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Concussion Management on the Field & Return to Play Decisions: A New Approach. Plan. Concussion Basics A Peak at the Zurich Consensus Statement Effective System of Concussion Management Collaboration between ATC and Neuropsychologist Concussion Evaluation Role of Neuropsychological Testing - PowerPoint PPT Presentation
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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*)
Sports as a Laboratory Assessment Model (SLAM*)
Dayy 12-16
*Barth et al., 2002
ConcussionConcussion
1-3 DaysPre-Concussion Baseline Testing
Sports as a Laboratory Assessment Model (SLAM*)
Sports as a Laboratory Assessment Model (SLAM*)
*Barth et al., 2002
ConcussionConcussion
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.
Zurich CIS Consensus
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
Zurich CIS Consensus
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.
Zurich CIS Consensus
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.
Zurich CIS Consensus
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/ mTBIDefinition
CDC Heads Up: Brain Injury in Your Practice (2007)
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.
Concussion/ mTBIDefinition
CDC Heads Up: Brain Injury in Your Practice (2007)
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
w/in 7 daysw/in 7 days
CollinsCollins
Lovell, et al. Lovell, et al.
20062006
134134 High SchoolHigh School ComputerComputer
ImPACTImPACT
NRNR NRNR 40% 40% recovered recovered
w/in 7 daysw/in 7 days
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
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)
Gradual Return-To-Play ProtocolGradual Return-To-Play Protocol
1-3 Days Dayy 5-10Pre-Concussion Baseline Testing
Dayy 12-16
*Barth et al., 2002
ConcussionConcussion
Clinical ProtocolNeurocognitive TestingClinical ProtocolNeurocognitive Testing
1-3 DaysPre-Concussion Baseline Testing
*Barth et al., 2002
ConcussionConcussion
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)
Gradual Return-To-Play ProtocolGradual Return-To-Play Protocol
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)
Gradual Return-To-Play ProtocolGradual Return-To-Play Protocol
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