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

500

400

300

200

0

50

100

% o

f nor

mal K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

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

23

“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.