Developing a
Concussion
Management
Program
Bill Borowski
MBA;ATC;LAT;LPTA
411 N Washington Suite 4000
Dallas TX 75246
billbor@baylorhealth.edu
CONCUSSION
• Concussion (cerbrum commotum)
“shaking of the brain”
Acute metabolic dysfunction due to posttraumatic hyperglycolysis and decreased
cerebral blood flow.
MTBI –Mild Traumatic Brain Injury
Confusion and amnesia are the hallmarks of concussion (recovery)
IMPORTANT DOCUMENTS
1. “Summary and Agreement Statement of the 2nd
International Conference on Concussion in Sport,
Prague 2004 (Prague Statement)
2. National Athletic Trainers’ Association Position
Statement of Sport-Related Concussion (NATA
Statement)
• 3. http://www.nocsae.org/about/history.html
• 4. CDC’s Toolkit (free)
www.cdc.gov/ConcussionInYouthSports
ASESSMENT AND EVALUATION
Objectives
Clinical History
Sideline-Assessment Strategies
Balance Testing
Neuroimaging Techniques
Neuropsychological testing
Return to Play decisions
CLINICAL HISTORY
• Concussion assessment about history of
previous head injuries
With Multiple Concussed Athletes,
Ask did the subsequent concussions:
Occur with lighter impacts?
Occur close in time to previous injury?
Require lengthier recovery time?
Have less complete recovery with each subsequent
concussion?
RECOGNITION OF A CONCUSSION
PHYSICAL
COGNITIVE
EMOTIONAL
SLEEP
•Headache
• Nausea
• Vomiting
• Balance Problems
• Dizziness
• Visual Problems
• Fatigue
• Sensitivity to light
• Sensitivity to noise
• Numbness/Tingling
• Dazed or Stunned
•Feeling mentally
"foggy"
• Feeling slowed
down
• Difficulty
concentrating
• Difficulty
remembering
• Forgetful of recent
information or
conversations
• Confused about
recent events
• Answers questions
slowly
• Repeats questions
•Irritability
• Sadness
• More emotional
• Nervousness
•Drowsiness
• Sleeping less than usual
• Sleeping more than
usual
• Trouble falling asleep
Cognitive Impairment (altered or decreased cognitive function)
SIDELINE ASSESSMENT
Orientation, anterograde and
retrograde amnesia, concentration,
memory
Maddocks’ Questions
SIDELINE ASSESSMENT
Standardized Assessment of Concussion (SAC) (Quantitative)
Brief standard neurological screening measure of:
Orientation
Concentration
Immediate Memory
Delayed Recall
Also assesses strength, coordination, sensation, and the presence of amnesia
r. Michael McCea and colleagues (1998)
AAN/1991 Colorado Guidelines
SIDELINE ASSESSMENT OF CONCUSSION (SAC)
SIDELINE ASSESSMENT
McGill Abbreviated Concussion Evaluation (ACE)
Immediate memory
Concentration
Delayed Memory Tasks
Orientation
Amnesia
Concussion Symptoms
**See Handout
McGill Sport medicine Clinic-Montreal, Quebec Canada
BALANCE/VESTIBULAR
Balance Testing
Romberg Test of postural stability
Balance Error Scoring System
*A postural stability study revealed that concussed athletes showed significant decrements
in measures of composite balance and the vestibular ratio from a sensory organization test
*McCrea et al. [21] found balance scores to be significantly lower in concussed subjects
when compared with controls as well.
MANAGEMENT AND REFERAL
Transport immediately to ED if:
LOC-Spineboard
Condition is changing/deteriorating (athlete unstable)
Deterioration of neurological function or consciousness
Decrease or irregularity in respirations or pulse
Unequal, dilated, or unreactive pupils
Signs or symptoms of associated injuries, spine or skull fracture, or bleeding
Mental status changes: lethargy, difficulty maintaining arousal, confusion or agitation
Seizures or cranial nerve deficits
RECOMMENDATIONS
Number Recommendation
#1
No return play after sustaining a concussion
#2
Stop activities that cause symptoms to increase
#3
School activities may need to be modified
#4
Neurocognitive testing is an important component of concussion
management
#5
No RTP until they symptom free, both at rest and with exercise and have
normal neurocognitive testing.
#6
All sports and health education programs should teach students the specific
signs and symptoms of concussions
Dr. Lee is a pediatrician with Pediatric Healthcare Associates in Southport, Connecticut specializing in adolescent and sports
medicine. He is a charter member of AMSSM and Medical Director of the Student Health Center at Fairfield University
LATER SIGNS OF CONCUSSION:
Post-Concussion Syndrome
• Decreased Processing Speed
• Short-Term Memory Impairment
• Concentration Deficit
• Irritability/Depression
• Fatigue/Sleep Disturbance
• General Feeling of “Fogginess”
• Academic Difficulties
Neuroimaging Techniques
STRUCTURAL:
CT Scans, MRI
•
Good for ruling out brain bleeds or emergency situations (e.g.-scull fractures
etc). Usually normal with most concussions
FUNCTIONAL: (Metabolic)
Position Emission Tomography (PET) –glucose utilization
Single Proton Emission Computed Tomography (SPECT) – Blood flow to brain
• Measures brain activity (fMRI)-oxygen utilization
• Functional testing not used widely due to expense, lack of availability, and
research status of some tests.
***Functional Testing : Will likely be the way of the future for
concussion assessment
Neuropsychological Testing
• Neurocognitive Tests –Indirect measures of brain
functioning via paper and pencil, Q&A or computerbased tests.
SPORT CONCUSSION:
Attention Span
Sustained and Selective
Attention Span
Reaction Time
Concentration
Response variability
Working Memory
Learning Quickness
Non-verbal problem-solving
Memory
Return to Play
Rehabilitation Stage
Functional exercise
Objective of stage
1. No activity
Complete cognitive (e.g. mental) rest
Recovery
2. Light aerobic exercise
Walking, swimming or stationary bicycle keeping intensity
less than 70% of maximum predicted heart rate
3. Sport-specific exercise
Skating drills in ice hockey, running drills in soccer. No head
impact activities
Add movement
4. Non-contact training drills
Progression to more complex training drills, e.g. passing drills
in football and ice hockey
Exercise, coordination and use of brain
5. Full contact practice
Following medical clearance, participate in normal training
activities
6. Return to Play
Normal game play
Increase heart rate
Restore confidence and assess functional skills by
coaching staff
Decision to RTP needs to be a consensus
between the Sportsmedicine team and
cleared by physician
Clinical Presentations and Concerns
School personnel observe for:
Change in personality/mood
Increased difficulty paying attention/concentrating, remembering/learning new
information
Longer time required to complete tasks
Increase in symptoms (e.g., headache, fatigue) during schoolwork
Greater irritability (less tolerance for stressors)
SCHOOL CONSIDERATIONS
Modification Options
Time off from school/shortened day
Longer time to complete coursework/assignments and tests
Reduced homework/class work load
No significant classroom or standardized testing at this time
Home care-decrease stimulus (phone, TV, video games, computer etc)
DOCUMENTATION
CLINIC FORMS
Sideline Assessment Cards (Maddocks, SCAT, SAC, ACE)
Fact Sheets (Athlete, Parent, Coach)
Clinical Protocol/Health History
Post-Concussion Exertional Activity form
Individualized Health Plan Form (classes etc)
Patient Excuse from School Form
Patient Excuse from Physical Activity Form
Patient Permission to Return to Activity Form
Written Concussion Management Plan
IMPACT TESTING
• ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)
• Developed in the early 1990's (Drs. Mark Lovell and Joseph Maroon)
•
20-minute test that is a standard tool used in comprehensive clinical
management of concussions for athletes of all ages.
• Allows management concussions on an individualized basis (baseline
testing and/or post-injury neurocognitive testing)
• Objectively evaluate the concussed athlete's post-injury condition and
track recovery for safe return to play, thus preventing the cumulative
effects of concussion.
•
ImPACT can be administered by an athletic trainer, school nurse, athletic director,
team coach, team doctor, or anyone trained to administer baseline testing.
Module 1 (Word Discrimination)
 Evaluates attentional processes/verbal recognition memory
 Utilizes a word discrimination paradigm.
 Twelve target words are presented for 750 milliseconds (twice to facilitate learning of the list)
 The subject is then tested for recall via the presentation of the 24-word list that is:
comprised
of 12 target words and 12 non-target words
 Words chosen from the same semantic category as the target word.
 EX: the word “ice” is a target word, while the word “snow” represents the
non-target word.
 The subject responds by mouse-clicking the “yes” or “no” buttons
 Individual scores are provided both for correct “yes” and “no” responses -In addition, a
total percent correct score is provided.
 There are five different forms of the word list.
Delay Condition: Following the
administration of all other test
modules (approximately
20 minutes), the subject is
again tested for recall via the
same method described above.
The same scores that are
described above are provided
for the delay condition.
22
Module 2 (Design Memory)
 Evaluates attentional processes and visual recognition memory
 Utilizes a design discrimination paradigm.
 Twelve target designs are presented for 750 milliseconds (twice to facilitate learning)
 The subject is then tested for recall via the presentation of the 24-designs
comprised of 12 target
designs and 12 non-target
designs
EX: target designs that
have been rotated in space
The subject responds by
mouse-clicking the “yes” or
“no” buttons
Individual scores are
provided both for correct
“yes” and “no” responses
In addition, a total
percent correct score is
provided
There are five different forms of this task
23
Module 3 (X’s and O’s)




Measures visual working memory, visual processing speed, and visual memory paradigm
Encorporates a distractor task.
The subject can practice the distractor task prior to presentation of the memory task
The distractor is a choice reaction time test: the subject is asked to click the left mouse
button if a blue square is presented and the right mouse button if a red circle is presented.
 Once the subject has completed this task, the memory task is presented.
 Memory task: a random assortment of X’s and O’s is displayed for 1.5 seconds
 For each trial: three of the X’s or O’s are illuminated in YELLOW (the subject has to remember
the location of the illuminated objects).
 Immediately after the presentation
of the 3 X’s or O’s, the distractor task
re-appears on the screen.
 Following the distractor task, the
memory screen (X’s and O’s)
re-appears and the subject is asked
to click on the previously illuminated
X’s and O’s.
 Scores are provided for correct
identification of the X’s and O’s
(memory), reaction time for the
distractor task, and number of
errors on the distractor task.
 For each administration of ImPACT, the subject completes 4 trials.
24
Module 4 (Symbol Matching)
 Evaluates visual processing speed, learning and memory
 Initially, the subject is presented with a screen that displays 9 common symbols (triangle,
square, arrow, etc).
 Directly under each symbol is a number button from 1 to 9
 .Below this grid, a symbol is presented.
The subject is required to click the matching
number as quickly as possible and to
remember the symbol/number pairings
Correct performance is reinforced
through the illumination of a correctly
clicked number in GREEN. Incorrect
performance illuminates the
number button in RED.
Following the completion
of 27 trials, the symbols disappear
from the top grid.
The symbols again appear below the
grid and the subject is asked to recall
the correct symbol/number pairing by
clicking the appropriate number button.
 This module provides an average reaction time score and a score for the
memory condition.
25
Module 5 (Color Match)
 Represents a choice reaction time task and measures impulse control/response
inhibition
 First, the subject is required to respond by clicking a red, blue or green button as they
are presented on the screen. This procedure is completed to assure that subsequent
trials would not be affected by color blindness
 Next, a word is displayed on the screen in the same colored ink as the word (e.g.
RED), or in a different colored ink (GREEN or BLUE)
 The subject is
instructed to click
in the box as
quickly as
possible only
if the word is
presented in the
matching ink.
 In addition to
providing a
reaction time
score, this task
also provides
an error score.
26
QUESTIONS?
Bill Borowski
Baylor SportsCare
411 N Washington Ste 4000
Dallas TX 75246
214-820-7333
billbor@baylorhealth.edu