Player Safety: Concussion &

Baseline Impact Testing

David Bernhardt, M.D.

University of Wisconsin Sports Medicine

Concussion

Mild traumatic brain injury

Vienna Consensus Statement 2001

Symptoms

• Dazed appearance

• Confusion• Memory Loss• Headache• Dizziness• Balance problems

• Irritable• Personality

change• Slowed response• Poor

focus/attention• +/- LOC

Memory

What if the athlete suffers brief LOC?

• Should this athlete be DQ’d for the remainder of the game?

• Does LOC predict long term prognosis?

What if the athlete suffers brief LOC?

• 383 MTBI patients (GCS 14-15)• Confusion, agitation, retrograde amnesia,

LOC• Poorer performance for all groups on

neuropsychological tests sensitive to MTBI

• No differences between groups based on LOC, uncertain LOC and no LOC

Lovell MR, et al. Clin J Sports Med 1999

Simple Concussion

• Resolves without complication in 7-10 days

• Rest until all symptoms have resolved

• Graded return to play

Complex Concussion

• Persistent symptoms• Specific sequelae (seizures)• Prolonged LOC (> 1 minute)• Prolonged cognitive impairment• Repeated concussions with less force

• Consider neuropsychological testing• Multidisciplinary approach

Sideline evaluation

Orientation ConcentrationMonth: ___________________ 0 1 Digits backward (If correct, go to Date: _____________________ 0 1 next string length. If incorrect, read Day of week: ______________ 0 1 trial 2. Stop if both incorrect.Year: ____________________ 0 1 4-9-3 6-2-9 ______0 1Time (within 1 hour): _______ 0 1 3-8-1-4 3-2-7-9 _____0 1

6-2-9-7-1 1-5-2-8-6 ______0 1Orientation Total Score _________ / 5 7-1-8-4-6-2 5-9-1-4-8 _____0 1

Months in reverse order: (entire sequence correct for 1 pt)

DecJan 0 1

Concentration Total Score ____ / 5

Sideline evaluationImmediate Memory: (all 3 trials are complete regardless of score on trial 1 & 2; total score equals sum across all

3 trials)

List Trial 1 Trial 2 Trial 3Word 1 0 1 0 1 0 1 Exertional maneuversWord 2 0 1 0 1 0 1 CoordinationWord 3 0 1 0 1 0 1 StrengthWord 4 0 1 0 1 0 1 SensationWord 5 0 1 0 1 0 1 Recall of injuryTotalImmediate Memory Total Score _____ / 15

Delayed recall

Word 1 0 1Word 2 0 1Word 3 0 1Word 4 0 1Word 5 0 1Delayed Recall Total Score _____/5 McCrea M et al. Summary of Total Scores _____ / 30 Neurology 1997

Serial 7’s

• 522 high school athletes, PPPE• Serial 7, serial 3, months in reverse• Seven consecutive or 11 with one

mistake• 51% serial 7’s, 79% serial 3’s• 89% months in reverse

Young CC, Jacobs BA et al. Clinical Journal of Sports Medicine 1997

DO NOT ALLOW RETURN TO PLAY

UNTIL COMPLETELY ASYMPTOMATIC

If You Do Not Know Athlete’s Baseline Neuropsychological Status, It Is Difficult To Judge

Normal

High school athletes often require a significantly longer period of time to become asymptomatic and for their cognitive function to return to normal than both collegiate and professional athletes

Catastrophic complications

• Epidural

• Subdural

• Second impact syndrome

Second impact syndrome

• Not fully recovered from previous head injury when sustain a second head injury

• Loss of vascular autoregulation• Cerebral vascular congestion• Malignant brain edema, brainstem

herniation, death

POST CONCUSSIVE SYNDROME

Recurrent headaches DizzinessMemory impairment DepressionLoss of libido TinnitusAtaxia AnxietyAlcohol intolerance PhotophobiaHyperacousis Concentration

Post concussive syndrome

• Not necessarily related to severity of concussion

• Attention and learning difficulty may be subtle

• Cumulative effects of multiple concussions

Neuropsychological testing

• Nature and degree of deficit acutely

• Relationship to standard sideline evaluation

• Recovery curves

Computerized Neurocognitive Testing

• IMPACT• Headminders• Cogsport

• http://www.wiyouthsoccer.com/impact.html