Oregon Concussion Awareness and Management Program: Making an Impact Michael C. Koester, MD, ATC, FAAP

6th Annual Pacific Northwest Conference on Brain Injury February 29th, 2008

Slocum Center for Orthopedics and Sports MedicineDirector, Sports Concussion Program

Eugene, Oregon

The Problem

We now realize that concussions occur more often than previously thought

Young athletes are at risk for serious short-term and long-term problems

The Problem

There is much variation in the knowledge of Health Care Providers managing concussed athletes

New and emerging technologies and research will lead to a continuing evolution of care

The Opportunity

Bill Bowers, Executive Director of the OADA, met with me last fall and expressed interest in developing a statewide concussion program similar to a program implemented in New York state last year.

I have envisioned a “dream program” for the past several years, but needed “buy-in” from the involved parties.

We have willing participants, OSAA & OADA backing, and multiple media stories trumpeting the problem--- the time is now!!!!

Extent of the Problem

Like all problems in sports- what is seen at the pro level is only a small part of the problem

Much more common in high school than any other level- due to large number of participants

Extent of the Problem

Estimated 300,000 sports-related head injuries in high school athletes yearly

9% of all sports injuries 678 head-injuries in

Oregon HS athletes in 2004-5 based on OSAA participation stats

The Goal

State-wide concussion management program involving all high schools Establish state-wide

physician network Uniform evaluation and

management protocol Consultation service for

coaches, athletes, parents, and physicians

ImPACT neuropsychologic testing available for all contact and collision sport athletes

How do we achieve our goals? What happens when

coaches and other members of the Sports Medicine Team work together to promote safety and injury prevention?

Episodes of Permanent Paralysis in Football

1976 – implementation of NCAA/High School rule changes and using coaching techniques eliminating the head as a battering ram

Episodes of Permanent Paralysis in Football

1987-1989 – gradual increase in permanent quadriplegia

Episodes of Permanent Paralysis in Football

1991 – distribution of video “Prevent Paralysis: Don’t Hit with your Head” and release of educational poster “Play Heads-Up Football”

The Plan

Three Tiers of Education

Medical Professionals Physicians Nurse

Practioners/Physician Assitants

Athletic Trainers Chiropractors Paramedics/EMT’s

Educators Athletic Directors Coaches Principals/Administrators Counselors

Community Parents/Athletes School Boards

The Plan

Identify Regional Leaders Portland- Jim Chessnutt, MD Eugene- M. Koester, MD, ATC Bend- Mark Belza, MD

Each regional leader will “oversee” programs at the “satellite” sites Phone/e-mail

consultation Office evaluation if

desired

Regional Presentations

Teams will carry out presentations throughout the state in late Spring and early Fall 2008

Portland Hillsboro Gresham Wilsonville Astoria The Dalles

Eugene Corvallis Salem Roseburg Medford

Bend Ontario La Grande John Day Hermiston Klamath Falls

Multimedia Campaign

Presentations at each site PowerPoint available to

anyone who asks Brochures Webcasts of presentations Podcasts available Local and regional

television, radio, and newspaper

Website- Link through OSAA or our own site

Neuropsychologic Testing

Immediate Post-Concussion Assessment and Cognitive Testing Computerized Neurocognitive Testing Available on-line- yearly cost of $350-450 per school on average

Used extensively in professional, collegiate, and high school athletes Vast majority of NFL and NHL teams Has received significant media attention

Athletes receive “baseline” testing prior to the start of the sports season Should be done at least every other year

What can we accomplish?

The opportunity presents itself for us to establish a program which can: Maximize the health and

safety of our athletes Minimize worry and

liability for our coaches and administrators

Provide a model for other western states to emulate

What is a Concussion?

A concussion is a mild traumatic brain injury that interferes with normal function of the brain

Evolving knowledge- “dings” and “bell ringers” are brain injuries

What happens to the brain?

A complex physiological process induced by traumatic biomechanical forces: sudden chemical changes- neurotransmitters

and glucose utilization disrupted stretching and tearing of brain cells

Structural brain imaging (CT or MRI) is almost always normal

Still many unanswered questions . . .

Increasing Exposure of the Problem High profile athletes with

severe or career ending injuries Steve Young Troy Aikman Merrill Hodge Trent Green

ESPN and Sports Illustrated frequently cover the issue-not always very well Highlights of hits Features in print and

television

Not Just a Football Problem

Injury rate per 100,000 player games in high school athletes

Football 47 Girls soccer 36 Boys soccer 22 Girls basketball 21 Boys basketball 7

JAT

Potential Complications

15% of all head-injured athletes suffer long-term complications

Increased risk for future and more serious concussions

Learning Disorders unmasked

Second Impact Syndrome?

Concussion and “same-day” RTP Long held that RTP

after 15 minutes if “symptom free” is acceptable standard (Grade 1 concussion)

43 HS athletes with Grade 1 concussion 32 with symptoms at 36

hours 36 with abnormal

ImPACT at 36 hours AJSM, 2004

Risk for further concussion

Everyone asks…. Prospective cohort of

2905 FB players at 25 colleges

184 with concussion, 12 with repeat in same season

Hx of 3 or more concussions: 3X more likely to have concussion

Risk for further concussion

These had slower recovery: 30% with hx had

symptoms > 1 week 14.6% without hx had

symptoms > 1 week

11/12 of the repeat concussions occurred within 10 days of first

JAMA, 2003

Neuropsychological Testing

ImPACT, Cogsport, Headminder

Traditional “pen and paper” battery

Great deal of controversy due to aggressive marketing and no “gold standard”

Neuropsychological Testing

Assesses 6 domains of brain function: Attention span      Working memory      Sustained and selective attention

time Response variability      Non-verbal Problem Solving      Reaction time

Not a perfect tool and not to be used in the absence of an experienced and knowledgeable physician.

Neuropsychological Testing

Computerized tests Can be administered to a group or at home Can be repeated multiple times

Ideally, baseline testing is done before the season starts Test is repeated after concussion and results are

compared to baseline Can compare to “population norms” if no baseline

ImPACT for Sports

Concussion Management

Concussion

The Diagnostic and Return to Play Dilemma

What ImPACT Is and Isn’t:

IS a useful concussion screening and management program

IS validated with multiple published studies

IS NOT a substitute for medical evaluation and treatment

IS NOT a substitute for comprehensive neuropsychological testing when needed

Demographics

Concussion History Questionnaire

Concussion Symptom Scale

Neurocognitive Measures Memory, Working Memory, Attention, Reaction Time, Mental Speed

Detailed Clinical Report Automatically Computer Scored

ImPACT: Post-Concussion Evaluation

24-72 Hours

Day 5-

10

Concussion

Beyond if necessary

Baseline

Testing Not

necessary for decision making

Clinical Protocol: Neurocognitive Testing

Unique Contribution of Neurocognitive Testing to Concussion Management

VerbalMemory

VisualMemory

50556065707580

859095100

Symptomatic Asymptomatic Control

N=215(Lovell et al., 2004)

Testing revealscognitive deficitsin asymptomaticathletes within 4 days post-concussion

ImPACT ‘Bell-Ringer’ StudyBrief versus Prolonged On-field Mental Status Changes

60

65

70

75

80

85

90

Baseline 36 Hours DAY 4 DAY 7

5-15 min < 5 min

ImPACT Memory-Percent Correct

N = 64High

SchoolAthletes

P<.02 P<.004

P<.04

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004

Recovery From Concussion:How Long Does it Take on ImPACT?

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

Neuropsych testing and RTP decisions Do I have to use this?

Not yet standard of care

Recommended to be used by current guidelines-Prague, 2004

Provides extra data Think of it like any lab test,

MRI, etc

ImPACT and RTP decisions

How well does ImPACT identify concussed athletes?

Sensitivity Identified 80% within 24

hours 68% identified by self-

report of symptoms J Neurosurg, 2007

ImPACT and RTP decisions

“Value-added” effect in 122 concussed HS and college athletes 83% abnormal ImPACT 64% with symptoms 93% with combo of both No one in control group

had abnormal ImPACT and symptoms

AJSM, 2006

ImPACT and RTP decisions

When to use ImPACT?

Recommended to be used 24-72 hours post-injury, 5-10 days post injury and beyond if needed.

No need to test if athlete is still symptomatic May need to use to show

coaches, parents, etc- BE CAREFULL!!

Prague Guidelines, 2004

What’s a Grade 1 concussion?

Notion of grading systems has been abandoned Over 20 classifications Can only be applied

retrospectively Simple versus Complex

Complex-persistent symptoms, specific sequelae, prolonged LOC, multiple concussions

Graded Return to Activity

Prague Guidelines, 2004

Simple concussion LOC < 1 minute resolves in 7-10 days first concussion

Complex concussion LOC > 1 minute symptoms last longer than 7 – 10 days history of multiple concussions increasing “concussability”

No athlete returns in

the current game or practice

(same day)

Return to Activity Protocol

7 Steps to a Safe Return

Step 1. Complete cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.

Step 2. Return to school full-time.

Return to Activity Protocol

7 Steps to a Safe Return (cont)

Step 3. Light exercise. This step cannot begin until you are cleared by your physician for further activity.

Step 4. Running in the gym or on the field. No helmet or other equipment.

Step 5. Non-contact training drills in full equipment. Weight-training can begin.

Return to Activity Protocol

7 Steps to a Safe Return (cont)

Step 6. Full contact practice or training.

Step 7. Game play. Must be cleared by your physician before returning to play.

Cannot advance to next level if symptomatic

Progression usually takes about 1 week

Return to Activity

Recommend written and standardized Return to Activity Plan for all concussed athletes

Sets standard and is understood by all coaches, parents and athletes

Cannot advance to next level if symptomatic

Education

No such thing as “just a concussion” Coaches, athletes, AD’s, and parents must

be educated on signs and symptoms, as well as need for proper management

CDC Tool Kit on Concussion for High School Coaches http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm

Prevention “Concussion prevention” has become the “holy grail” for

sports equipment marketers “Special” helmets, soccer head pads, mouth guards- NO

PROVEN PROTECTION FROM CONCUSSION!! Multiple flaws in recent study looking at “newer helmet

technology.” Neurosurgery, 2006

Conclusions

Concussion management continues to evolve. Health care providers must be knowledgeable of the most up to date management recommendations.

Neuropsychological testing plays an important role in concussion management- but cannot stand alone.

Schools should have evaluation and RTP policies and procedures in place to ensure excellent and consistent care.

THANK YOU!!!!!!

Thad Stanford, MD, JD- Salem Bill Bowers- Executive Director, OADA Tom Welter- Executive Director, OSAA Mark Belza, MD- Bend Mickey Collins, PhD- Pittsburgh Ron Savage, EdD- New Jersey Brian Rieger, PhD- New York Ann Glang, PhD- Eugene