Concussions in the Office: Who, What, Where, When, and How Do I Know

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Concussions in the OfficeWho, What, Where,
When, and How Do I Know

• Daniel E. Kraft M.D.
• Riley Hospital for Children
• Sports Medicine

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Athletes at Games

• I can remember what happened, so I do not have a
  concussion
• I just got my bell rung, that is not really a
  concussion
• Are you sure you know what a concussion is
  because I dont think you are right
• I still know my birthday so I cant have a
  concussion

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History of Concussions

• 2006- Zackery Lystedt suffers permanent
  disability due to second concussion syndrome
• 2007- questions start about chronic brain
  injuries in NFL players
• 2009- NFL passes new concussion guidelines
• 2009- Washington state passes Lystedt Law

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Recent Developments

• 2010- NCAA develops new rules prohibiting same
  day return to play with concussion symptoms
• 2010- IHSAA follows National High School
  Federation recommendation for same day concussion
  rule
• 2011- Madden Football video game adds concussion
  rule

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Indiana State Concussion Law

• Passed as law in 2011
• Begins enforcement July 1, 2012
• 3 Main Features of Law
• Education all student athletes and parents must
  receive yearly concussion education
• All athletes with concussion symptoms must be
  removed from game
• All athletes diagnosed with concussion must be
  cleared by appropriate medical personel before
  return to play

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Concussions

• In the United States, the annual incidence of
  sports-related concussion is estimated at
  300,000.
• Likelihood of an athlete in a contact sport
  experiencing a concussion may be as high as 19
  per season.
• One study at Nationwide Childrens Hospital
  showed 41 of young athletes go back to sports
  too soon
• Second Impact Syndrome has led to 30-40 deaths
  over the past decade.

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Danger of Concussions

• Most importantly, athletes may not understand the
  potential consequences of concussion and often
  minimize or deny symptoms so that they can return
  to play.
• Such under-reporting of symptoms is a common
  practice at all levels of sport participation.

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Second Impact Syndrome

• Suffering a second blow to the head while
  recovering from the initial concussion can have
  catastrophic consequences.
• Athletes that are not fully recovered from an
  initial concussion are significantly vulnerable
  for recurrent, cumulative, and even catastrophic
  consequences of a second concussive injury.

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Recent Developments That Affect Primary Care
Physicians in Indiana

• National High School Sports Federation recommends
  new same day concussion rule
• IHSAA requires MD clearance for return to play
• New Indiana state law regarding concussions

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Objectives

• What is a concussion?
• How do I know if an athlete has suffered a
  concussion?
• How do we treat concussions?
• What is computerized neurocognitive testing?
• When can athletes return to play after a
  concussion?

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What is a concussion?

• Injury to the brain caused by acute trauma
• More than a Bruise on the brain
• Functional injury, not just structural

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Functional Injury to Brain Cells

• Affects cell membrane permeability
• Affects K and Ca flow
• Ultimately decreases glucose availability to
  brain cells for energy energy crisis for the
  brain

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How do you know when a concussion has
occurred?Criteria for Diagnosis

• Acute trauma/injury to the head- athlete is
  exposed to a force to the head that causes
  injury
• Symptoms- athlete has a reaction to the injury in
  the form of symptoms

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Possible Concussion Symptoms

• Headache
• Dizziness
• Disorientation
• Dazed
• Blurred vision
• Memory loss
• Confusion
• Fatigue

• Inability to concentrate
• Change in mood
• Headache made worse by light or noise
• Loss of consciousness

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Diagnosis

• Even athletes who finish games can be diagnosed
  with a concussion
• Some athletes may not report symptoms til after a
  contest

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Sideline Diagnosis

• Same criteria as in the office
• Recommendations at all level of competition and
  ages is no return to play on same day if any
  concussion-like symptoms
• Most concussions do not need to go to ER, though
  you must use own judgement

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Who Has Concussions

• All ages, have seen 8 year olds and older
• Both males and females
• Many different sports
• Football
• Soccer
• Cheerleading
• Basketball
• Lacrosse

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Concussions in Girls

• Girls have higher risk for concussion in both
  basketball and soccer
• Cheerleading becoming higher risk sport
• Girls sports can be ignored by schools when it
  comes to neurocognitive testing and risk for
  concussions

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What is the goal of medical treatment for
concussions?

• Try to determine as best we can using available
  information and testing when an athlete has
  completely recovered from a concussion before
  allowing that athlete to participate in any
  activity with increased risk of concussion
  (return to play for athletes)

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What is the goal of medical treatment for
concussions

• Try to prevent a concussion injury from occurring
  on top of a concussion that has not healed
  completely
• Manage the athletes concussion symptoms and
  issues to help them try to continue normal
  academic and daily activities as much as possible
  while the concussion injury heals

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Treatment Parameters

• New research over past 5-10 years has changed
  approach to concussion management
• Computerized neurocognitive testing has helped
  gather new information regarding the effects of
  concussions on athletes
• Better realization now about the more significant
  effects of concussions (both short term and long
  term)

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Treatment Parameters

• All concussion patients are treated individually
  with no time standards
• No longer 1 week for mild concussion,etc
• Athletes must complete 3 phases of
  treatment/management before return to play
• Physical Exam must be normal

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Physical Exam

• Normal neurologic exam
• Normal balance exam
• Normal vestibular exam

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Treatment Parameters3 Phases of Treatment

• No symptoms with activities of daily living
• No symptoms with exertion testing
• Normal neurocognitive testing

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Phase 1No Symptoms with ADLs

• No headaches (unless hx of headaches)
• Normal sleep patterns
• No abnormal mood issues different from their
  baseline
• No memory or concentration issues at home or in
  school

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Phase 1No Symptoms with ADLs

• No headaches with bright lights or loud noises
• Athlete must report that they feel 100 back to
  their normal self
• Parents must state that they believe athlete is
  100 back to their normal self

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Phase 2 No Symptoms with Physical Exertion
Testing

• Will typically start phase as symptoms with ADLs
  are decreasing or at 3-4 weeks if still with
  significant symptoms
• Exertion tests can be done by ATCs, coaches, or
  parents
• If athlete develops increasing symptoms during
  exertion, then need to hold for a some days
  before re-trying

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Phase 2No Symptoms with Exertion

• Athlete is exercised individually with running,
  stationary bike, elliptical, or weight-lifting
• Start light 12-15 minutes and advance both length
  and intensity of work
• Typically must advance to at least 2-3 days of
  HEAVY exertion with no symptoms to pass

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Neurocognitive Testing

• Concussions are really a functional injury versus
  a structural injury

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Phase 3Neurocognitive Testing

• Determining the functioning ability of an
  athletes brain requires neurocognitive testing
• Using computerized neurocognitive testing is
  becoming a part in the standard of care for
  managing athletes with concussions

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Computerized Neuropsychological Tests

• Impact
• Axon (Cog Sport)
• Others

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Impact

• Proven validity
• Most research published
• Most widely used in USA
• Internet based
• Ease of obtaining baseline studies
• Established credentialing process for medical
  personnel to learn to interpret test scores

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ImPACT

• Computerized test of cognition
• Not an IQ test
• Used in NFL, MLB, NHL, Major League Soccer
• Used by military for combat troops

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How it works

• 22-25 minute test
• Almost any computer will work
• Mouse
• Network connectivity
• Internet connectivity
• Quiet room

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Evaluates

• Attention span
• Working memory
• Reaction time
• Problem solving
• Response variability

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How it works

• Objective measure
• Accurate to 1/100th of second
• No learning effect

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Who is it for

• Mild traumatic brain injury
• Athletic related concussion
• Current age 11 and up
• Best with access to baseline
• Compare to normative data
• Pediatric test
• Calculations for peds population

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Baseline Testing

• Can be done over the internet from any computer
  and using a mouse
• Currently costs no more than 5 per baseline test
• Can be completed in Indiana thru various websites
• Test scores are stored
• Can be organized thru schools or clubs

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The Test

• Module 1 Word Discrimination Twelve target
  words are shown twice to the athletes. After they
  have gone through twice they are then shown the
  twelve words and then twelve non target words and
  they have to pick the twelve target words.

• Delay Condition Following the administration of
  all other test modules (approximately 20
  minutes), the subject is again tested for recall
  via the same method described above. The same
  scores that are described above are provided for
  the delay condition.

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Module 2

• Design Memory- Twelve target designs are
  presented twice to facilitate learning. The
  subject is tested for recognition via the
  presentation of 24-designs comprised of 12 target
  designs and 12 non-target designs

• Delay Condition- Following the administration of
  all other test modules (approximately 20
  minutes), the subject is again tested for recall
  via the same method described above. The same
  scores that are described above are provided for
  the delay condition.

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Module 3

• XS and Os
• This module measures visual working memory as
  well as visual processing speed and consists of a
  visual memory paradigm with a distracter task.
• Subject is asked to click the left mouse button
  if a blue square is presented and the right
  mouse button if a red circle is presented.
• Once the subject has completed this task, the
  memory task is presented. For each of the trials
  of the memory task, a screen is displayed for 1.5
  second that has a computer generated random
  assortment of Xs and Os. For each of the
  trials, three of the Xs or Os are illuminated
  in YELLOW on the screen. The subject is asked to
  remember the location of the illuminated objects

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Module 4

• Symbol Matching
• This module evaluates visual processing speed,
  learning and memory.
• Subject is shown 9 common symbols, directly under
  each is the numbers 1-9.The subject is required
  to click the matching number as quickly as
  possible and to remember the symbol/number
  pairings
• They have 27 trials and following that the
  symbols disappear and they must recall the
  number/symbol pairing correctly.
• Provides an average reaction time score and a
  score for the memory condition.

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Module 5

• Color Match
• This module represents a choice reaction time
  task and also measures impulse control /response
  inhibition.
• Subject is required to respond by clicking a
  read, blue or green button as they are presented
  on the screen. This procedure is completed to
  assure that subsequent trials would not be
  affected by color blindness.
• Next, a word is displayed on the screen in the
  same colored ink as the word (e.g. RED), or in a
  different colored ink (GREEN or BLUE). The
  subject is instructed to click in the box as
  quickly as possible only if the word is presented
  in the matching ink.
• In addition to providing a reaction time score,
  this task also provides an error score.

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Module 6

• Three Letters/Count Backward
• Measures working memory and visual-motor response
  speed.
• Consists of 25 numbered buttons (5 x 5 grid). The
  subject is instructed to click as quickly as
  possible on the numbered buttons in backward
  order starting with "25.
• He/she is presented with three consonant letters
  that are displayed on the screen.
• They have 18 seconds to complete task and then
  must be repeated 5 times
• This module yields a memory score (total number
  of correctly identified letters) and a score for
  the average number of correctly clicked numbers
  per trial from the distracter test

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Interpretation
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Interpretation after Injury

• Meant to be interpreted by credentialed
  physicians
• Most useful when athlete has baseline test to
  compare current test scores
• Post-injury tests must be at least equal to
  baseline scores
• If no baseline, can develop estimate of baseline
  based on comparison to athletes peer group
• Each composite score has a confidence interval

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ImPact (Neurocognitive) testing is part of
concussion management, not the only piece
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When can athlete return to play?

• Athlete must satisfactorily complete all 3 phases
  of treatment with no symptoms and normal
  neurocognitive testing
• Have normal physical exam
• There are no standard time limits anymore before
  athletes can return to play after a concussion
• Athlete should return to full practice before
  returning to game

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Risk for Further Concussion

• Currently our determination for return to play
  corresponds to determination of
  resolution/healing of the concussion
• Are athletes at higher risk for another
  concussion when they return to play?
• Do athletes have a lower threshold for further
  concussion injury?

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Other Concussion Issues
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Issues While Recovering from Concussions

• Athletes may have increased fatigue and sleep
  more than usual
• Should warn parents of possible mood issues
• Patients should not do any video games and limit
  texting, computer work, and TV

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School Issues

• MD should give written notice to school of
  patients concussion
• Warn parents that grades may drop during recovery
  phase
• School Accommodations untimed tests, pre-printed
  notes, no more than 1 test per day, modified
  school schedule

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Long Term Effects

• Headaches
• Academic difficulties
• Mood swings/behavioral issues
• Sleep disturbances

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Vestibular Problems

• New area of research for concussion management
• Sx- motion sickness, dizziness with exercise,
  headaches
• Now involve in clinical exam horizontal,
  vertical, and rotational gaze
• Believe vestibular therapy can help alleviate sx
  more quickly
• Will not start vestibular therapy for at least 3
  weeks from date of injury

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Diagnostic Testing

• CT Scan- may be done initially to evaluate for
  bleeding or structural abnormalities if symptoms
  indicate need for test
• MRI- done 4 weeks after injury, can miss small
  bleeds if done early, often done if no
  improvement for 4-5 weeks after concussion

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Young Athletes

• Concussions resolve more slowly in younger
  athletes
• Younger athletes with higher risk of long term
  affects if concussion occurs upon a concussion
  that has not healed

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Multiple Concussions

• Multiple concussions may lower the threshold for
  new concussions to occur
• Younger the athlete with concussion, more likely
  to cause long-term problems
• Multiple concussions can disqualify an athlete
  from contact sports for life

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Multiple Concussions

• There is no magic number of concussions that will
  DQ athlete from sports
• Must weigh pros and cons for each individual case
• Other factors are age at time of concussions, how
  far apart did injuries occur, length of recovery
  time

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Who Should Take Care of Athletes with Concussions

• Any MD who is certified to use neurocognitive
  testing data and is comfortable taking care of
  concussed athletes
• Athletic trainers?
• Neuro-psychologists?
• Best- combination of all above

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Why is it important to recognize and treat
concussions?

• Protect players from long-term injury
• Protect players from themselves
• Second Impact Syndrome

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Thank you

• Daniel E. Kraft M.D.
• Riley Hospital for Children
• Sports Medicine
• DKraft_at_IUHealth.org

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Questions??