Title: Oregon Concussion Awareness and Management Program: Making an Impact
1Oregon 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
2The 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
3The 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
4The 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!!!!
5Extent 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
6Extent of the Problem
- Estimated 300,000 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
7The 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
8How 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
12The 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
13The 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
14Regional 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
15Multimedia 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
16Neuropsychologic 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
17What 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
18What 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
19What 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 . . .
20Increasing 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
21Not Just a Football Problem
- Injury rate per 100,000 player games in high
school athletes - Football 47
- Girls soccer 36
- Boys soccer 22
- Girls basketball 21
- Boys basketball 7
- JAT
-
-
22Potential 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?
23Concussion 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
24Risk 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
25Risk 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
26Neuropsychological Testing
- ImPACT, Cogsport, Headminder
- Traditional pen and paper battery
- Great deal of controversy due to aggressive
marketing and no gold standard
27Neuropsychological 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.
28Neuropsychological 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
29ImPACT for Sports Concussion Management
30Concussion The Diagnostic and
Return to Play Dilemma
31What 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
32ImPACT 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
33Clinical Protocol Neurocognitive Testing
24-72 Hours
Day 5-10
Beyond if necessary
Baseline Testing Not
necessary for decision making
Concussion
34Unique Contribution of Neurocognitive Testing to
Concussion Management
Testing reveals cognitive deficits in
asymptomatic athletes within 4 days
post-concussion
N215(Lovell et al., 2004)
35ImPACT 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 98296-301,2003 Lovell,
Collins, Iverson, Johnston, Bradley Amer J
Sports Med 3247-54,2004
36Recovery 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
37Neuropsych 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
38ImPACT 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
39ImPACT 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
40ImPACT 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!!
41Prague 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
42Prague 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)
43Return 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.
44Return 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.
45Return 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
46Return 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
47Education
- 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
48Prevention
- 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
49Conclusions
- 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.
50THANK 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