Oregon Concussion Awareness and Management Program: Makin

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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

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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!!!!

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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

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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

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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

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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

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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
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Episodes of Permanent Paralysis in Football
1987-1989 gradual increase in permanent
quadriplegia
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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
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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

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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

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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

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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

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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

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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

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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

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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 . . .

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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

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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

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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

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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

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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

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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

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Neuropsychological Testing

• ImPACT Cogsport Headminder
• Traditional pen and paper battery
• Great deal of controversy due to aggressive
  marketing and no gold standard

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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.

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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

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ImPACT for Sports Concussion Management
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Concussion The Diagnostic and
Return to Play Dilemma
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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

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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

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Clinical Protocol Neurocognitive Testing
24-72 Hours
Day 5-10
Beyond if necessary
Baseline Testing Not
necessary for decision making
Concussion
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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)
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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
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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
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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

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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

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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

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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!!

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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

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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)
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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.

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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.

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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

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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

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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

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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

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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.

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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