Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer ImPACT Applications, Inc.
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Transcript of Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer ImPACT Applications, Inc.
Mark Lovell PhD, FACPN, D.SciChairman and CEO
Software DeveloperImPACT Applications, Inc.
Management of Sports Concussion and The ImPACT Program
Micky Collins, PhDUniversity of Pittsburgh Medical Center
Department of Orthopaedic SurgeryDepartment of Neurological Surgery
Program DirectorUPMC Sports Concussion ProgramCo-Founder, ImPACT Applications
Jon French, PsyDUniversity of Pittsburgh Medical Center
Department of Orthopaedic SurgeryClinical Fellow and Neuropsychologist
UPMC Sports Concussion Program
To Provide Background Information Regarding Concussion Management
To Present Data Pertaining to Outcomes and Risk Factors Associated with Sports Concussion
To Discuss Academic Needs for Recovering Student Athlete with Concussion
To Review the Utility of Computerized Neurocognitivie Testing and ImPACT as a Tool for
Effective Concussion Management To Review Clinical Case Material
Workshop Goals
Concussion 101: Biomechanics, Pathophysiology, Definition
Micky Collins, PhDAssociate Professor and Director
UPMC Sports Medicine Concussion Program
C o p y r i g h t © 2 0 1 1
Neurometabolic Cascade Following Cerebral Concussion/MTBI
2 6 12 20 30 6 24 3 6 10minutes hours days
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f nor
mal K+
Glutamate
Glucose
Cerebral Blood Flow
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UCLA Brain Injury Research Center
(Giza & Hovda, 2001)
Acute ManagementRule out more serious intracranial pathology
• CT, MRI, neurologic examination primary diagnostic tests
Post Injury ManagementPrevent against Second Impact SyndromePrevent against cumulative effects of injury
• Less biomechanical force causing extension of injuryPrevent presence of Post-Concussion Syndrome
Determination of asymptomatic status essential for reducing repetitive and chronic morbidity of injury
Concussion Management: Areas of Focus
Most Commonly Reported SymptomsAthletes with Concussion – 1-7 days following concussion
Kontos, Elbin, French Collins, Data Under Review; N = 1,438
SYMPTOM PERCENT
# 1 Headache 75%
# 2 Difficulty Concentrating 57 %# 3 Fatigue 52 %# 4 Drowsiness 51 %# 5 Dizziness 49 %# 6 Foggy 47 %# 7 Feeling Slowed Down 46 %# 8 Light Sensitivity 45 %# 9 Balance Problems 39 %
# 10 Difficulty with Memory 38 %
N=327, High School and University Athletes Within 7 Days of Concussion
EMOTIONAL • More emotional• Sadness• Nervousness• Irritability
COGNITIVE SYMPTOMS• Attention Problems• Memory dysfunction• “Fogginess”• Fatigue• Cognitive slowing
SLEEP DISTURBANCE • Difficulty falling asleep• Sleeping less than usual
PHYSICAL-MIGRAINE• Headaches • Visual Problems• Dizziness• Noise/Light Sensitivity• Nausea
Post-Concussion Symptom
Groups
(Pardini, Lovell, Collins, et al. 2004)
The Evolving Definition of ConcussionCDC Physicians Toolkit 2007
Regarding Cerebral Concussion……
A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.”
CDC Physicians Toolkit; Collins, Gioia et al 2006
Grading systems ineffective/not data based. CT and MRI insensitive to subtleties of injury. Self-report predicates management directives. Variability in clinician recommendations. Lack of education and awareness of injury. Inadequate/Improper recommendations from
ED/Trauma Departments.
Management of MTBI: Topics of Concern
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“When it comes to concussion,
don’t believe me when I tell you that I’m OK ”
NFL Athlete, 2010
In some cases (not all), athletes will minimize difficulties Athletes are naïve to the subtleties of the injury Young athletes lack insight into self-assessment of MTBI
symptomsStudies suggest that up to 50% of athletes experience
concussion symptoms per year but only 10 % report having an injury
Need for comprehensive understanding of athletes recovery status
Return to Play Following mTBI:Can we safely rely on symptoms alone?
CURRENTLY AVAILABLE PROGRAMS:
Cogsport (Axon)
Headminders (CRI)
ANAM
CNS Vital Signs
ImPACT
Computer-Based Neurocognitive Testing
Extensive research since 2001
Immediate Post-Concussion Assessmentand Cognitive TestingComputerized Neurocognitive Testing
Mark Lovell, PhD, FACPN, Dsci, Software Developer, ImPACT
Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery
Joseph Maroon, MD - UPMC Dept. of Neurological Surgery
ImPACT
Demographic / Concussion History QuestionnaireConcussion Symptom Scale 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)8 Neurocognitive Measures Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary
ScoresDetailed Clinical Report Outlines Demographic, Symptom, Neurocognitive Data Automatically Computer ScoredInternal baseline validity checks built into programDesktop and On-Line Versions Available Extensive normative data available from ages 11-60Over 100 peer-reviewed research articles/books/chapters, published since 2000 Extensive data published on reliability, validity, sensitivity/specificity of test
ImPACT: Post-Concussion Evaluation
Neurocognitive Testing: What it is and Isn’t
IS a tool to help determine recovery from injury.
IS a tool to help manage concussion (e.g. return to academics, return to exertion return to play).
IS a tool to help communicate post-concussion status to coaches, parents, clinicians.
IS NOT a substitute for medical evaluation / treatment
Concussion Evaluation Timeline
Return to Play
Baseline Testing
Concussion
First Follow-Up
Follow-up Testing
as needed
Supervised at SchoolOr clinic
Remove From Play
Evaluation
Pre-season
1-3 Days
Measuring Neurocognitive Recovery from
Sports mTBIHow Long Does it Take?
Concussion Recovery Rates Vary by Age/Dependent Measure Authors Sample
SizePopulation Tests Utilized Total Days Cognitive
ResolutionTotal Days Symptom
Resolution
Lovell et al.2005
95 Pro (NFL) Paper and Pencil NP 1 day 1 day
McCrea et al.2003
94 College SAC <1 Day 7 days
McCrea et al.2003
94 College Paper and Pencil NP
5-7 days 7 days
Echemendia2001
29 College Paper and Pencil NP
3 days 3 days
Guskiewicz et al.2003
94 College BalanceBESS
3-5 Days 7 Days
Bleiberg et al.2005
64 College ComputerNP (ANAM)
3-7 days Did Not Evaluate
Iverson et al.2006
30 High School ComputerNP (ImPACT)
10 days 7 Days
McClincy et al. 2006
104 High School ComputerNP (ImPACT)
14 days 7-10 Days
Lovell, Collins et al2008
208 High School ComputerNP (ImPACT)
26 days 17 Days
Covassin et al2011
72 High School Computer NP (ImPACT)
21 days 7 Days
Maugans et al2011
12 Ages 11-15 Computer NP (ImPACT)
30 days 14 Days
Three-year prospective study in Western PA.17 high school football teams (2,141 total sample)
134 athletes with diagnosed concussion (6.2%)All athletes referred for evaluation at UPMC
Recovery determined by “Back to Baseline” on computer neurocognitive test scores & symptom inventory
Determined by Reliable Change Index Scores-RCI’s)
Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, 2006:58;275-283
Individual Recovery From Sports MTBI: How Long Does it Take?
0102030405060708090
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 Male Football Athletes
WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5
40%RECOVERED
60%RECOVERED
80%RECOVERED
Collins et al., 2006, Neurosurgery
Lovell, Collins, Eddy, Becker, Pardini, Maroon, Field, Marion, and Boada (2001-2006) RO1 HD 42386-05
Functional MRI and Sports Concussion
Brain Metabolism is Related to Recovery Over 200 High School Athletes Studied using fMRI
Tested w/in 7 days of concussion and at point of clinical recoveryHyperactivation predicts CLINICAL recovery timeResolution of hyperactivation correlates with recovery on ImPACT
Lovell et al., Neurosurgery, 2007
Recovery: fMRI Subsample (UPMC Program)(Lovell, Pardini, Collins et al; Neurosurgery 2007)
Mean Age: 16.2 yrsGender: 78% male
N = 208Cumulative Percent Recovery
15 days 25%
26 days 50%
45 days 75%
92 Days 90%
Days to Recover
Range 4 – 211 days*
Mean 26.2 days* End of study period
Micky Collins, Ph.D.University of Pittsburgh Medical Center
Associate ProfessorDepartment of Orthopaedic SurgeryDepartment of Neurological Surgery
DirectorUPMC Sports Concussion Program
Prognosticating Concussion Outcomes:
An Evidence-Based Analysis
Helps to set up clear communication to player, coaches, and medical personnel regarding recovery expectations
May help to alleviate some pressure on RTP issue
May help to immediately provide individualized clinical management recommendations (e.g. need for academic accommodations/physical rest, etc.)
Begins to create a risk profile for sports concussion and may set stage to effectively research treatment and rehabilitation strategies.
Because it is the next stage in our scientific understanding of this injury….
Researching/Determining Prognosis for Sports Concussion: Why is it Important?
Which On-Field Symptoms Predict Protracted
Recovery(i.e. Post-Concussion Syndrome)?
Lau B, Kontos A, Lovell MR, Collins MW, AJSM: 2011
176 Male HS Football Players (Mean Age = 16.2 years)
Athletes had baseline ImPACT testing and were revaluated within 3 days of injury.
All followed until clinical recovery (Mean = 4.1 evaluations)Within RCI of baseline on ImPACT for neurocognitive/symptom scores
32% of sample required < 7 days until recovery (N =56) “Rapid Recovery” (Mean = 4.9 days)
39% of sample required 7-14 days until recovery (N = 68)
17% of sample required > 21 days until recovery (N = 31) “Protracted Recovery” (Mean = 33.2 days)
12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21)
MANOVA used to determine differences between rapid/> 3 week recovery
ATC’s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, etc)
Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011
Which On-Field Symptoms Increase Risk ofPost Concussion Syndrome in High School Football Players?
Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players
Lau, Kontos, Collins,
Lovell , AJSM 2011
On-Field Marker N Chi2 P Odds Ratio 95% Confidence Interval
Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42
Retrograde Amnesia 97 .120 0.729 1.179 0.46-3.00
Confusion 98 .114 0.736 1.164 0.48-2.82
LOC 95 2.73 0.100 0.284 0.06-1.37
On-Field Symptom N Chi2 P Odds Ratio 95% Confidence Interval
Dizziness** 98 6.97 0.008 6.422 1.39-29.7
Headache 98 0.64 0.43 2.422 0.26-22.4
Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63
Visual Problems 97 0.62 0.43 1.400 0.61-3.22
Fatigue 97 0.04 0.85 1.080 0.48-2.47
Balance Problems 98 0.28 0.59 0.800 0.35-1.83
Personality Change 8 0.86 0.35 0.630 .023-1.69
Vomiting 97 0.68 0.41 0.600 0.18-2.04
The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.
**p<.01
Brief LOC (<30 sec) not predictive of subacute or protracted outcomes following sports-concussion
Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery
On-Field dizziness best predictor of protracted recovery and “post concussion syndrome”
Etiology of dizziness?• Migraine variant?• Central Vestibular Dysfunction?• Peripheral Vestibular Dysfunction?• Cervico-genic?• Psychiatric?
On-Field Symptom Summary
Which Subacute Symptoms
Predict Protracted Recovery?
Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21
108 concussed high school football players • Athletes had baseline ImPACT testing and were revaluated within 3
days of injury (Mean = 2.2 days)• All followed until clinical recovery
- Within Reliable Change Score of baseline for neurocognitive/symptom scores
• 43.5% of sample recovered < 10 days = “Quick”- Mean = 5.9 Days
• 56.5% of sample required >10 days until recovery = “Protracted” - Mean = 29.2 Days
• MANOVA conducted on which individual symptoms and neurocognitive domains predicted “quick” versus “protracted” recovery
Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21
Post-ConcussionSymptom Scale
Current Symptoms
Headache
Nausea
Vomiting
Balance Problems
Dizziness
Fatigue
Trouble falling asleep
Sleeping more than usual
Sleeping less than usual
Drowsiness
Sensitivity to light
Sensitivity to noise
Irritability
Sadness
Nervousness
Feeling more emotional
Numbness or tingling
Feeling slowed down
Feeling mentally foggy
Difficulty concentrating
Difficulty remembering
Visual problems (blurry or double vision)
0
0.5
1
1.5
2
FOGGY DIFF CONC VOMIT DIZZYNAUSEA HEADACHE SLOWNESS BALANCELIGHT SENS NOISE SENS NUMBNESS
Expressed as Effect Sizes (Cohen’s D). Only includes symptoms with large (greater than .80) effect sizes. Sample is composed of 108 male HS football athletes.
Top 11 Symptom Predictors of Protracted Recovery
Lau, Lovell, Collins et al. 2009, CJSM
“Fogginess” Athlete Descriptions
“It is like going from a high definition TV worldto standard TV world”
“Feeling one step removed from my surroundings”
“It is like my vision is impaired, but it isn’t”
“Feeling like I am underwater”
Iverson, Lovell, Collins. JINS (2004),10, 94-906.
NEUROPSYCHIATRIC • More emotional• Sadness• Nervousness• Irritability
COGNITIVE SYMPTOMS• Attention Problems• Memory dysfunction• “Fogginess”• Fatigue• Cognitive slowing
SLEEP DISTURBANCE • Difficulty falling asleep• Sleeping less than usual
MIGRAINE (PHYSICAL SX)• Headaches • Visual Problems• Dizziness• Noise/Light Sensitivity• Nausea
Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004)
N=327, High School and University Athletes Within 7 Days of Concussion
Rank Order of Most Predictive Symptoms of Outcome
Lau, Lovell, Collins et al. CJSM, 2009
*Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.
Variables Classification Z-Score (Simple vs. Complex)
Fogginess Cognitive 4.3*Difficulty Concentrating Cognitive 2.46 Vomit Migraine 2.391* Dizziness Migraine 2.09 Nausea Migraine 1.96 Headache Migraine 1.71 Slowness Cognitive 1.53 Balance Migraine 1.53Light Sensitivity Migraine 1.52Noise Sensitivity Migraine 1.52Numbness Migraine 1.46
Trouble Sleeping Sleep 1.231*Visual Problems Migraine 0.97Difficulty Remembering Cognitive 0.93Sleeping Less Sleep .52Drowsiness Cognitive 0.5Fatigue Cognitive 0.48Emotional Neuropsychiatric 0.37*Irritability Neuropsychiatric 0.3Sadness Neuropsychiatric 0.09Nervousness Neuropsychiatric -0.03Sleeping More Cognitive -0.05
The Role of Sub-Acute Migraine-Symptoms in Determining
Outcomes Following Concussion
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; data in preparation for publication
• Post-traumatic Migraine– Headache, nausea, AND sensitivity to
light OR noise (International Headache Society Guidelines)
• Determined by utilizing PCSS at 1-7 days post-concussion
Post-traumatic Migraine (PTM) Defined
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
• 174 high school athletes with a concussion– No prior hx of LD, moderate TBI, psychiatric disorder
• Athletes followed until recovery– Neurocognitive scores returned to baseline (w/in RCI)– Symptom free and rest and exertion
• 97 athletes met Rapid or Protracted Criteria for Recovery:– Rapid (≤7 days)= 61– Protracted (≥21 days)= 36
• Recovery studied for three groups– No headache group – Headache only group– Post-traumatic migraine group (headache with nausea and/or light and noise
sensitivity) • Data Analysis
– Chi-square analysis with Odds Ratios for Recovery Time Groups – Repeated measures ANOVAs for ImPACT scores across 3 time periods
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
Study Overview
How does PTM compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97)
Variable Wald pOdds Ratio 95% CI
Headache v. No Headache
2.20 .14 2.83 0.72-11.20
PTM v. Headache 3.93 .04 2.57 1.10-6.54
PTM v. No Headache
7.60 .006 7.29 1.80-29.91
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
Comparison of Recovery for PTM, Headache, No Headache/PTM groups (χ2= 9.05, p= .009, n= 97)
N = 97 HS Athletes with concussionComparison of ImPACT Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ= .88, F= 4.24, p= .002, η2 = .06)**PTM significantly different than both groups at 1-7 and 8-14 daysPTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)
ImPACTVisual Memory Raw Score
PTM =Post Traumatic Migraine
Comparison of Reaction Time scores for PTM, Headache, and No PTM or Headache groups (λ= .87, F= 4.96, p= .001, η2= .07)*PTM significantly different than both groups at 1-7 and 8-14 daysPTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)
PTM =Post-Traumatic MigraineImPACT
Reaction Time Raw Score
Conclusion“It’s more than just a headache”:
– Athletes with migraine-type symptoms (headache with nausea and/or light-noise sensitivity) exhibit more protracted recovery than with athletes with headache only
– 81% of post-traumatic migraine group also reported dizziness (post-traumatic vestibular migraine??)
– Important to assess for quality and type of headache in athletes with concussion
Utilizing Sub-acute Neurocognitive Test
Data (ImPACT)to Determine
Prognosis
Schatz P, Pardini J, Lovell MR, Collins MW. Archives of Clinical Neuropsychology 2005:21;91-99.
Discriminate Function Analysis Statistical classification of Concussed (physician dx)/Control subjects No Clinician Input Testing completed within 3 days post injury
Positive Predictive Value (90%) (Probability that that a concussion is present when test is positive)
Negative Predictive Value (82%) (Probability that a concussion is not present when test is negative)
Sensitivity and Specificity of ImPACT in ClassifyingAthletes with Concussion
N = 138 controls/concussed athletes
Determination of Neurocognitive Cutoff
Scores that Predict Protracted Recovery
(at 2 days post injury)
Lau B, Collins MW, Lovell MRNeurosurgery 2012;Feb 70(2):371-79.
108 concussed HS and Collegiate Athletes Athletes had baseline computerized NP testing and were revaluated within 3 days of injury (Mean = 2.2 days) All followed until clinical recovery
Within Reliable Change Score of baseline for neurocognitive/symptom scores
43.5% of sample recovered < 14 days = “Quick” Mean = 5.9 Days
56.5% of sample required >14 days until recovery = “Protracted” Mean = 33.0 Days
ImPACT composite cutoff scores statistically calculated at 75%, 80%, and 85% sensitivity to predict protracted recovery (i.e. 1 month or longer for clinical recovery)
Lau B, Collins MW, Lovell MR. Neurosurgery In Press
Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery
Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (>14 days; Mean = 1 month) in an athlete.
75% Sensitivity
80% Sensitivity
85% Sensitivity
Neurocognitive Domain Cutoff Cutoff Cutoff
Verbal Memory 66.5 64.5 60.5
Visual Memory 48 46 44.5
Processing Speed 24.5 23.5 22.5
Reaction Time 0.72 0.78 0.86
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
- At three days post-injury, if athlete exhibit three or more RCI changes on ImPACT composite scores (relative to baseline), there is a 94% chance that recovery will require >10 days.
- Exhibiting a high symptom score did not improve classification accuracy over neurocognitive test scores in isolation.
- Athletes with prior history of concussion were not statistically more likely to have “protracted” recovery from concussion.
Iverson G. CJSM; 2008Predicting Quick versus Protracted Recovery fromSports mTBI
When computerized neurocognitive testing is utilized, athletes are less likely to return to play within a week compared to those in whom it was not utilized-13.6% vs 32.9%
(Meehan et al, AJSM, 2010).
Other Recent Peer Reviewed Research Examining Neurocognitive Testing
41.2% of US High Schools that employ at least 1 ATC utilized computerized neurocognitive testing during 2009-2010 academic year (25.7% in 2008-2009 year)
93% use ImPACT
100% of schools utilizing testing reported that scores were utilized in making RTP decisions
86% of these schools performed baseline testing
Athletes who underwent computerized NP tesing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, p < .01) and were more likely to be returned to play by a physician (60.9% vs 45.6%, p <.01)
Use of Computerized Neurocognitive TestingIn High School Athletes (Meehan et al, 2011)
Established (?) Constitutional Risk FactorsFor More Complicated Recovery
Age - Field, Lovell, Collins et al. J of Pediatrics, 2003- Pellman, Lovell et al. Neurosurgery, 2006
Migraine History & Symptoms
- Mihalik, Collins,Lovell et al, J Neurosurgery, 2006
Learning Disability - Collins, Lovell et al, JAMA, 1999- Kontos, Elbin, Collins, Data submitted for publication
Repetitive Concussion? - Collins, Lovell et al, Neurosurgery, 2004- Iverson et al, CJSM, 2004- Moser et al, JCEN, 2011
Gender? - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009- Covassin et al, CJSM, 2009
Summary Outcomes are highly variable Vestibular-related symptoms following injury predict
more protracted recoveries Migraine-type symptoms (and potentially preexisting
history of migraine) may place individuals at increased risk of injury and longer recovery
Neurocognitive testing is valuable in determining prognosis and recovery in sports-related mTBI
Clinical management key to preventing poor outcomesThe “mild” injuries may become severe and the
“severe” injuries may become mild
Scientific Evolution and Building Consensus: Where are we Headed?
Sports Concussion
CDC Physician Toolkit (Collins, Gioia, et al. 2007)
Post-Injury Management Removal from contest if concussion suspected-no RTP in same gameNo return to play while symptomatic or if symptomatic with exertion
Carefully monitored and graded increase in exertion over timeNeed to be mindful of cognitive exertion on role of recovery
Need for conservative management in children/adolescentsNeurocognitive testing recommended for athletes sustaining concussion
Criteria for Return to Play1. Symptom-Free at Rest2. Symptom-Free with Cognitive/Physical Exertion3. Normal Neurocognitive Data/Objective Evaluation
Recommended Sports Concussion Management
2009 NFL Guidelines for Concussion Management
- “Conservative” approach to management of concussion
- Out of play for game/practice with any LOC, amnesia, or confusion
- Out of play for game/practice if new and persistent dizziness, headache (particularly if accompanied by photo/phonophobia, dizziness, nausea, or vomiting) or any other persistent symptoms of concussion
- Follow up evaluation to be conducted by team physician as well as independent “neurological consultant ”
- Clearance for RTP required by both
- Baseline and post-injury neurocognitive testing mandated by league
- No return to play until athlete exhibits normal neurological evaluation and is… 1) asymptomatic at rest
2) asymptomatic with progressive exertion, and 3) neurocognitive test scores back to baseline (within RCI indices on ImPACT)
C o p y r i g h t © 2 0 1 1
NCAA Concussion Policy - April 29, 2010
- Institutions must have concussion plan on file
- Any athlete exhibiting signs/symptoms of concussion shall be removed from practice/game and evaluated by healthcare practitioner with training in management of concussion-no RTP until formal clearance
- Neuropsychological testing is an important component of an institutional concussion management plan.
- “Best Practices” should include a baseline/post injury assessment using, at minimum, sideline tool (e.g. symptom checklist, SAC, SCAT, BESS), and, optimally, formal computerized or paper and pencil neurocognitive testing
C o p y r i g h t © 2 0 1 1
PA State Law-Effective July 1, 2012Safety in Youth Sports Act- Education necessary- Dept of Education will post concussion educational information; Student/parents must sign form prior to participation that they have reviewed concussion fact sheet. Coaches must complete concussion management training course on yearly basis. Informational school meetings are encouraged that educate on concussion management and importance of baseline assessments that can aid in evaluation and management of injury.
- Any athlete exhibiting signs/symptoms of concussion shall be removed from practice/game and no RTP on day of injury. Medical clearance must occur from: Physician trained in concussion management OR licensed physician designee trained in concussion management, OR licensed neuropsychologist (fellowship trained) who has specific training in concussion management. Penalties occur with any infraction.