James Bryan, M.D.

Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines James W. Bryan IV, MD Little Rock, AR

Concussion defined  Concussion is a brain injury and is defined a a complex pathophysiological process affection the brain, induced by biomechanical forces.  Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive injury include: Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Concussion defined: common features  Caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head  Typically results in the rapid onset of short-lived neurological function that resolves spontaneously  Symptoms and signs may evolve over minutes to hours

 May result in neuropathological changes  Reflect a functional disturbance rather than a structural injury  No abnormalities are typically seen on standard neuroimaging studies Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Concussion defined: Neurometabolic cascade

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Concussion defined: Neurometabolic cascade

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Concussion defined: common features  Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness.  Resolution of the clinical and cognitive symptoms typically follows a sequential course  In some cases the symptoms may be prolonged  The majority of cases resolve in a 7-10 day period  The recovery time frame may be longer in children and adolescents

Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Background *First concussion symposium: Vienna, 2001 -International Ice Hockey Association, FIFA (soccer), and the International Olympic Committee *Second symposium: Prague, 2004 -Sideline assessment tool (SCAT) *Third symposium: Zurich, 2008 -SCAT revised (SCAT 2) -Designed to follow US NIH consensus criteria *Each produced a summary-and-agreement statement on concussion in sport.

Background  The Fourth Conference: Zurich 2012  Used the same format as previously:      

32 international experts 2 full days of new research presentations Extensive structured discussion Drafted a consensus paper, edited until all were in agreement Updated version of SCAT (SCAT 3)-with 3 distinct tools Final drafting of 12 critical review papers, co-published in multiple journals

British Journal of Sports Medicine April 2013; 47: 250-258 Panel included Stanley Herring and Margot Patukian from AMSSM

American Medical Society for Sports Medicine position statement: concussion in sport

 Kimberly G Harmon, Jonathan A Drezner, Matthew Gammons, Kevin M Guskiewicz*, Mark Halstead, Stanley A Herring, Jeffrey S Kutcher*, Andrea Pana, Margot Putukian*, William O Roberts  Endorsed by the National Trainers’ Athletic Association and the American College of Sports Medicine  Press release December 13, 2012  British Journal of Sports Medicine April 2013, 47, 15-26  Clinical Journal of Sport Medicine Jan 2013, 23 issue 1, 1-18  [Asterisk indicates Zurich 2012 participants]

AMSSM Position Statement: concussion in sport --Purpose- To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion  To establish the level of evidence, knowledge gaps and areas requiring additional research

AMSSM Position Statement: concussion in sport --Importance- While directed toward sports physicians, it may help other health care providers in the care of concussed patients  Care is ideally performed those with specific training and experience—not dictated by specialty  Sports physicians are trained to provide care from the time of injury to return-to-play

Pathophysiology  Both human and animal studies support the concept of postconcussion vulnerability  A second blow sustained before recovery results in worsening metabolic changes within the neuron  This concept is distinct from “second impact syndrome”

 The concussed brain is less responsive to usual neuron activation  Prolonged dysfunction may result from premature cognitive activity or vigorous physical activity AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Incidence  3.8 million sports related concussions annually in the USA  Estimated that up to 50% are unreported or unrecognized  Concussions occur in all sports  Football, hockey, rugby , soccer, and basketball

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Risk factors for sports-related concussion  History of previous concussion  The greater the number, severity, and duration of symptoms predict a prolonged recovery  In sports with similar rules, female athletes experience a higher incidence of concussion  Certain positions within a sport present a greater exposure risk

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Risk factors for sports-related concussion  Pre-injury mental health conditions complicate the diagnosis and management of concussion  Youth athletes have additional considerations  More prolonged recovery  Greater susceptibility to concussion accompanied by catastrophic injury

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Diagnosis of concussion  Concussion is a clinical diagnosis  Diagnosis is ideally made by a healthcare provider who is  familiar with the athlete  knowledgeable in the recognition and evaluation of concussion

 Graded symptoms checklists [e.g. SCAT3]  Objective tool for assessing a variety of symptoms  Useful in tracking the severity of symptoms over serial exams AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Diagnosis of concussion  Standardized assessment tools  Can provide a helpful structure in evaluation  Limited valuation of the assessment tools is available  Examples include      

The Maddocks Questions Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS, modified BESS) SCAT2, SCAT3, SCAT3 Child, CRT (lay person) NFL Sideline Concussion Assessment Tool Glasgow Coma Score

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Diagnosis of concussion  SCAT3  http://bjsm.bmj.com/content/47/5/259.full.pdf+html

 SCAT3-CHILD  http://bjsm.bmj.com/content/47/5/263.full.pdf+html

 Pocket Concussion Recognition Tool  http://bjsm.bmj.com/content/47/5/267.full.pdf+html

Neuropsychological testing  NP testing is an objective measure of brain-behavior relationships  More sensitive for subtle cognitive impairment than clinical exam  Should be used as part of a comprehensive management strategy and not relied upon alone  Ideal timing, frequency and type of NP testing is not established  Unknown if NP testing helps prevent recurrent concussion, catastrophic injury, or long-term complications AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Neuropsychological testing  Paper and pencil NP tests  Can be more comprehensive  Can test different domains and assess for other conditions which may mask or complicate the assessment of concussion

 May provide added value to assess cognitive function and recovery  Helpful in the management of patients with prolonged symptoms and complicated courses AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Neuropsychological testing  Computerized NP testing should be interpreted by providers trained and familiar with     

The type of the test The individual test limitations The reliable change index The baseline variability False-positive and false-negative rates

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Neuropsychological testing CPT ® codes  96118 Neuropsychological testing, interpretation and reporting per hour by a psychologist ($92/unit)  96119 Neuropsychological testing per hour by a technician ($74/unit)  96120 Neuropsychological testing by a computer, including time for the psychologist’s interpretation and reporting ($103)  Formal NP testing, scoring, interpretation and conference may require up to 4-8 hours http://www.apapracticecentral.org/update/2012/11-29/medicare-payment.aspx, accessed 5/14/13

Return to class  Students will require a period of cognitive rest  May require academic accommodations  Reduced workload  Extended time to complete tests  Protections afforded under Section 504 / ADA

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Education  Arkansas ACT 1435

 Sen. David Sanders/SB1158  Rep. Gary Deffenbaugh

 Signed April 23, 2013  Requires the State Department of Health to develop concussion protocols to all youth athletes involved in youth athletic activities  Based on existing AAA guidelines for sanctioned sports in grades 7-12 enacted in 2012 As of April 2013, 47 states have enacted legislation

Education  “Heads Up” Tool Kit for Youth Sports  CDC  Coaches, athletes and parents  Online videos  Fact sheets, wallet cards

 NFLEvolution.com

 Promotion of the Lystedt Law’s three tenets

 Inform and educate youth athletes, their parents and guardians and require them to sign a concussion information form  Removal of a youth athlete who appears to have suffered a concussion from play or practice at the time of the suspected concussion  Requiring a youth athlete to be cleared by a licensed health care professional trained the evaluation and management of concussions before returning to play or practice.

Education  AMSSM  2014 AMSSM 23rd Annual Meeting  April 5-9, 2014  Hyatt Regency New Orleans  New Orleans, LA

 Advance Team Physicians Course  Cosmopolitan Hotel Las Vegas, NV December 5-8, 2013

• 2013 AAFP Scientific Assembly: Concussion and Minimal Brain Injury • Thursday, September 26, 2013, San Diego Convention Center

Summary of evidence-based guideline update: Evaluation and management of concussion in sports Neurology; Published online before print March 18, 2013 Christopher C. Giza, MD, Jeffrey S. Kutcher, MD,

Stephen Ashwal, MD, FAAN, Jeffrey Barth, PhD, Thomas S.D. Getchius, Gerard A. Gioia, PhD, Gary S. Gronseth, MD, FAAN, Kevin Guskiewicz, PhD, ATC, Steven Mandel, MD, FAAN, Geoffrey Manley, MD, PhD, Douglas B. McKeag, MD, MS, David J. Thurman, MD, FAAN and Ross Zafonte, DO

 Objective: To update the 1997 AAN practice parameter regarding sports concussion focusing on 4 questions

AAN Guideline Update: 4 questions  1. What factors affect risk?

 2a.What diagnostic tools identify those with concussion and (2b)those at increased risk?

 3.What clinical factors identify those at increased risk for severe/ prolonged early impairments, neurological catastrophe, recurrent concussion, or chronic impairment?  4.What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae?

Neurology, Mar 18, 2013

AAN Concussion Guidelines  Preparticipation Counseling  Number and type of previous concussions  Symptoms and duration  Other neurologic conditions (e.g. seizures)

 Assessment  Post-Concussion Symptom Scale or Graded Symptom Checklist  Standardized Assessment of Concussion  Neuropsychological testing  Balance Error Scoring System  Sensory Organization Test  Combination of measures Neurology, Mar 18, 2013

AAN Concussion Guidelines Management of suspected concussion

 Train inexperienced licensed HCPs to use a standardized assessment tool  Use standardized assessment tools  Warm handoff from sideline HCP and clinical HCP

 Obtain baseline scores  Remove athlete from play  No RTP without clearance by licensed HCP  Don’t perform imaging to make concussion diagnosis  Do perform imaging to rule out suspected TBI Neurology, Mar 18, 2013

AAN Concussion Guidelines: DIAGNOSED CONCUSSION  No RTP until resolved & asymptomatic  Conservative approach for youth and high school  Assessment tools specific for preteens  Consider NP testing  Individualize management plan  No indication for “absolute rest” Neurology, Mar 18, 2013

AAN Concussion Guidelines: Multiple concussions  Professional athletes:  Refer for neurologic and neuropsychological evaluation  Contact-sports with chronic impairment: RETIREMENT

 Amateur athletes:  Formal neurologic/cognitive assessment  Offer risk factor counseling

Neurology, Mar 18, 2013

Conclusions  Numerous organizations have published guidelines regarding the management of sports-related concussions  Emerging consensus that education is a key factor  Treatment considerations differ slightly between youth, adolescent, and adult/professional athletes  Inconclusive data regarding long-term risk