselors
Community
Parents/Athletes
School Boards
13 The Plan
Identify Regional Leaders
Portland- Jim Chessnutt MD
Eugene- M. Koester MD ATC
Bend- Mark Belza MD
Each regional leader will oversee programs at the satellite sites
Phone/e-mail consultation
Office evaluation if desired
14 Regional Presentations
Teams will carry out presentations throughout the state in late Spring and early Fall 2008
Portland
Hillsboro
Gresham
Wilsonville
Astoria
The Dalles
Eugene
Corvallis
Salem
Roseburg
Medford
Bend
Ontario
La Grande
John Day
Hermiston
Klamath Falls
15 Multimedia Campaign
Presentations at each site
PowerPoint available to anyone who asks
Brochures
Webcasts of presentations
Podcasts available
Local and regional television radio and newspaper
Website- Link through OSAA or our own site
16 Neuropsychologic Testing
Immediate Post-Concussion Assessment and Cognitive Testing
Computerized Neurocognitive Testing
Available on-line- yearly cost of 350-450 per school on average
Used extensively in professional collegiate and high school athletes
Vast majority of NFL and NHL teams
Has received significant media attention
Athletes receive baseline testing prior to the start of the sports season
Should be done at least every other year
17 What can we accomplish
The opportunity presents itself for us to establish a program which can
Maximize the health and safety of our athletes
Minimize worry and liability for our coaches and administrators
Provide a model for other western states to emulate
18 What is a Concussion
A concussion is a mild traumatic brain injury that interferes with normal function of the brain
Evolving knowledge- dings and bell ringers are brain injuries
19 What happens to the brain
A complex physiological process induced by traumatic biomechanical forces
sudden chemical changes- neurotransmitters and glucose utilization disrupted
stretching and tearing of brain cells
Structural brain imaging (CT or MRI) is almost always normal
Still many unanswered questions . . .
20 Increasing Exposure of the Problem
High profile athletes with severe or career ending injuries
Steve Young
Troy Aikman
Merrill Hodge
Trent Green
ESPN and Sports Illustrated frequently cover the issue-not always very well
Highlights of hits
Features in print and television
21 Not Just a Football Problem
Injury rate per 100000 player games in high school athletes
Football 47
Girls soccer 36
Boys soccer 22
Girls basketball 21
Boys basketball 7
JAT
22 Potential Complications
15 of all head-injured athletes suffer long-term complications
Increased risk for future and more serious concussions
Learning Disorders unmasked
Second Impact Syndrome
23 Concussion and same-day RTP
Long held that RTP after 15 minutes if symptom free is acceptable standard (Grade 1 concussion)
43 HS athletes with Grade 1 concussion
32 with symptoms at 36 hours
36 with abnormal ImPACT at 36 hours
AJSM 2004
24 Risk for further concussion
Everyone asks.
Prospective cohort of 2905 FB players at 25 colleges
184 with concussion 12 with repeat in same season
Hx of 3 or more concussions 3X more likely to have concussion
25 Risk for further concussion
These had slower recovery
30 with hx had symptoms gt 1 week
14.6 without hx had symptoms gt 1 week
11/12 of the repeat concussions occurred within 10 days of first
JAMA 2003
26 Neuropsychological Testing
ImPACT Cogsport Headminder
Traditional pen and paper battery
Great deal of controversy due to aggressive marketing and no gold standard
27 Neuropsychological Testing
Assesses 6 domains of brain function
Attention span
Working memory
Sustained and selective attention time
Response variability
Non-verbal Problem Solving
Reaction time
Not a perfect tool and not to be used in the absence of an experienced and knowledgeable physician.
28 Neuropsychological Testing
Computerized tests
Can be administered to a group or at home
Can be repeated multiple times
Ideally baseline testing is done before the season starts
Test is repeated after concussion and results are compared to baseline
Can compare to population norms if no baseline
29 ImPACT for Sports Concussion Management 30 Concussion The Diagnostic and Return to Play Dilemma 31 What ImPACT Is and Isnt
IS a useful concussion screening and management program
IS validated with multiple published studies
IS NOT a substitute for medical evaluation and treatment
IS NOT a substitute for comprehensive neuropsychological testing when needed
32 ImPACT Post-Concussion Evaluation
Demographics
Concussion History Questionnaire
Concussion Symptom Scale
Neurocognitive Measures
Memory Working Memory Attention
Reaction Time Mental Speed
Detailed Clinical Report
Automatically Computer Scored
33 Clinical Protocol Neurocognitive Testing 24-72 Hours Day 5-10 Beyond if necessary Baseline Testing Not necessary for decision making Concussion 34 Unique Contribution of Neurocognitive Testing to Concussion Management Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion N215(Lovell et al. 2004) 35 ImPACT Bell-Ringer StudyBrief versus Prolonged On-field Mental Status Changes Plt.04 Plt.004 N 64 High School Athletes Plt.02 ImPACT Memory-Percent Correct Lovell Collins Iverson Field Podell Cantu Fu J Neurosurgery 98296-3012003 Lovell Collins Iverson Johnston Bradley Amer J Sports Med 3247-542004 36 Recovery From ConcussionHow Long Does it Take on ImPACT WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 N134 High School athletes Collins et al. 2006 Neurosurgery 37 Neuropsych testing and RTP decisions
Do I have to use this
Not yet standard of care
Recommended to be used by current guidelines-Prague 2004
Provides extra data
Think of it like any lab test MRI etc
38 ImPACT and RTP decisions
How well does ImPACT identify concussed athletes
Sensitivity
Identified 80 within 24 hours
68 identified by self-report of symptoms
J Neurosurg 2007
39 ImPACT and RTP decisions
Value-added effect in 122 concussed HS and college athletes
83 abnormal ImPACT
64 with symptoms
93 with combo of both
No one in control group had abnormal ImPACT and symptoms
AJSM 2006
40 ImPACT and RTP decisions
When to use ImPACT
Recommended to be used 24-72 hours post-injury 5-10 days post injury and beyond if needed.
No need to test if athlete is still symptomatic
May need to use to show coaches parents etc- BE CAREFULL!!
41 Prague Guidelines 2004
Whats a Grade 1 concussion
Notion of grading systems has been abandoned
Over 20 classifications
Can only be applied retrospectively
Simple versus Complex
Complex-persistent symptoms specific sequelae prolonged LOC multiple concussions
Graded Return to Activity
42 Prague Guidelines 2004
Simple concussion
LOC lt 1 minute
resolves in 7-10 days
first concussion
Complex concussion
LOC gt 1 minute
symptoms last longer than 7 10 days
history of multiple concussions
increasing concussability
No athlete returns in the current game or practice (same day) 43 Return to Activity Protocol
7 Steps to a Safe Return
Step 1. Complete cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.
Step 2. Return to school full-time.
44 Return to Activity Protocol
7 Steps to a Safe Return (cont)
Step 3. Light exercise. This step cannot begin until you are cleared by your physician for further activity.
Step 4. Running in the gym or on the field. No helmet or other equipment.
Step 5. Non-contact training drills in full equipment. Weight-training can begin.
45 Return to Activity Protocol
7 Steps to a Safe Return (cont)
Step 6. Full contact practice or training.
Step 7. Game play. Must be cleared by your physician before returning to play.
Cannot advance to next level if symptomatic
Progression usually takes about 1 week
46 Return to Activity
Recommend written and standardized Return to Activity Plan for all concussed athletes
Sets standard and is understood by all coaches parents and athletes
Cannot advance to next level if symptomatic
47 Education
No such thing as just a concussion
Coaches athletes ADs and parents must be educated on signs and symptoms as well as need for proper management
CDC Tool Kit on Concussion for High School Coaches
http//www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
48 Prevention
Concussion prevention has become the holy grail for sports equipment marketers
Special helmets soccer head pads mouth guards- NO PROVEN PROTECTION FROM CONCUSSION!!
Multiple flaws in recent study looking at newer helmet technology.
Neurosurgery 2006
49 Conclusions
Concussion management continues to evolve. Health care providers must be knowledgeable of the most up to date management recommendations.
Neuropsychological testing plays an important role in concussion management- but cannot stand alone.
Schools should have evaluation and RTP policies and procedures in place to ensure excellent and consistent care.
50 THANK YOU!!!!!!
Thad Stanford MD JD- Salem
Bill Bowers- Executive Director OADA
Tom Welter- Executive Director OSAA
Mark Belza MD- Bend
Mickey Collins PhD- Pittsburgh
Ron Savage EdD- New Jersey
Brian Rieger PhD- New York
Ann Glang PhD- Eugene
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