concussion management on the field & return to play decisions: a new approach

Concussion Management on the Field & Return to Play Decisions: A New Approach

Plan Concussion BasicsConcussion Basics A Peak at the Zurich Consensus StatementA Peak at the Zurich Consensus Statement Effective System of Concussion ManagementEffective System of Concussion Management

Collaboration between ATC and Collaboration between ATC and NeuropsychologistNeuropsychologist

Concussion EvaluationConcussion Evaluation Role of Neuropsychological TestingRole of Neuropsychological Testing

Concussion Treatment Concussion Treatment Managing Managing CognitiveCognitive Exertion in the School Exertion in the School

Seminal Study (Barth et al., 1989) Problem in MTBI: Adequate controls, controlling for Problem in MTBI: Adequate controls, controlling for

premorbid functioning, detecting changepremorbid functioning, detecting change Test-retest designTest-retest design – collegiate football players – collegiate football players Baseline neuropsychological testing, serial post-injury Baseline neuropsychological testing, serial post-injury

testing (P&P)testing (P&P) 10 universities – n=2350 players baseline tested10 universities – n=2350 players baseline tested Neurocognitive deficits at 24 hrs and 5 days post-injury, with Neurocognitive deficits at 24 hrs and 5 days post-injury, with

return to preseason baseline by Day 10return to preseason baseline by Day 10 Sports arena recognized as a unique, relatively well-Sports arena recognized as a unique, relatively well-

controlled lab for assessing mTBI.controlled lab for assessing mTBI.

1-3 Days Dayy 5-10Pre-Concussion Baseline Testing

Sports as a Laboratory Assessment Model (SLAM*)


Dayy 12-16

*Barth et al., 2002

ConcussionConcussion

1-3 DaysPre-Concussion Baseline Testing



*Barth et al., 2002


Zurich CIS Consensus

Abandon the simple vs. complex terminology Abandon the simple vs. complex terminology Majority (80-90%) of concussions resolve in a short Majority (80-90%) of concussions resolve in a short

(7-10 day) period, although the recovery time (7-10 day) period, although the recovery time frame may be longer in frame may be longer in children and adolescentschildren and adolescents. .

SCAT2SCAT2 form – incorporates SAC & BESS form – incorporates SAC & BESS Sideline: A player with diagnosed concussion Sideline: A player with diagnosed concussion

should not be allowed to return to play on the day should not be allowed to return to play on the day of injury. Occasionally in adult athletes, there may of injury. Occasionally in adult athletes, there may be return to play on the same day as the injury. be return to play on the same day as the injury.


CONCUSSION INVESTIGATIONSCONCUSSION INVESTIGATIONS: additional : additional exams utilized to assist diagnosis and/or exams utilized to assist diagnosis and/or exclusion of injuryexclusion of injury

Neuroimaging: still limitedNeuroimaging: still limited Objective Balance Assessment (eg BESS, force plate)Objective Balance Assessment (eg BESS, force plate) Neuropsychological Assessment: Use of neuropsychologists in Neuropsychological Assessment: Use of neuropsychologists in

the interpretationthe interpretation There may be situations (e.g. child and adolescent student-There may be situations (e.g. child and adolescent student-

athletes) where testing may be performed early whilst the athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining patient is still symptomatic to assist in determining management.management.

Zurich CIS Consensus Concussion ManagementConcussion Management

Physical AND Cognitive RestPhysical AND Cognitive Rest Graduated RTP: when asymptomatic at restGraduated RTP: when asymptomatic at rest

stepwise progression, proceed to next level if stepwise progression, proceed to next level if asymptomatic at current. asymptomatic at current.

Each step take 24 hours; would take Each step take 24 hours; would take approximately one week to proceed through the approximately one week to proceed through the full rehabilitation protocol full rehabilitation protocol

Same Day RTP: not appropriate in child or Same Day RTP: not appropriate in child or adolescent student-athlete (possible in adult adolescent student-athlete (possible in adult ONLY if within well established system)ONLY if within well established system)

Recognized delayed onset of symptomsRecognized delayed onset of symptoms

MODIFYING FACTORS IN CONCUSSION MODIFYING FACTORS IN CONCUSSION MANAGEMENTMANAGEMENT

A range of ‘modifying’ factors may influence the A range of ‘modifying’ factors may influence the investigation and management of concussion and in some investigation and management of concussion and in some cases, may predict the potential for prolonged or persistent cases, may predict the potential for prolonged or persistent symptoms. symptoms.

May be additional management considerations beyond May be additional management considerations beyond simple RTP advice. More important role for formal NP simple RTP advice. More important role for formal NP

testing, balance assessment, and neuroimaging.testing, balance assessment, and neuroimaging. Concussion history, LOC > 1 minute, Concussion history, LOC > 1 minute,

comorbidities/premorbiditiescomorbidities/premorbidities


Child and adolescent student-athlete Child and adolescent student-athlete Clinical evaluation include patient and parent, and Clinical evaluation include patient and parent, and

school when appropriateschool when appropriate Evaluation generally similar to adults; timing of testing Evaluation generally similar to adults; timing of testing

differs to assist treatment planning in school and differs to assist treatment planning in school and homehome

Age-appropriate baseline necessaryAge-appropriate baseline necessary More important to use neuropsychologists to interpret More important to use neuropsychologists to interpret

assessment data, particularly with LD and ADHD.assessment data, particularly with LD and ADHD.


Child and adolescent student-athlete Child and adolescent student-athlete Strongly endorsed view no return to practice or play Strongly endorsed view no return to practice or play

until clinically completely symptom free until clinically completely symptom free Cognitive rest highlightedCognitive rest highlighted More conservative return to play approach; appropriate More conservative return to play approach; appropriate

to extend the amount of time of asymptomatic rest to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and and/or the length of the graded exertion in children and

adolescents.adolescents. It is not appropriate for a child or adolescent student-It is not appropriate for a child or adolescent student-

athlete with concussion to RTP on the same day as the athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance. injury regardless of the level of athletic performance.

Concussion modifiers apply even more than adults and Concussion modifiers apply even more than adults and may mandate more cautious RTP advice.may mandate more cautious RTP advice.


Goals of the Effective Sports Concussion Program

Student-AthleteStudent-Athlete Safeguard Health Safeguard Health #1#1 Facilitate Speedy Return to Play/ Life Activities Facilitate Speedy Return to Play/ Life Activities

Athletic SystemAthletic System Reduce Risk/ Liability for Student-athlete safetyReduce Risk/ Liability for Student-athlete safety Achieve Greater SuccessAchieve Greater Success

Effective Sports Concussion ProgramPre-Injury

Pre-Injury Concussion-Education

Parent, athleteCoach, ATC

Emergency DeptPrimary Care PhysicianOther Medical Specialist

School Personnel(School RN, Psycholologist)

Knowledge and Preparation of All is the Foundation

On-field evaluation ATC/MD

Athlete ConcussionSuspected

Preseason BL Testing

No

Injury Monitoring

Early Identification

Return To Play (RTP)

Evidence of concussion?

Decision

Evidence of concussion?

Decision

Parent contacted

PCP contacted

ED evaluation?

Post-Injury Clinical

Evaluation(24 hours)

Yes

Post-InjuryCommunication/

Coordination

Removal from Play

Effective Sports Concussion ProgramPost-Injury

Neuropsychological &Balance Testing

Symptoms

Comparison to “BL”

Post-Injury Clinical Evaluation

(24-72 hours)

Neuropsychological &Balance Testing

Symptoms

Comparison to “BL”

Management/ TreatmentMedicalSports

AcademicHome

No

Gradual ExertionalRTP Protocol

(ATC)

Yes

Stage 1 Recovery? (at rest)

Initiate RTP?

No

Yes

Stage 1 Recovery7?

Initiate RTP?

Stage 2 Recovery?(w/ exertion)

RTP?

Yes

Return To Play (RTP)No

Effective Sports Concussion ProgramPost-Injury

Concussion: “Facts & Figures”

Annually, millions of children sustain a TBIAnnually, millions of children sustain a TBI 80-90% “ mild”80-90% “ mild”

New CDC estimates of New CDC estimates of sports/ recreationsports/ recreation TBI alone TBI alone (adults and children): 1.6 – 3.8 million per year (adults and children): 1.6 – 3.8 million per year (revised from previous estimate of 300K)(revised from previous estimate of 300K)

A concussion (or mild traumatic brain injury)A concussion (or mild traumatic brain injury) is defined as a is defined as a complex pathophysiologic process affecting complex pathophysiologic process affecting

the brain,the brain, induced by traumatic biomechanical forces induced by traumatic biomechanical forces

secondary to direct or indirect forces to the secondary to direct or indirect forces to the head.head.

Concussion/ mTBIDefinition

CDC Heads Up: Brain Injury in Your Practice (2007)

Disturbance of brain function is related to: Disturbance of brain function is related to: neurometabolic dysfunction, rather than neurometabolic dysfunction, rather than

structural injurystructural injury typically associated with normal structural typically associated with normal structural

neuroimaging findings (i.e., CT scan, MRI). neuroimaging findings (i.e., CT scan, MRI). Concussion may or may not involve a loss of Concussion may or may not involve a loss of

consciousness (LOC). consciousness (LOC).



Concussion results in a constellation of symptoms:Concussion results in a constellation of symptoms: physical, cognitive, emotional and sleep-related. physical, cognitive, emotional and sleep-related.

Duration of symptoms are variable may last for as Duration of symptoms are variable may last for as short as several minutes and last as long as short as several minutes and last as long as several days, weeks, months or even longer in several days, weeks, months or even longer in some cases.some cases.



Glasgow Coma Scale Glasgow Coma Scale >> 13 13 (3-15 scale)(3-15 scale)

Loss of Consciousness no longer than 10 minutes Loss of Consciousness no longer than 10 minutes (typically (typically no longer than 30-60 sec.)no longer than 30-60 sec.)

No evidence of complicated TBI/ structural abnormality No evidence of complicated TBI/ structural abnormality (skull fracture, intracranial bleed, known lesion)(skull fracture, intracranial bleed, known lesion)

Concussion/ mTBIAdditional Criteria

Anatomical Timeline of a ConcussionDefining the Key Factors

LOC<10%

Antero-grade

Amnesia25-40%

CONCUSSIOCONCUSSIONNPre-Injury

Risks

Retro-grade

Amnesia20-35%

Neurocog dysfx &Post-Concuss Sx’s

Sec-Hrs Hours - Days - Weeks+Sec-MinSec-Hrs

A. Injury Characteristics B. Symptom AssessmentC. Risk Factors

Sports ConcussionA Few Facts

Some Injuries are worse than others.Some Injuries are worse than others. Some athletes are more vulnerableSome athletes are more vulnerable Pre-injury risk factors combine with injuryPre-injury risk factors combine with injury

# previous concussions, headache, ADHD, LD, mood# previous concussions, headache, ADHD, LD, mood Other possible factors that influence recoveryOther possible factors that influence recovery

Magnitude of force that is receivedMagnitude of force that is received Location that force is receivedLocation that force is received Defensive position/ prep of individual receiving forceDefensive position/ prep of individual receiving force Size, speed factorsSize, speed factors

Symptoms can take Symptoms can take significantly longersignificantly longer to recover. to recover. Player is Player is more likelymore likely to be re-injured. to be re-injured. Second/ third... injuries:Second/ third... injuries:

Are more likely to be more severe Are more likely to be more severe Could cause permanent brain damageCould cause permanent brain damage Can take longer to recover fromCan take longer to recover from Increase risk of retirement from sportIncrease risk of retirement from sport

Increased Risks if not properly identified and

managed

Exertional Effects Increase or re-emergence of post-Increase or re-emergence of post-

concussion symptoms following concussion symptoms following significant exertional activitysignificant exertional activityPhysical activityPhysical activityCognitive activityCognitive activity

Effects of Concussive Forces on the Brain

Typically, the “software” of the brain is Typically, the “software” of the brain is affected affected Neurometabolic/ neurochemical processesNeurometabolic/ neurochemical processes PhysiologicalPhysiological

Not the “hardware” Not the “hardware” Structure Structure

4 Symptom Categories

PhysicalPhysical• HeadacheHeadache• Fatigue Fatigue • Dizziness Dizziness • Sensitivity to light Sensitivity to light

and/or noiseand/or noise• NauseaNausea• Balance problemsBalance problems

EmotionalEmotional• IrritabilityIrritability• SadnessSadness• Feeling more emotionalFeeling more emotional• NervousnessNervousness

• Cognitive• Difficulty remembering• Difficulty concentrating• Feeling slowed down• Feeling mentally foggy

• Sleep• Drowsiness• Sleeping less than usual• Sleeping more than usual• Trouble falling asleep

Everyday Functional Effects HomeHome

Difficulty completing tasks at homeDifficulty completing tasks at home Reduced play/ activityReduced play/ activity Irritability with challengesIrritability with challenges

SchoolSchool ConcentrationConcentration Remembering directionsRemembering directions DisorganizedDisorganized Completing assignmentsCompleting assignments FatigueFatigue Fall behind, fail tests, reduced gradesFall behind, fail tests, reduced grades

Neuropsychological Effects of Concussion

Attention, concentrationAttention, concentration ““Working memory” (holding info in mind during Working memory” (holding info in mind during

activity)activity) New learning & memory storage/ retrievalNew learning & memory storage/ retrieval Speed of processing informationSpeed of processing information Reaction timeReaction time

How Long Does It Take The Athlete To How Long Does It Take The Athlete To Recover from Concussion?Recover from Concussion?

Studies Reporting Individual Recovery Rates

AuthorsAuthors Sample Sample SizeSize

PopulationPopulation Tests UtilizedTests Utilized Total DaysTotal DaysCognitive Cognitive

ResolutionResolution

Total Days Total Days Symptom Symptom ResolutionResolution

IndividualIndividualRecoveryRecovery

RatesRates

McCrea,McCrea,

Guskiewicz et Guskiewicz et al.al.

20032003

9494 CollegeCollege Paper and PencilPaper and Pencil 3-5 Days3-5 Days 7 Days7 Days 91% 91% recoveredrecovered

w/in 7 daysw/in 7 days

Iverson et al.Iverson et al.

20062006

3030 High SchoolHigh School ComputerComputer

ImPACTImPACT

10 days10 days 7 Days7 Days 50% 50% recovered recovered


CollinsCollins

Lovell, et al. Lovell, et al.

20062006

134134 High SchoolHigh School ComputerComputer

ImPACTImPACT

NRNR NRNR 40% 40% recovered recovered


Recovery From Concussion:How Long Does it Take?

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

However! Every individual injury is differentEvery individual injury is different Many will recover within 1-2 weeksMany will recover within 1-2 weeks Some take longer, some shorterSome take longer, some shorter We MUST evaluate EVERY concussion individuallyWe MUST evaluate EVERY concussion individually

Just like every other injury –Just like every other injury – If not recognized and managed If not recognized and managed earlyearly, much greater , much greater

chance of more severe injury and longer recoverychance of more severe injury and longer recovery

“What’s the worst thing that can happen to my son?”

[Father of football player with multiple concussions in one season, 2003]

Second Impact Syndrome Diffuse cerebral swelling with delayed Diffuse cerebral swelling with delayed

catastrophic deterioration, a known catastrophic deterioration, a known complication of brain trauma complication of brain trauma postulated to occur after repeated postulated to occur after repeated concussive brain injury in sports.concussive brain injury in sports.

Second Impact Syndrome Athlete who has sustained an initial mild brain Athlete who has sustained an initial mild brain

injury sustains a second mild brain injury before injury sustains a second mild brain injury before symptoms associated with the first have fully symptoms associated with the first have fully cleared cleared

Death usually follows rapidly (2-5 minutes) due to Death usually follows rapidly (2-5 minutes) due to brainstem herniationbrainstem herniation

Disordered cerebral autoregulation of cerebral Disordered cerebral autoregulation of cerebral blood flow blood flow vascular engorgementvascular engorgementincreased increased ICPICPBrainstem herniationBrainstem herniation

MortalityMortality 50-100% 50-100%

Effective System of Sports Concussion

Management

Effective Concussion Program

Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason)Baseline Neuropsychological & Balance Testing (preseason)

On Field SurveillanceOn Field Surveillance

Standardized Sideline AssessmentStandardized Sideline Assessment

Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing

ManagementManagement

Physical ExertionPhysical Exertion

Cognitive Exertion (Academics)Cognitive Exertion (Academics) Gradual Return-To-Play ProtocolGradual Return-To-Play Protocol

Heads Up: Concussion in High School Sports

Parent Fact SheetParent Fact Sheet Athlete Fact SheetAthlete Fact Sheet Guide for CoachesGuide for Coaches

www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

Effective Concussion Program

Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury)

Baseline Neuropsychological & Balance Baseline Neuropsychological & Balance Testing (preseason)Testing (preseason)

On Field SurveillanceOn Field Surveillance Standardized Sideline AssessmentStandardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing ManagementManagement

Physical ExertionPhysical Exertion Cognitive Exertion (Academics)Cognitive Exertion (Academics)

Gradual Return-To-Play ProtocolGradual Return-To-Play Protocol

Relying on Athlete Symptom ReportRelying on Athlete Symptom Report

Do Athletes Underreport Symptoms?Do Athletes Underreport Symptoms?

Lovell MR, Collins MW, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

UNIQUE CONTRIBUTION OF UNIQUE CONTRIBUTION OF Neuropsychological TestingNeuropsychological Testing

TO CONCUSSION MANAGEMENTTO CONCUSSION MANAGEMENT

50556065707580859095

100

Verbal MemoryComposite

Visual MemoryComposite

Symptomatic Asymptomatic Control

N=115 MANOVA p<.000000

ImPACT revealscognitive deficitsin asymptomaticathletes within 4 days post-injury

25

30

35

40

45

50

Processing Speed

Symptomatic Aysmptomatic Control

N=115 MANOVA p<.000000

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Reaction Time

Symptomatic Asymptomatic Control

ImPACT Reaction TimeImPACT Processing Speed

UNIQUE CONTRIBUTION OF UNIQUE CONTRIBUTION OF Neuropsychological TestingNeuropsychological Testing

TO CONCUSSION MANAGEMENTTO CONCUSSION MANAGEMENT

To evaluate concussion recovery, we cannot rely on

athlete symptom report alone!

(How many other injuries do we allow (How many other injuries do we allow the athlete to decide when they can the athlete to decide when they can

return to play?)return to play?)

Preseason Baseline Neuropsychological Testing

25 minute computer-based test25 minute computer-based test Memory, Processing Speed, Reaction TimeMemory, Processing Speed, Reaction Time Baseline symptomsBaseline symptoms

Conducted in group format (up to 15 per)Conducted in group format (up to 15 per) Load on computers in labLoad on computers in lab Baseline data available for comparison post-Baseline data available for comparison post-

injuryinjury Ages 11-18 (currently)Ages 11-18 (currently)

Balance (Postural Stability) Balance (Postural Stability) TestingTesting

Effective Concussion Program Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason)Baseline Neuropsychological & Balance Testing (preseason) On Field SurveillanceOn Field Surveillance Standardized Sideline AssessmentStandardized Sideline Assessment

Post-Injury Neuropsychological & Post-Injury Neuropsychological & Balance Re-Testing Balance Re-Testing

ManagementManagement

Physical ExertionPhysical Exertion Cognitive Exertion (Academics)Cognitive Exertion (Academics)


1-3 Days Dayy 5-10Pre-Concussion Baseline Testing

Dayy 12-16

*Barth et al., 2002


Clinical ProtocolNeurocognitive TestingClinical ProtocolNeurocognitive Testing

1-3 DaysPre-Concussion Baseline Testing

*Barth et al., 2002


Clinical ProtocolNeurocognitive TestingClinical ProtocolNeurocognitive Testing

Effective Concussion Program Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason)Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance, Standardized Sideline AssessmentOn Field Surveillance, Standardized Sideline Assessment

Post-Injury Neuropsychological & Balance Re-TestingPost-Injury Neuropsychological & Balance Re-Testing ManagementManagement

Physical ExertionPhysical ExertionCognitive Exertion (Academics)Cognitive Exertion (Academics)


Management

Rest, Rest, RestRest, Rest, Rest Essential for brain’s recoveryEssential for brain’s recovery

SleepSleep Low activity, not increasing Low activity, not increasing

heartrate significantlyheartrate significantly

Concerns are broader than SportsConcerns are broader than Sports SportSport AcademicAcademic Daily activityDaily activity

Treatment / Management

Managing Exertion Managing physical and Managing physical and cognitivecognitive activity activity Risk for increase or re-emergence of post-Risk for increase or re-emergence of post-

concussion symptoms following significant concussion symptoms following significant exertional activityexertional activity

Managing school demands and physical Managing school demands and physical activitiesactivities

Physical Rest? No sportsNo sports No exerciseNo exercise No weightliftingNo weightlifting Exertion with Activities of Daily Living?Exertion with Activities of Daily Living?

REST = ABSOLUTE REST!REST = ABSOLUTE REST!

Mental/ Cognitive Rest? No prolonged concentrationNo prolonged concentration No prolonged homeworkNo prolonged homework No prolonged classes (block scheduling)No prolonged classes (block scheduling) No prolonged daysNo prolonged days

REST = ABSOLUTE REST!REST = ABSOLUTE REST!

ACE Care Plan

Linking Diagnosis With TreatmentLinking Diagnosis With Treatment

Purpose of Care Plan

Guide recovery

Educate

Manage exertional activity, safety

ACE Care Plan

Current Symptoms & Red FlagsCurrent Symptoms & Red Flags Daily ActivitiesDaily Activities Return to SchoolReturn to School Return to WorkReturn to Work Return to SportsReturn to Sports

Effective Concussion Program Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury)

Baseline Neuropsychological & Balance Testing (preseason)Baseline Neuropsychological & Balance Testing (preseason)

On Field Surveillance, Standardized Sideline AssessmentOn Field Surveillance, Standardized Sideline Assessment

Post-Injury Neuropsychological & Balance Re-TestingPost-Injury Neuropsychological & Balance Re-Testing ManagementManagement

Physical ExertionPhysical Exertion

Cognitive Exertion (Academics)Cognitive Exertion (Academics)


When Return to Play?

““It is not appropriate for a child or adolescent It is not appropriate for a child or adolescent student-athlete with concussion to RTP on student-athlete with concussion to RTP on the same day as the injury.”the same day as the injury.”

ZurichZurich consensus statement on concussion in consensus statement on concussion in sport (2008)sport (2008)

When Return to Play?Criteria for RTP

No longer have symptomsNo longer have symptoms No longer need medicine to control symptoms.No longer need medicine to control symptoms.

Cognitive/ thinking skills & balance back to “normal.”Cognitive/ thinking skills & balance back to “normal.” After rest and gradual activity (exertion)After rest and gradual activity (exertion) Cleared by medical professional.Cleared by medical professional.

ZurichZurich: Recognition that the child/ adolescent student-: Recognition that the child/ adolescent student-athlete may take longer, and we should proceed athlete may take longer, and we should proceed more cautiouslymore cautiously

MANAGEMENT STRATEGIESMANAGEMENT STRATEGIESCIS Group, 2001, 2004, 2008CIS Group, 2001, 2004, 2008

Emphasis on careful on-field evaluationRestriction of play for symptomatic student-athletesNeuropsychological testing recommended

Graduated return to play RestRest Aerobic exerciseAerobic exercise Sport Specific trainingSport Specific training Non-contact drillsNon-contact drills Full-contact trainingFull-contact training

Coach/ Player/ Parent Concern: Isn’t this

Concussion program going to hold my players out

longer?

Clinicians’ Return to Play Decisions

100

80

60

40

20

00

ATC used GSC, SAC, BESS (testing w/ symptom report)

ATC used only GSC (player symptom report)

Marshall, Guskiewicz, & McCrea; In Review, 2006.

• We know a lot about injuries to the brainWe know a lot about injuries to the brain• We have systems that can be put in place toWe have systems that can be put in place to

• Safeguard the student-athletes Safeguard the student-athletes • Facilitate speedy but safe return to playFacilitate speedy but safe return to play• Reduce risk/ liability to the athletic systemReduce risk/ liability to the athletic system• Improve overall athletic system performanceImprove overall athletic system performance

SummarySummary

• Relying on symptom assessment Relying on symptom assessment alonealone is relying is relying on limited and possibly faulty informationon limited and possibly faulty information

• Neuropsychological & balance testing are sensitive Neuropsychological & balance testing are sensitive and valid tools to help augment clinical evaluation and valid tools to help augment clinical evaluation and guide concussion management and guide concussion management

• Student-athlete should not return to play until Student-athlete should not return to play until symptom free & post-injury test results are normal symptom free & post-injury test results are normal at rest and after exertion. at rest and after exertion.

SummarySummary

Summary Careful Careful individualizedindividualized clinical assessment and clinical assessment and

tracking from time of injury is necessarytracking from time of injury is necessary Sideline assessmentSideline assessment Sensitive computerized Neuropsychological testingSensitive computerized Neuropsychological testing Balance testingBalance testing Symptom reportingSymptom reporting

What Must Youth & High Schools Sports Programs Do?

Begin the Process of Implementing an Effective Sports Concussion Begin the Process of Implementing an Effective Sports Concussion ProgramProgram

1.1. Outfit All High School Athletics Programs with Certified Outfit All High School Athletics Programs with Certified Athletic Trainers Athletic Trainers

2.2. Consultative Input to Youth Sports ProgramsConsultative Input to Youth Sports Programs

Education & Awareness (Pre-Injury)Education & Awareness (Pre-Injury)

Preseason Baselining testing Preseason Baselining testing Organized Sideline assessmentOrganized Sideline assessment Post-Injury Neuropsychological & balance testing, symptom Post-Injury Neuropsychological & balance testing, symptom

assessmentassessment Support Management & RecoverySupport Management & Recovery CautiousCautious and and gradualgradual return to play based on individual assessment return to play based on individual assessment

data of recoverydata of recovery

Typical Outcome

16 year old male

Injury - elbowed in forehead during basketball gameInjury - elbowed in forehead during basketball game Initially, no symptoms but within 10 minutes, Initially, no symptoms but within 10 minutes,

became “foggy” with poor concentration, memory, became “foggy” with poor concentration, memory, dizzinessdizziness

Subsequent loss of memory for event, irritability, Subsequent loss of memory for event, irritability, headaches, reduced energy, sensitive to light and headaches, reduced energy, sensitive to light and noise, sleeping more than usual, poor balancenoise, sleeping more than usual, poor balance

16 year old male 10th grade honors student 10th grade honors student Seen in the SCORE Concussion Clinic at Day 7 & Seen in the SCORE Concussion Clinic at Day 7 &

1414 Neuropsychological Concussion Evaluation initially Neuropsychological Concussion Evaluation initially

demonstrated:demonstrated: Poor attentionPoor attention Poor “working memory”Poor “working memory” Slowed processing speedSlowed processing speed Reduced reaction timeReduced reaction time

By 14 days, excellent recovery & return to By 14 days, excellent recovery & return to “baseline”“baseline”

16 year old male

Able to educate and guide the family and patientAble to educate and guide the family and patient Consulted with the ATC and pediatricianConsulted with the ATC and pediatrician Made recommendations for accommodations in Made recommendations for accommodations in

schoolschool Kept him safe by managing his gradual return to Kept him safe by managing his gradual return to

sportssports

concussion management on the field & return to play decisions: a new approach

Documents

management of concussion

day of injury

diagnosed concussion

concussion history

day rtp

assessment data

day period

concussion managementa