Download Delay Condition- Following the administration of all other test

Concussions in the Office:
Who, What, Where, When, and
How Do I Know
Daniel E. Kraft M.D.
Riley Hospital for Children
Sports Medicine
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 don’t think you
are right”
• “I still know my birthday so I can’t have a
concussion”
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
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
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
Concussions
• In the United States, the annual incidence of sportsrelated 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 Children’s 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.
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.
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.
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
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?
What is a concussion?
• Injury to the brain
caused by acute
trauma
• More than a “Bruise”
on the brain
• Functional injury, not
just structural
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”
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
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
Diagnosis
• Even athletes who finish games can be
diagnosed with a concussion
• Some athletes may not report symptoms til
after a contest
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
Who Has Concussions
• All ages, have seen 8 year olds and older
• Both males and females
• Many different sports:
– Football
– Soccer
– Cheerleading
– Basketball
– Lacrosse
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
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)
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 athlete’s concussion
symptoms and issues to help them try to
continue normal academic and daily
activities as much as possible while the
concussion injury heals
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)
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
Physical Exam
• Normal neurologic exam
• Normal balance exam
• Normal vestibular exam
Treatment Parameters:
3 Phases of Treatment
• No symptoms with activities of daily living
• No symptoms with exertion testing
• Normal neurocognitive testing
Phase 1
No Symptoms with ADL’s
• 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
Phase 1
No Symptoms with ADL’s
• 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
Phase 2
No Symptoms with Physical
Exertion Testing
• Will typically start phase as symptoms with
ADL’s are decreasing or at 3-4 weeks if
still with significant symptoms
• Exertion tests can be done by ATC’s,
coaches, or parents
• If athlete develops increasing symptoms
during exertion, then need to hold for a
some days before re-trying
Phase 2
No 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
Neurocognitive Testing
• Concussions are
really a functional
injury versus a
structural injury
Phase 3
Neurocognitive Testing
• Determining the functioning ability of an
athlete’s brain requires neurocognitive
testing
• Using computerized neurocognitive testing
is becoming a part in the standard of care
for managing athletes with concussions
Computerized Neuropsychological
Tests
• Impact
• Axon (Cog Sport)
• Others
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
ImPACT
• Computerized test of cognition
• Not an IQ test
• Used in NFL, MLB, NHL, Major League Soccer
• Used by military for combat troops
How it works
• 22-25 minute test
• Almost any computer will work
– Mouse
– Network connectivity
– Internet connectivity
• Quiet room
Evaluates
• Attention span
• Working memory
• Reaction time
• Problem solving
• Response variability
How it works
• Objective measure
• Accurate to 1/100th of
second
• No learning effect
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
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
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.
Module 2
• Design MemoryTwelve target designs are
presented twice to
facilitate learning. The
subject is tested for
recognition via the
presentation of 24designs comprised of 12
target designs and 12
non-target designs
• Delay ConditionFollowing 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.
Module 3
• X’S and O’s
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 X’s and O’s. For each of the trials, three
of the X’s or O’s are illuminated in YELLOW on the screen. The
subject is asked to remember the location of the illuminated
objects
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.
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.
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
Interpretation
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 athlete’s peer group
• Each composite score has a confidence interval
ImPact (Neurocognitive) testing
is part of concussion
management, not the only piece
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
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?
Other Concussion Issues
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
School Issues
• MD should give written notice to school of
patient’s 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
Long Term Effects
• Headaches
• Academic difficulties
• Mood swings/behavioral issues
• Sleep disturbances
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
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
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
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
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
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
Why is it important to recognize
and treat concussions?
• Protect players from
long-term injury
• Protect players from
themselves
• Second Impact
Syndrome
Thank you
Daniel E. Kraft M.D.
Riley Hospital for Children
Sports Medicine
[email protected]
Questions??