ASSESSING THE FIELD OF CONCUSSION IMPACTSconference.ohioschoolboards.org/2015/wp-content/... · Avoid spinning carnival rides. ! Avoid alcohol/drugs ! “Return to Learn” These

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ASSESSING THE FIELD OF CONCUSSION IMPACTS

Joseph A. Congeni, MD Medical Director Sports Medicine Akron Children’s Hospital

More questions than answers? CONCUSSION

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DEFINITION

WHAT IS A CONCUSSION?

!  Functional brain injury – MRI/CT Normal - NOT structural

!  Metabolic Brain Injury – slowdown of cerebral blood flow chemical “energy crisis” in the brain

!  Study of axonal injury

!  The brain is a non-renewable resource (Hovda-UCLA)

!  86 billion neurons in the human brain

When does this injury become irreversible/cumulative?

! Closed head injury with structural defect (brain bleed or brain swelling)

! Epidural

! Subdural

! Parenchymal

! MRI/CT Scan usually normal

WHAT IS NOT A CONCUSSION?

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! Linear acceleration ! Angular/Rotational

acceleration ! Measured by G-Forces

(accelerometer/gyroscope)

MECHANISM OF INJURY

Indirect/Rotational

“a forceful blow to the body that results in rapid

movement of the head.”

Rapid acceleration / deceleration = WHIPLASH

or “SNAP-BACK”

or “JOLT” to the brain

MECHANISM OF INJURY

!  CDC estimate 3.8 million concussion per year in US sports

!  1997-2007: (Peds 2010) !  ER visits for sports concussion doubled (8-13 yrs)

!  Increased by greater than 200% (14-19 yrs)

!  Recurrence Risk !  4-5x increase for 2nd injury

!  85-90% full clinical recovery in 1st two weeks

Incidence WHO IS AT RISK

What is the cause of the 15%?

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DIAGNOSIS

What is the Clinical Presentation DIAGNOSIS

! “Silent Epidemic” ! “Invisible Injury” ! “Subtle but Serious” ! “Energy crisis in

the brain”

CHALLENGES SYMPTOM EVALUATION

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Traumatic Brain Injury is an Evolving Process NOT a Static Injury

“If you’ve seen one concussion you’ve seen one concussion” (Herring, Seattle)

CHALLENGES SYMPTOM EVALUATION

! Back of Head ! LOC (RAS)

! Visual (Visual Center)

! Balance (Cerebellum)

!  Temporal ! Memory Center

!  Frontal ! Repetitive Actions

! Emotionality

LOCATION WHERE IS THE INJURY IN THE BRAIN?

!  McCrea, et al (Duke 2001) !  SAC Exam !  Months of the year in reverse (90%) !  Serial 7’s (51%)

Young et al, Clin J Sport Med. 1997 Jul;7(3):196-8

!  SAC replaced by SCAT Sports Concussion Assessment Tool

!  Added balance testing

THE SIDELINE? HOW DO WE ASSESS ON

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> 12 years old

5-12 years old

(Silent Epidemic)

! What was a concussion?

! 461 athletes(pre-season survey 1995 - 2000)

! only 19% reported concussion

! 80% of concussions missed initially U of A (CJSM) Kaut, DePompei, Kerr, Congeni, 2003

! 60% of Athletes concussion unreported (UNC 2012)

UNIVERSITY OF AKRON STUDY PROBLEMS WITH INITIAL DIAGNOSIS

What is the risk of sub-concussive blows to the brain?

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! BrainScope

! X2 Impact Mouthpiece

SIDELINE TOOLS WHAT’S NEW/DIAGNOSIS

Is there an objective test to help us diagnose?

! Riddell (InSite)

! Reebok (Checklight)

! Shockbox

! Riddel Revolution (HITS)

SENSORS WHAT’S NEW/DIAGNOSIS

!  Double vision/blurred vision/ pupils unequal

!  Change in consciousness/ unarousable

!  Numbness, weakness, unequal/asymmetry one extremity or part of body

!  Change in breathing pattern

!  Seizures

!  Make sure athlete is not left alone for 1st 24 hrs.

FIRST 24 HOURS EMERGENT EVALUATION

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! The way the person feels !  Headache or fatigue

! How they think !  Memory or concentration

! Change in emotions !  Irritable or sad

! How they sleep !  Trouble falling asleep

! “Monday Morning Concussion”

“MONDAY MORNING CONCUSSION”

OFFICE EVALUATION

! Three legged stool

! > 30% of concussion patients with normal symptom scale had cognitive deficit

Not all patients need a full evaluation (RTP/ prolonged recovery)

HOW DO WE ASSESS IN THE OFFICE?

! Can we do a “QUICKIE” exam?

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(helpful, but has limitations) SYMPTOM SCALE

! Head injury and postural stability

! Model postural control (steadiness)

! Firm and foam evaluation

BALANCE ASSESSMENT

All tests are performed for 20 second trials with the score equaling the number of errors that occurred; therefore, the higher the score the worse the performance.

Number of Errors Eyes Open Eyes

Closed

1. Double leg stance on hard surface _________ _________ 2. Single leg stance on hard surface _________ _________ 3. Tandem stance on hard surface _________ _________ 4. Double leg stance on foam _________ _________ 5. Single leg stance on foam _________ _________

6. Tandem stance on foam _________ _________ Guskiewicz, 2001, CJSM

BESS (Balance Error Scoring System) BALANCE ASSESSMENT (Cont’d)

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! Manual testing (PSU/UA 1992-93)

! Computerized testing (2002)

!  ImPACT/Axon/ Headminder

COGNITIVE TESTING NEUROPSYCHOLOGICAL/

1.  Visual Memory 2.  Verbal Memory 3.  Problem Solving 4.  Reaction Time

ImPACT

! #1. Cognitive/Fatigue

! #2. Cervical

! #3. Vestibular

! #4. Occulomotor

! #5. Post-Traumatic Migrane

! #6. Mood Disorders

!  Treatment ! Mental Rest/Meds/Aerobic /

Neuropsychologist

! Rehab/Strengthening

! Vestibular Rehab/Aerobic

! Eye evaluation by specialist

! Meds/Neuro

! Neuropsychology/Meds

Sports Traumatol. 2014 Michael W. Collins

CONCUSSION: SUB-TYPES

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EXERTIONAL TESTING

! Bike, treadmill, step test

! Can be done in the physician’s office or at school under the direction of the Athletic Trainer. (30% failure rate)

! Asymptomatic at rest

! Asymptomatic with exertion

! Normal neurocognitive test

! Normal subjective scale (<7)

! Normal neurological and cervical exams, awell normal balance testing.

(100%?) WHEN TO RETURN TO PLAY?

! Buffalo Concussion Treadmill Test (BCTT)

!  Trazer (simulate playing conditions)

!  Sway Balance (objectify balance)

! C3 App Heart Rate/Movement

Speed/Reaction Time/Balance

VIRTUAL REALITY/BALANCE ASSESSMENT WHAT’S NEW/RETURN TO PLAY

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Diffusion Tensor Imaging (DTI)

IMAGING WHAT’S NEW/RETURN TO PLAY

WHEN TO RETIRE

CONSIDER:

! Increased length of symptoms

! Decreased trauma includes concussions

! Decreased time between concussions

PROGNOSIS

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N=134 High School athletes

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

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

HOW LONG DOES IT TAKE? RECOVERY FROM CONCUSSION:

!  Age

!  Field, Lovell, Collins et al. J of Pediatrics 2003

!  (Pellman, Lovell et al. Neurosurgery 2006

!  Guskiewicz. 2011 Pm R

!  Previous concussion

!  Collins, Lovell et al, Neurosurgery 2004

!  Iverson, Lovell, Collins, Brit J Sport Med, 2006

!  Hollis. 2009 Am J of SM

!  Migraine History !  Lipton. JAMA 2004

!  Genetics !  APOE e4: Tierney. Clin J Sport Med 2010

!  Gender Differences !  Females have higher rate of concussion

1:7:1 !  Females more prone to post-concussion

symptoms !  Neck strength differences? !  Lovell. Clin Sports Med 28 (2009) 95-11

!  Mood Disorders !  Kontos. Arch Phys Med Rehab 2012

Is depression, anxiety, irritability pre, post, or part of the biochemical brain injury?

RECOVERY FOLLOWING SPORTS RISK FACTORS FOR PROLONGED

CONCUSSION

INITIAL MANAGEMENT

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Physical Rest &

Mental Rest

MANAGEMENT CAN WE TREAT CONCUSSION?

! Students held from school ! Full day/partial day/rest periods

! Driving may be restricted

! Workload/homework reduced

! Tests restricted/postponed (esp SAT, PSAT, finals)

(BRAIN REST) SCHOOL AND ACTIVITY MODIFICATIONS

ACUTE TREATMENT MENTAL REST

! Avoid loud activities (parties, dances, concerts, sports events) or (I-pods, headphones)

! Avoid bright sunlight (sunglasses, shade) and computer games

! Avoid spinning carnival rides. ! Avoid alcohol/drugs ! “Return to Learn”

These modifications seem to hasten recovery ! Moser RS, et al., J Pediatrics 2012

How long?

MENTAL REST (BRAIN REST) (cont’d) ACUTE TREATMENT

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PHYSICAL REST UNTIL ASYMPTOMATIC Stage I Light aerobic training (no resistance)

Stage II Sport specific training (can start resistance)

Stage III Non-contact training drills

Stage IV Full contact after physician clearance

Stage V Competition

McCrory et al, Clin J of Sp Med (2005)

PHYSICAL REST – RETURN TO PLAY ACUTE TREATMENT

PREVENTION

#1. Education

! Parents, Coaches, Teachers, Officials

! Physicians, Athletic Trainers, Emergency Medical, Physical Therapists

! Early Recognition/Management

! Appropriate Sports Specific Strengthening (Core & Shoulder Girdle/Neck)

CAN WE PREVENT HEAD INJURIES?

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#2. Prevention/Pretest (Baseline)

!  Ideal time is at the PPE


#3. Prevention/Rules Changes

! Rules Changes

! More strict helmet to helmet rules (2010-2013)

! New kickoff rules (2012)

! Targeting with crown of helmet (2013)

! Strike Zone (2013)

! Penalty box?


!  “BRAINSAVERS”

!  Be aware of subtle changes in behavior

!  HELP CHANGE CULTURE

!  Can’t tough out head injuries

!  Difference between pain & injury

!  No dings, bell ringers, seeing stars

!  NO BLINDSIDE HIT DRILLS

!  Learn to take and deliver a blow

!  “Heads Up” tackling technique (AAP)

!  NEW GUIDELINES – Pop Warner rules 2012 (limit number of contact practices)

!  Can we change the “Culture of Tough” when it comes to head injuries?

COACHES / PARENT’S ROLE PREVENTION – YOUTH CHANGES

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! Prevent rough play especially with goalie

! Avoid backwards “head flick”

! Avoid heading with arms above head

! Padded goal post

! Head gear?

PREVENTION - SOCCER

! Eliminate blind sided hits

! No body checking until age 13 (Bantam level)

PREVENTION – HOCKEY/LACROSSE

!  Fastest growing HS sport

1.  Girls Basketball

2.  Girls Soccer

!  Top 5 sports

1.  Football

2.  Ice Hockey

3.  Soccer

4.  Lacrosse

5.  Wrestling

!  66% of catastrophic head injuries occur in cheerleading (J Peds 2013)

“FOOTBALL” PROBLEM? IS CONCUSSION ONLY A

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#4. Prevention/Research

!  Special attention to youth sports, rather than just extrapolating high school/college/professional


#5. Prevention-Legislation

! Washington State – Return to play law

!  Zachery Lystedt’s Law (2009)

1.  No return to contact sport following concussion without medical clearance

2.  5 stage gradual return after clearance

3.  Mandatory education for coaches/players

! All States with concussion legislation - 2014


#6. Prevention/ Technology/ Equipment ! The Helmet that can Save Football (Popular Science Jan. 2013)

! Stockholm, Sweden – MIPS Helmet (Multi-directional Impact Protection System)

! Technology to help with diagnosis/return to play

! Fall 2014 – Riddell SpeedFlex


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COMPLICATIONS

!  Learning disability/cognitive deterioration (Neurosurg 2005)

!  Concentration issues

!  Short term meds – ADHD

! (Arch Phys Med Rehabil. 2003)

!  Depression

!  Psychotherapy, antidepressants

!  3 time increase (Medicine Science and Sports Exchange 2007)

!  Chronic headache – (Pain Med. 2008)

!  Permanent brain damage (ESPN – Outside The Lines 2007)

!  (CTE / Lou Gehrig’s ALS, 2ND Impact Syndrome)

LONG TERM COMPLICATIONS

Reported Rates US Men Age 30-49

US Men Age 50+

NFL Retirees Age 40-49

NFL Retirees Age 50+

Dementia, Alzheimer's (%)

0.1

1.2

1.9

6.1

408% increase in NFL Retirees age 50+ $760 million settlement – summer 2013

“NFL Study” – Rates of Dementia UNIVERSITY OF MICHIGAN STUDY 2009

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!  Boston University School of Medicine,

Center for the Study of Traumatic Encephalopathy

! 79 deceased athletes studied

! 90% had Chronic Traumatic Encephalopathy

! >400 athletes have pledged their brains (Oct 2014)

Dr. Ann McKee

Ryan Freel

“BRAIN COLLECTORS”

SUMMARY

! Must have LOC to be a concussion (10-20%) ! Normal MRI/CT – R/O concussion (R/O bleed)

! Concussion are all brief, transient, no complications (see complications….)

! No treatment (physical and mental rest)

MYTHS

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Over-Reacting/Hysteria? Knee-Jerk Reaction

!  Compare with MVA/ a.) “one and done” (single

Teenage Drinking concussion-out for sports season

b.) eliminate youth football (flag)

c.) eliminate all American Football

!  Prevention

Prevent occurrence Improve Timely Neuro/Cognitive

Rehab Recognition Significant Brain Injury

(Initial Management)

BOTTOM LINE DISCUSSIONS

REFERENCES

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BASELINE EVALUATION & CONCUSSION REHAB

Pete Laikos President Performance Evaluation Group, LLC

! REASON 1. In the event of a concussion, your physician & other medical professionals will have a clearer before & after snapshot of your child or athlete which can help them objectively determine when to return them safely back to play.

3 REASONS WHY YOUR CHILD NEEDS A ‘MOVEMENT BASED’ BASELINE EVALUATION

! REASON 2. In the event of a sports related injury, your physician & other medical professionals will have a clearer before & after snapshot of your child or athlete which can help them identify any deficiencies in their movement caused by the injury. This in turn, can help the medical professional more clearly assess the type of therapy to perform or administer, which can help your child or athlete return to play safer & sooner.


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! REASON 3. In the event your athlete does not sustain a concussion or sports injury, they will have a clearer indication of their athletic abilities or deficiencies from month to month or year to year. These objective measurements will provide valuable information about their athletic performance areas needing improvement, as well as their athletic performance progress being made.


THE EVALUATION PROVIDES:

! A baseline objective measurement

! Comparative when a concussion occurs

! Physicians with meaningful information when determining if an athlete is ready to return to play.

! Parents “peace of mind”

ADVANCED TECHNOLOGY FOR CONCUSSIONS EVALUATIONS

WHY USE AN EVALUATION?:

! Simulates game like activity

! Elevates athlete’s heart rate to allow for more accurate evaluation of concussion symptoms

! Objectively measures athlete’s reaction

! Objectively measures & challenges athlete’s vision and balance

ADVANCED TECHNOLOGY FOR CONCUSSIONS EVALUATIONS

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HEALTH RISK ASSESSMENT PATIENT MONITORING

HEALTH RISK ASSESSMENT BESS OVERVIEW

HEALTH RISK ASSESSMENT

! The Objective BESS test measurement takes human guess work out of the equation

! The user receives an objective and accurate balance and error score

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! Compare an athletes pre-concussion baseline score to post concussion scores using the BESS protocol.

! Measure balance and stability during the resting heat rate phase and after the heart rate has been elevated and endured aerobic and anaerobic stresses


! Measurements of reaction time, speed, acceleration deceleration, max heart rate, average heart rate and distance traveled

!  These measurements are designed to mimic situations found in any athletic contest

HEALTH RISK ASSESSMENT BALANCE

!  Jumping, running, shuffling, elevational changes, jogging and backpedaling will athletically challenge any athlete and help to assess global capacities

!  The evaluation will assist in the prowess of determining if an athlete is ‘fit to play’

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HEALTH RISK ASSESSMENT BALANCE !  Step 1: Immediately Post

Concussion Objective BESS Test

!  Step 2: Cognitive and Physical Rest

!  Step 3: Light Aerobic Exercise Objective BESS Test Pre and Post Exertion

!  Step 4: Moderate Aerobic Exercise Objective BESS Test Pre and Post Exertion

EVALUATION OF FIT-TO-PLAY (CONCUSSION REHABILITATION PROGRAM)

!  Objective measurements

!  Balance/vestibular assessment pre and post exertion

!  SCAT score stored in one place

!  BORG score stored in one place

!  Can be used parallel to neurocognitive testing program of choice

!  Exertional aerobic and anaerobic thresholds met

!  Continual marketing and software support

!  HIPPA-compliant summary report

!  Heart rate constantly monitored and reported

!  Reaction time, speed, acceleration, distance traveled measurements taken in at same time while preforming sport specific movements

!  Elevational changes to challenge vestibular systems

!  Phases follow Zurich Protocol recommendations

CONCUSSION PROTOCOL ON AND OFF THE FIELD

Alli King, MEd, ATC Athletic Trainer Princeton City Schools

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Any student, while practicing for or competing in an interscholastic contest, who exhibits signs, symptoms or behaviors consistent with having sustained a concussion or head injury (such as loss of consciousness, headache, dizziness, confusion or balance problems) shall be immediately removed from the practice or contest by either of the following:

OHSAA CONCUSSION POLICY

1)  The individual who is serving as the student’s coach during that practice or competition.

2)  An individual who is serving as a contest official or referee during that practice or competition.

OHSAA CONCUSSION POLICY

If a student is removed from practice or competition due to a suspected concussion or head injury, the coach or referee who removes the student shall not permit the student, ON THE SAME DAY THE STUDENT IS REMOVED, to return to that practice or competition or to participate in any other practice or competition for which the coach or contest official is responsible.

RETURN TO PLAY

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RETURN TO PLAY

Thereafter, which means no earlier than the next day, the coach or contest officials shall not permit the student to return to practice or competition until both of the following conditions are satisfied:

RETURN TO PLAY 1) The student’s condition is assessed by either of the following: a. A physician, who is a person authorized under Chapter 4731 of the Ohio Revised Code (OCR) to practice medicine and surgery or osteopathic medicine or surgery (M.D. or D.O.) b. Any other licensed health care provider that the school district board of education or other governing authority of a chartered or non-chartered nonpublic school, authorizes to assess the student who has been removed from practice or competition.

RETURN TO PLAY

2) The student receives written authorization that it is safe for the student to return to practice or competition from a physician or other licensed health care provider authorized to grant the clearance.

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PRINCETON HIGH SCHOOL CONCUSSION PROTOCOL

ON-FIELD MANAGEMENT

If an athlete incurs a head injury during play, and a concussion is suspected by the coach/ATC/MD/referee on the sideline, the athlete will be removed from play immediately and for the remainder of the session.


ON-FIELD MANAGEMENT

If play is suspended and the ATC/MD are called onto the field of play; The medical staff will evaluate to rule out spinal injury and level of consciousness


ON-FIELD MANAGEMENT – LEVEL OF CONSCIOUSNESS

1. If the athlete is unconscious, ATC/MD will activate EMS system; stabilize the athlete’s injury; monitor athlete; maintain the head position for moving/transporting the athlete.

2. If the athlete is conscious, ATC/MD will continue with on-field spinal injury/concussion assessment

3. If it is determined necessary by the ATC/MD based on on-field assessment, conscious athlete may be transported by EMS for evaluation at the hospital.

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If the athlete is able to be removed from the field of play; athlete will be assisted from the field of play by ATC/MD, medical staff and evaluated in further detail on the sideline.

The following functions/ systems will be assessed;

!  Visual signs of distress

!  Reported symptoms

!  Subjective discussion of events (pre/post injury memory)

!  Visual/Auditory Acuity

!  Pupils Equal/Reactive

!  Dermatomes/Myotomes

!  Short/Long term memory

!  SCAT 3 Assessment Test


OFF-FIELD MANAGEMENT

1. Athlete’s parents/guardians notified

2. Take Home Instruction Sheet

3. Daily Symptom Scale Sheet given to Athlete until clearance

4. Athlete must by symptom free and cleared by physician in order to start return to play protocol


OFF-FIELD MANAGEMENT

!  PHS Return to Play Protocol

1.  Light aerobic exercise

2.  Moderate aerobic exercise

3.  Non-contact activities (ie, drills, conditioning)

4.  Full-contact activities

5.  Game participation

Note: Athlete must remain symptom free throughout steps, if symptoms arise, athlete will remain on

current and must remain symptom free for 24 hours before repeating the current step.

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IMPACT TESTING PHS utilizes Impact Testing for Pre and Post Concussion Testing

1. Baseline testing done on all contact athletes for first year they participate in that sport (ie. Football, Soccer, Wrestling, Basketball)

2. Post Concussion Testing done 48 hours post concussion

3. Impact Testing is a tool used for ‘Return to Play’

ASSESSING THE FIELD SURFACE

Craig A. Honkomp, PE, PS, LEED AP Group Leader Sportworks Field Design

!  The field surface is a contributing factor in many concussion injuries !  Surface collisions:

!  10% of football injuries

!  16% of soccer injuries

!  Concussions caused by surface impact !  22% in NCAA study on artificial

surface

!  10% in NFL study

FIELD SURFACE

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! ASTM F355 “A” missile:

! 1960’s and 70’s Ford and GM test data

! Accelerometer in middle linebacker’s helmet; impact threshold of 40 ft/lb

! Replicated with a 20 lb missile with impact surface of 20 in² dropped from 2’

Test Methods for Impact Attenuation

! ASTM F1292 Hemispherical Headform

! Playgrounds

! 4.5 KG = mass of adult head at C3 vertebrae (3rd from base of skull)


! ASTM Clegg Hammer

! 5-lb flat surfaced hammer designed to measure hardness in road surfaces

! Adopted into the golf course industry and natural grass surfaces


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! ASTM F1936 = 200 g’s

! Based on studies from 1980’s by the CPSC for playground equipment when concussions were correlated to skull fractures, loss of consciousness, and rupture of blood vessels

! Today 90% of concussions occur without loss of consciousness

! Synthetic Turf Council = 165 g’s

Industry Standard Values

! Natural grass

! 90 to 110 g’s

Industry Standard Values

! Turf infill material

! Synthetic turf fibers tufted into a backing material

! Shock attenuation underlayment pad

! Base & drainage gravel

Synthetic Turf Construction

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!  Shock attenuation underlayment pad

!  Turf infill material

! Depth

! Maintenance

What Provides Impact Attenuation?

Infill Material

Turf Fibers

! Pad Characteristics

!  Infill Characteristics


!  Warranty

! How long will the pad manufacturer warranty the resilience of the pad?


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!  Soft and bouncy !  Leg fatigue !  Firm under foot !  Shock absorbing !  Speed of play

Performance Trade-Offs

Thank You

! Questions?

Documents

ASSESSING THE FIELD OF CONCUSSION IMPACTSconference.ohioschoolboards.org/2015/wp-content/... · Avoid spinning carnival rides. ! Avoid alcohol/drugs ! “Return to Learn” These