Player Safety: Concussion &
Baseline Impact Testing
David Bernhardt, M.D.
University of Wisconsin Sports Medicine
Symptoms
• Dazed appearance
• Confusion• Memory Loss• Headache• Dizziness• Balance problems
• Irritable• Personality
change• Slowed response• Poor
focus/attention• +/- LOC
What if the athlete suffers brief LOC?
• Should this athlete be DQ’d for the remainder of the game?
• Does LOC predict long term prognosis?
What if the athlete suffers brief LOC?
• 383 MTBI patients (GCS 14-15)• Confusion, agitation, retrograde amnesia,
LOC• Poorer performance for all groups on
neuropsychological tests sensitive to MTBI
• No differences between groups based on LOC, uncertain LOC and no LOC
Lovell MR, et al. Clin J Sports Med 1999
Simple Concussion
• Resolves without complication in 7-10 days
• Rest until all symptoms have resolved
• Graded return to play
Complex Concussion
• Persistent symptoms• Specific sequelae (seizures)• Prolonged LOC (> 1 minute)• Prolonged cognitive impairment• Repeated concussions with less force
• Consider neuropsychological testing• Multidisciplinary approach
Sideline evaluation
Orientation ConcentrationMonth: ___________________ 0 1 Digits backward (If correct, go to Date: _____________________ 0 1 next string length. If incorrect, read Day of week: ______________ 0 1 trial 2. Stop if both incorrect.Year: ____________________ 0 1 4-9-3 6-2-9 ______0 1Time (within 1 hour): _______ 0 1 3-8-1-4 3-2-7-9 _____0 1
6-2-9-7-1 1-5-2-8-6 ______0 1Orientation Total Score _________ / 5 7-1-8-4-6-2 5-9-1-4-8 _____0 1
Months in reverse order: (entire sequence correct for 1 pt)
DecJan 0 1
Concentration Total Score ____ / 5
Sideline evaluationImmediate Memory: (all 3 trials are complete regardless of score on trial 1 & 2; total score equals sum across all
3 trials)
List Trial 1 Trial 2 Trial 3Word 1 0 1 0 1 0 1 Exertional maneuversWord 2 0 1 0 1 0 1 CoordinationWord 3 0 1 0 1 0 1 StrengthWord 4 0 1 0 1 0 1 SensationWord 5 0 1 0 1 0 1 Recall of injuryTotalImmediate Memory Total Score _____ / 15
Delayed recall
Word 1 0 1Word 2 0 1Word 3 0 1Word 4 0 1Word 5 0 1Delayed Recall Total Score _____/5 McCrea M et al. Summary of Total Scores _____ / 30 Neurology 1997
Serial 7’s
• 522 high school athletes, PPPE• Serial 7, serial 3, months in reverse• Seven consecutive or 11 with one
mistake• 51% serial 7’s, 79% serial 3’s• 89% months in reverse
Young CC, Jacobs BA et al. Clinical Journal of Sports Medicine 1997
High school athletes often require a significantly longer period of time to become asymptomatic and for their cognitive function to return to normal than both collegiate and professional athletes
Second impact syndrome
• Not fully recovered from previous head injury when sustain a second head injury
• Loss of vascular autoregulation• Cerebral vascular congestion• Malignant brain edema, brainstem
herniation, death
POST CONCUSSIVE SYNDROME
Recurrent headaches DizzinessMemory impairment DepressionLoss of libido TinnitusAtaxia AnxietyAlcohol intolerance PhotophobiaHyperacousis Concentration
Post concussive syndrome
• Not necessarily related to severity of concussion
• Attention and learning difficulty may be subtle
• Cumulative effects of multiple concussions
Neuropsychological testing
• Nature and degree of deficit acutely
• Relationship to standard sideline evaluation
• Recovery curves