Post on 15-Mar-2018
1
Jamie Pardini, Ph.D.UPMC Concussion ProgramUniversity of Pittsburgh Medical Center
Department of Orthopaedic Surgery
UPMC Sports Concussion Program
How I Manage Concussion:
A Neuropsychologist’s Perspective
Concussion:
The
Diagnostic
and
Return to
Play
Dilemma
Pressure to Play in Sports: Can We Trust What the Athlete Tells Us?
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Evolution of Concussion
Definition and Management
Vienna Meeting-2001
Prague Meeting-2004
Zurich Meeting-2008
1st-3rd International
Symposia
On Concussion
In Sport
Sponsored by FIFA, IOC,
IIHF
Vienna, Prague, Zurich:
Clinical/General Points of Emphasis
1. Abandonment of grading scale approach, recommend individualized
management of injury and determination of severity once symptoms
resolve.
2. When an athlete exhibits any signs/symptoms of concussion,he/she
should be removed from contest and not allowed to return to play in
that same contest (Zurich allows RTP in same game in athletes >18
years after prudent evaluation).
3. Objective tools of assessment via sideline assessment tools, balance
testing, and formal neurocognitive testing significantly contributes to
understanding of recovery from injury.
4. Role of physical and cognitive exertion important to recovery and
once symptom free, athlete should engage in stepwise progression
prior to RTP
5. RTP following concussion in sports is always a clinical decision
RETURN TO PLAY CRITERIAAccording to the Vienna Conference and CIS
guidelines, the athlete has to meet three criteria for return to play:
• Symptom Free at Rest
• Symptom Free with exertion
• Normal Neurocognitive Functioning
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Immediate Post-Concussion
Assessment and Cognitive Testing
Computerized Neurocognitive Testing
Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery (Program Developer)
Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery (Co-Founder)
Joseph Maroon, MD - UPMC Dept. of Neurological Surgery (Co-Founder)
ImPACT
Disclosure-Mark Lovell, PhD is co-owner of ImPACT Applications, LLC
Concussion Management ProgramsImPACT Computerized Neurocognitive Testing
NFL (All Teams Mandated)
NHL (All Teams Mandated)
MLB (All Major/Minor League Teams Mandated)
Major League Soccer (all teams)
US Ski/Snowboarding Teams
NASCAR, IRL, CHAMP Racing Leagues
USA Rugby/US Lacrosse
USA Soccer
Cirque de Soleil
Irish National Rugby
New Zealand Rugby Football Union
South African Rugby
European Professional Soccer
World Wrestling Federation
Over 2,000 high schools currently using ImPACT
Over 350 Colleges/Universities
201 concussed high
school and collegiate
athletes tested with 2
days of injury.
Abnormal performance
determined by RCI’s (van
Kampen, 2004).
Neurocognitive Testing
Increases Diagnostic
Yield to 93%
% Declined
from baseline
SYMPTOMS
NEUROPSYCH
EITHER
93
82
65
0102030
40
50
60
70
80
90
100
Value Added of Neurocognitive Evaluation
(Lovell et al, AJSM In Press).
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On-Field and Post-Injury Concussion Management
UPMC and Pittsburgh Steelers Protocol
First
Evaluation
Follow
up
Concussion
Beyond
if
Necessary based on
Guidelines
Baseline
Testing (Not necessary
for decision
making)
Clinical Protocol: Neurocognitive Testing
What Sports?Which Athletes?
•HIGH SCHOOLS
•COLLEGE
•MIDDLE SCHOOL
•CLUB TEAMS
•AGES 10-60
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On-field Assessment (Usually ATC)
Signs/Symptoms Evaluation
Neurologic Examination
Mental Status Testing
Orientation, Concentration, Anterograde / Retrograde Amnesia
Serial Evaluation Necessary
Possible Exertional Testing
Any Positive Findings Preclude Return to Play
UPMC Return to Play Protocol
Stage ONE Sideline Testing
1. ImPACT AssessmentEvaluation should occur in first few days after concussion
Clinical Interview, ImPACT
Referral (as needed) to other specialists
Recommendations Regarding Cognitive and Physical Activity
School Attendance
Gym Class Attendance
Academic Accommodations
Athletic Participation
2. Future Evaluations As Recommended
3. Return to Baseline (or estimated preinjury status)Symptom data AND Cognitive data
4. Progress through Exertion/Practice
5. Return to Competition
UPMC Return to Play Protocol
Stage TWO Follow Up Evaluation
Somatic Symptoms• Visual Problems
• Dizziness
• Balance Difficulties
• Headaches
• Light Sensitivity
• Nausea
Emotionality• More emotional
• Sadness
• Nervousness
• Irritability
Sleep Disturbance • Difficulty falling asleep
• Sleeping less than usual
Factor Analysis, Post-Concussion Symptom Scale (Lovell, Pardini et al. 2004)
N=327, High School and University Athletes Within 7 Days of Concussion
Cognitive Symptoms• Attention Problems
• Memory dysfunction
• “Fogginess”
• Fatigue
• Cognitive slowing
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Managing Kids• Need a Dedicated, Educated Team
• Coaches
• Athletic Trainers
• School Nurses
• Teachers
• Guidance Counselors
• Neuropsychologists
• Physicians
• Parents
• Athletes
• School Administrators
RETURN TO PLAY CRITERIAAccording to the Vienna Conference and CIS
guidelines, the athlete has to meet three criteria for return to play:
• Symptom Free at Rest
• Symptom Free with exertion
• Normal Neurocognitive Functioning
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The Role of the
Neuropsychologist:
Neuro
ATCPCP
PM&R
PT
Parent
School
Vestibular
Tx
Coach
Cog
Rehab
Academic
Accommodations
• Recommendations made based on
symptoms and pattern of test performances
• Acutely, accommodations are usually more restrictive
• Attendance recommendations
• Cognitive load
• Proper accommodations should allow student to continue learning “core” information, while controlling symptoms and maintaining grades.
• Balancing restrictions and involvement… PE class, watching practice, extra-curricular activities, social activities
• “Healthy” appearance of student is usually a difficulty, not advantage, in terms of self- and other-expectations
Sports-Concussion Rehabilitation
• Exertion Based
• Physical Therapy (Stages 1-3)
• Sports Performance (Stages 4-5)
• Specialized/Individualized
• Vestibular Evaluation/PT
• Medication management
• Monitoring recovery thru
Computerized Neurocognitive
Testing
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UPMC Concussion Program
Treatment/Rehabilitation Protocol
NOTE:*Off-label use
Emotionality
SSRIs
Escitalopram (Lexapro)
Sertraline (Zoloft)
Therapy
Sleep Disturbance
Melatonin
Trazodone
Cognitive Symptoms
Neurostimulants
Amantadine*
Methylphenidate*
Atomoxetine (Strattera)*
Somatic Symptoms
Headaches Prophylaxis
Propranolol*
Verapamil*
Amitriptyline*
Escitalopram (Lexapro)
Sertraline (Zoloft)
Vestibular Therapy
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004
It was just a “ding;” I don’t feel so
bad: Why do I have to go through
this program?
ImPACT Memory Composite ScoresBrief 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 = 64
High
School
Athletes
P<.02 P<.004
P<.04
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004
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ImPACT Symptom Scale ScoresBrief versus Prolonged On-field Mental Status Changes
0
5
10
15
20
25
30
35
40
Baseline 36 hours DAY 4 DAY 7
5-15 min < 5 min
N = 64
High School
Athletes
P<.003
P<.061
NS
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54, 2004
NS
Recovery from Concussion
in Athletes:
How Long Does it Take?
Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, In Press
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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
Age
History of prior concussion
History of headache
Pre-existing psychiatric condition
History of learning disability
Genetics?
Factors That Affect Recovery
Thank YouJamie Pardini Ph.D. 412-432-3681
pardinij@upmc.edu