Brain Injury Professional, vol. 4 issue 4 by Nikolai Alexeev

In The Midst Of a Paradigm Shift: Data-Based Management of Sports-Related Concussion Ten Steps and Commitments for an Effective Youth Sports Concussion Program Sports-Related Concussion: New Frontiers in Neuroimaging Pathophysiology Of Sports Concussion: Are Kids Different? A Neurologistâ&#x20AC;&#x2122;s Perspective Of Sports Related Concussion: Advancements in Management A Treatment Paradigm for Sports Concussion BIP Expert Interview: Michael Matheny Traumatic Brain Injury In Sports: An Update from the Centers for Disease Control and Prevention The Role of the Athletic Trainer in the Proper Management of Sports Concussion Implementing a Statewide Concussion Management Program

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contents departments 4 Executive Vice President’s Message 4 In Memoriam 6 Guest Editor’s Message

BRAIN INJURY professional vol. 4 issue 4, 2007

The official publication of the North American Brain Injury Society

north american brain injury society

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

brain injury professional

features 8 In The Midst Of a Paradigm Shift: Data-Based Management of Sports-

Related Concussion by Michael Collins, PhD 14 Ten Steps and Commitments for an Effective Youth Sports Concussion

Program By Gerard A. Gioia, PhD 16 Sports-Related Concussion: New Frontiers in Neuroimaging By Jamie E. Pardini, PhD, Mark R. Lovell, PhD, and Andrew Wroblewski, PhD

publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

EDITORIAL ADVISORY BOARD Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries 20 Pathophysiology Of Sports Concussion: Are Kids Different? by Melvin Field, MD & Michelle Dolske, PhD 22 A Neurologist’s Perspective Of Sports Related Concussion: Advance-

ments in Management BY Ellen Deibert, MD 24 A Treatment Paradigm for Sports Concussion By Cara Camiolo Reddy, MD and Lisa A. Lombard, MD 26 BIP Expert Interview: Michael Matheny 28 Traumatic Brain Injury In Sports: An Update from the Centers for Dis-

ease Control and Prevention Marlena M. Wald, MPH, Jane Mitchko, Med, Kelly Sarmiento, MPH, Jean A. Langlois, ScD 32 The Role of the Athletic Trainer in the Proper Management of Sports

Concussion Kevin Guskiewicz, PhD, A.T.C. 36 Implementing a Statewide Concussion Management Program Caroline Leipf, Ron Savage, EdD, and David Gealt, DO

Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2007 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

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executive vice president’s message Three little monkeys jumping on the bed. One fell off and bumped his head. Took him to the doctor and the doctor said, “That’s what you get for jumping on the bed!” This nursery rhyme tells a story about concussion--the bumps, bangs and shakings to the brain that many adults and children experience. Unfortunately, just like the monkeys jumping on the bed, professionals may not understand concussion well enough to evaluate its significance and/or offer support to the individuals who sustain concussions. Individuals who sustain concussions, particularly in sports and recreation activities, may just try and “shake it off ” and, therefore, end up not being evaluated and treated properly by professionals. Or, it is not uncommon for individuals to be sent home from emergency rooms (ER’s) with no follow-up care only to later experience lingering symptoms that no one understands. According to the Centers for Disease Control and Prevention (CDC), an estimated 1.6 to 3.8 million sports- and recreation-related concussions occur in the U.S. each year, including those for which no medical care is sought. This range includes both concussions with and without loss of consciousness (LOC) and is based on studies that suggest that injuries involving LOC may account only for between 8% and 19.2% of sports concussions. And, obviously, the more risk to your body, the more risk of serious harm and permanent damage, and the greater the

chances that a concussion or more permanent brain injury can occur. Fortunately, our knowledge about concussion and MTBI is rapidly changing. As Dr. Michael Collins states in his lead article: “It is reasonable to state that we are currently in the midst of a paradigm shift regarding sports-concussion assessment and management of injury. In short, there is more scientific evidence available in the area of sports concussion over the past 5-10 years, than the previous 100 years combined. In fact, our understanding of sports-concussion is helping to pave the way to better understand general mild traumatic brain injury, as studying head injury in athletes is a proverbial “Petri-dish” to better understand more general MTBI.” Yet, even with all this new information, many questions are still unanswered, including: Why are some individuals more at risk for long term problems after concussion, including children? Why do some people adjust better after a concussion than others? Why do concussive symptoms change over time? Why can’t professionals tell if there will be permanent deficits after more severe concussions? And, lastly, as we all know, the only cure for brain injury is prevention. Hence, the treatment of concussion starts with prevention planning. Thoughtful preparation before activities includes baseline testing; knowing

Ronald Savage, EdD one’s personal limits; minimizing risk to one’s head by wearing protective gear such as seat belts, helmets, hard hats; and being substance free when activities require concentration such as driving, bicycling, swimming, boating and skiing. NABIS wants to thank Dr. Michael Collins, recognized in 2006 as the recipient of the NABIS Innovations in Clinical Services Award, for serving as Guest Editor of this important issue of BIP and for assembling an outstanding array of experts.

Ronald Savage, EdD

in memoriam Charles Walter Haynes, the publisher of this magazine and long-time brain injury advocate, passed away in November, 2007, in Houston, Texas. Charles worked as an executive with a multinational corporation for most of his professional career. After his daughter, Bonnie, was injured in a car accident in 1979, Charles started a new chapter in his life as an advocate for persons with brain injury and their families. He was the founder and first president of the Texas Head Injury Foundation, and later served as chairman of the board of the Brain Injury Association of America (then known as the National Head Injury Foundation). Over the years, he testified before national and state governments, served on numerous boards and was active in a variety of brain injury causes and initia4

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tives. Charles was passionate about improving the quality of life for persons with brain injury and although unable to play an active role in advocacy issues during the last few years of his life, he was keenly interested in following developments in the field. In the 1990s Charles launched HDI Publishers, a company specializing in the area of neurotrauma. Over the years, HDI has published a variety of material on the subject of brain injury for both survivors and professionals. He is survived by Grace Grainger Haynes, his wife of 52 years, and three children, Sam, Bonnie, and Chas, and three grandchildren. In lieu of flowers, friends are asked to please consider a donation to the Brain Injury Association of America, 1608 Spring Hill Road, Suite 110, Vienna, VA 22182, or on the web at www.biausa.org.

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guest editor’s message It is a true honor to be chosen as guest editor of this current issue of the Brain Injury Professional on the topic of Sports-Related Concussion. Thanks to the contributors of this issue, the reader will find the most recent advances in our understanding of this injury. Not long ago, evaluation of concussion was essentially non-existent and return to play was predicated on “how many

Michael W. Collins, PhD fingers am I holding up?” or the effectiveness of smelling salts. Such archaic practices have been positively transcended with the hard work of several pioneers in this field, the names of whom are too many to mention in their entirety, though include visionaries such as Drs. Mark Lovell, Joe Maroon, Robert Cantu, James Kelly, Jeffrey Barth, and many, many others. Their collective work during the 1980-1990’s to the current date have laid the foundation for all of us who genuinely strive to improve the care of the concussed athlete. Without the perseverance and integrity of these individuals, the information herein and the clinical advances at all levels of sport participation would simply not exist. Though healthy scientific debate (and even bare-knuckle academics) occurs daily in this “subspecialty” of sports medicine, it can be confidently stated that a cohesive consensus has been reached regarding core aspects of the phenomenology of concussive injury, risk factors for poor outcome, criteria needed to achieve “recovery,” and even accepted practice at determining return to play following injury. Fruits of these labors are now being systematically practiced at playing fields and clinical offices across the world, and pediatric, adolescent, and professional athletes are the true benefactors of this work. Moreover, such work can serve as a “petri-dish” to better understand more general mild traumatic brain injury. For the readership of this issue who do not follow sports, take note of our advances, as this information can certainly be generalized to the millions of non-athletes who suffer mTBI. Advances 6

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and positive changes in our field will continue, as the spotlight is iridescent on this injury, and very smart individuals across varying disciplines are devoting entire careers to this topic. Within this context, we, as a field, have much work to do regarding an accepted definition of concussive injury (and related on-field management), scientifically determining potential long-term effects of repetitive injury, and treatment and rehabilitation of those athletes with chronic, lingering sequelae (for which I am struck by the shear numbers in this respect). As a relative newcomer to this field, I am just thankful for the daily opportunity of combining two personal passions…sports and the brain. I cannot imagine a more rewarding profession. In assembling this issue, I intended to choose a multidisciplinary group of esteemed professionals who could lend an area of expertise to the many facets of sports concussion. Following my lead review article, Dr. Gerry Gioia, a Pediatric Neuropsychologist, discusses the coordination of effective assessment, education, and awareness as integral components of youth-related sports concussion initiatives. Though extensive research has been conducted on adolescents, collegiate, and professional athletics in terms of understanding sports concussion, a paucity of data and effective management programs exist at the youth sports level. The second article in this issue is a cogent discussion on sports-related concussion and new frontiers in neuroimaging. Though traditional CT and MRI are grossly ineffective at identifying structural pathology with sports concussion, new advances are clearly emerging. Dr. Mark Lovell, my esteemed mentor, as well as Dr. Jamie Pardini, our new faculty member at the University of Pittsburgh Medical Center, discuss advances in neuroimaging and functional MRI research. Drs. Melvin Field, a neurosurgeon, and Michelle Dolski, a neuropsychologist, subsequently provide a germane discussion on why children are different from a physiologic standpoint as it pertains to sports concussion. Recent data and clinical experience reveals a heightened vulnerability in children and adolescents to protracted recovery following sports-related concussion. Using animal model research, these authors explain hypotheses as to why this occurs. Subsequently, Dr. Ellen Deibert, a Neurologist, examines the general inadequacy of a grading system approach to sports concussion management, and appropriately focuses on more individualized and data-driven management protocols. Dr. Deibert’s discussion addresses the core issues as to why a “paradigm shift” is occurring in our understanding and management of sports related concussion. Next, Drs. Cara Camiolo and Lisa Lombard, both Physical and Medicine Rehabilitation specialists provide an excellent overview regarding our understanding of specific symptom clusters of sports concussive injury and related pharmacologic interventions to address these “subtypes” of concussive injury. It is felt that improvements in treatment

and rehabilitation are the next frontier of sports concussion research and intervention. As noted above, the true morbidity of this injury is grossly under-appreciated and naively misunderstood by the general clinician, and this article helps to set the stage for clinical trials and improved work in treatment of sports concussion. In reviewing this current collection of articles, the most powerful discussion of this injury occurs through the experiences of Mike Matheny, a 13year Major League Baseball veteran and 4-time winner of the prestigious Gold-Glove award. I have come to know Mike very well over the past 18 month’s time, and his story of experiencing the cumulative effects of concussion is a powerful narrative and at the core of why I do this work. In all my experiences of working with professional athletes, I have never heard more positive testimonials from teammates, coaches, and acquaintances as that of Mike Matheny. I wish to personally thank Mike for taking a leadership role with this injury and for bravely sharing his experiences. As a direct result of his case, starting in 2008, Major League Baseball has mandated the use of baseline and post-injury computerized neurocognitive testing for all Major and Minor league players, as well as Umpires. Following Mike’s expert interview, Jean Langlois and colleagues from the CDC share important epidemiological data and discuss the national awareness and educational campaigns that have been a mission for the CDC. The CDC has been a clear leader and played an integral role in educating the community, coaches, and professionals on this injury, and their efforts have helped countless athletes as a result. Next, Dr. Kevin Guskiewicz, the Nation’s leading athletic trainer in the area of sports concussive injury, discusses the critical role of the athletic trainer in managing concussion. In short, it is my strong opinion that every high school and collegiate sports program should have direct access to an Athletic Trainer, who invariably serve as the front line for this injury and are as well educated as any professional group on the topic of sports concussion. Lastly, Caroline Leipf and Ron Savage discuss their successful venture in implementing a state wide concussion management program in the state of New Jersey. I wish to personally thank Ron for his help in assembling the panel of experts throughout the process of writing and editing the information within this issue. Ron’s contributions to this topic, as well as his leadership in many other areas of traumatic brain injury, are truly appreciated and admired. In closing, I wish to thank the North American Brain Injury Society for the opportunity to serve as Guest Editor of this issue. I also wish to thank the many contributors of this issue, your work and leadership in this area is appreciated and is assuredly helping countless athletes nationally and internationally. Michael W. Collins, PhD

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In the Midst of a Paradigm Shift Data-Based Management of Sports-Related Concussion Michael Collins, PhD

A 16 year old, Junior High School soccer player leaves his feet to head a ball, an opponent clips his knees, and the athlete falls unprotected, striking the posterior aspect of his un-helmeted cranium to the ground. Though there is no loss of consciousness or mental status change, the athlete immediately perceives disturbing symptoms such as blurred vision in both eyes, severe dizziness when he arises from the turf, a sense of fatigue or slowing, and also experiences a generalized pressure headache that seems to worsen with the noises and lights on the playing field. Undeterred, the athlete plays on and notices that subsequent exertion seems to increase the pressure in his head, and also worsens all other symptoms. Ten minutes later, the athlete heads an oncoming ball and teammates now notice that the athlete is slow to respond to questions and is even repeating himself upon inquiry of his status. He is removed from the game under his 8

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own power, assessed on the sideline by his Athletic Trainer, and sent to a local Emergency Room for evaluation. At the ER, he is noted to have a completely normal neurological evaluation, though a CT scan is ordered and is read as normal. In this scenario, and likely unbeknownst to the family, and even perhaps his treating clinicians, critical decisions need to be made regarding proper post-concussion management and data-based evaluation. Of concern is that an uneducated parent or clinician may not be aware that mismanagement of this athlete, at this point, could lead to protracted, and perhaps a chronic presentation of potentially disabling symptoms such as severe headaches, dizziness, neurobehavioral change, severe cognitive deficits that impair academic functioning, and many other physical symptoms that may be tacit, though potentially incapacitating. Similarly, one may not be aware that until full recovery is achieved, less biomechanical force will likely result in extended injury (and resultant post-concussion effects), that simple cognitive exertion (e.g. studying in school) or physical exertion (e.g. going back to non-contact practice) will extend the length of recovery, and that “recovery” is a fairly well-defined and an even evidence-based clinical construct that has specific criteria that need be achieved before return to play. A naïve parent or clinician may also be unaware that certain risk factors can predict an extended period of recovery and an increased vulnerability for recurrent, and potentially more serious secondary injury. Lastly, one may not be aware that there are well-validated assessment techniques that can help to answer a myriad of questions that the parents of this athlete are certain to ask: How severe is the concussion? Prognostically, what can we expect in terms of time to recovery? How do we know our son is being honest in reporting symptoms? When is my son allowed to return to weight-lifting, running, etc? What are the potential short or long-term effects on his academic function? When may my son safely return to the sport that he loves? Thankfully, all of these questions can now be answered in an evidenced-based fashion. It is reasonable to state that we are currently in the midst of a paradigm shift regarding sports-concussion assessment and management of injury. In short, there is more scientific evidence available in the area of sports concussion over the past 5-10 years, than the previous 100 years combined. In fact, our understanding of sports-concussion is helping to pave the way to better understand general mild traumatic brain injury, as studying head injury in athletes is a proverbial “Petri-dish” to better understand more general mTBI. After all, athletes sustaining concussive injuries will often minimize injury to get back to the playing field and secondary gain is very rarely an issue. Moreover, many studies utilize a baseline/post-injury testing model that clarifies typical recovery and risk factors associated with injury, and patients are most often seen acutely (within days of injury) and tracked until recovery is complete. Moreover, given that there are 1.6 to 3.8 million sports and recreation concussive injuries per year in the United States alone (Langlois et al., 2006), there is no shortage of data available to elucidate the phenomenology of mild traumatic brain injury. For the current review, it is the authors’ intention to summarize our current state-of-the-art understanding regarding the basics of sports concussion, including defining the injury, pathophysiology, assessment/management of injury, typical re-

covery rates, risk factors for protracted recovery, as well as clinical protocols for appropriate management and safe return to sport participation. Defining the Injury

One might assume that defining the construct of sports-related concussion (i.e. mild traumatic brain injury) is straight-forward and that consensus has been achieved. Such is not the case. In fact, despite hundreds of studies and years of research, there is no universally accepted definition of concussion. This lack of consensus becomes especially problematic when operating in the “field” and determining if an athlete has sustained a concussion or whether they are experiencing pre-existing or unrelated symptoms secondary to “extra-cranial” reasons. After all, determining return to play in the same contest is dependent upon this initial assessment, which is not an easy task for the sideline clinician. Within this context, there have been specific definitions proposed over the years by various academic organizations, including the Committee on Head Injury Nomenclature of Neurological Surgeons (Congress of Neurological Surgeons, 1966) and the American Academy of Neurology (Quality Standards Subcommittee, 1997). Most recently, the Centers for Disease Control and Prevention (CDC) have recently proposed and disseminated a comprehensive definition of concussion that attempts to educate the clinician as to the individualized nature of the injury and key concepts that allow for a flexible approach to diagnosing and managing the injury. The CDC’s definition is as follows (Aubry et al., 2002; McCrory et al., 2005). “An mTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. mTBI is caused by a jolt to the head or body that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e. CT Scan, MRI). mTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or longer in some cases.” Pathophysiology of Concussion

Recent animal model (rodent) work by Giza and Hovda at UCLA have led to burgeoning insights regarding the pathophysiology of sports-concussion and mTBI. Perhaps most important in summarizing these seminal findings is that concussion is found to be a metabolic, rather than structural brain injury, with acute, post-traumatic changes occurring in both intracellular and extracellular environments. These changes are the result of excitatory amino acid (EAA)-induced ionic shifts with increased Na/ KATPase activation and resultant hyperglycolysis (See Figure 1). This process is accompanied by a decrease in cerebral blood flow that is not well understood, though may be secondary to accumulation of endothelial calcium, which is thought to cause widespread cerebral neurovascular constriction. The resulting “metabolic mismatch” between energy demand and energy supply has been postulated to propagate a cellular vulnerability that is particularly susceptible to even minor changes in cerebral blood flow, increases in intracranial pressure, and apnea. Ani-

Pathophysiology of Cerebral Concussion in the Rodent Model

Figure 1 500 400

K+

Ca2+

300 CMRgluc

200

Lactate

100

Glutamate CBF

0 0 1

2 4 6 8 12 16 20 25 30 1 6 12 24 2 3 4 6 Time (minutes) (hours) (days)

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mal models have indicated that this dysfunction can last up to 2 weeks or theoretically longer in the human model (Giza and Hovda, 2001). Given that concussion is a metabolic, rather than structural injury, traditional neurodiagnostic techniques (e.g. CT scan, MRI, Neurological Exam) are almost invariably normal following concussive insult (McAllister et al., 2001). It should be stressed, however, that these techniques are invaluable in ruling out more serious pathology (e.g. cerebral bleed, skull fracture) that may occur with head trauma. Understanding the metabolic process of concussion in the human model is premature, but this model of pathology raises many questions regarding the threat of vulnerability, how long it lasts, and the potential synergistic effects of multiple injuries. It has been postulated that metabolic dysfunction, until fully resolved, may lead to significantly increased neurological vulnerability if a subsequent trauma (even minor) is sustained. Such metabolic dysfunction is theoretically linked to second impact syndrome (Cantu and Voy, 1995) and may also form the basis for the less severe, though occasionally incapacitating, presentation of post-concussion syndrome. Clearly, progress is being made in understanding the pathophysiology of concussive injury, and how management likely plays a critical role in preventing cumulative morbidity of injury. Recognition of Concussion: The First Step in Management

As outlined above, restoring the post-injury neurophysiological homeostasis in the brain following concussive injury is of critical importance in preventing poor outcomes, protracted recovery, and increased vulnerability to recurrent injury. In short, once the pathophysiological process of concussion begins, subsequent sub-threshold contact and even exertion can lead to worsening presentation of injury. Table 1 outlines the common signs/ symptoms of concussive injury. It should be stressed that sideline presentation of symptoms may vary widely from athlete to athlete, depending on the biomechanical forces involved, severity of injury, and specifically affected brain areas. For example, a posterior blow to the head may more likely produce a loss of consciousness (due to reticular activating system dysfunction), and result in a constellation of sympBRAIN INJURY PROFESSIONAL

toms such as visual changes, incoordination, and fatigue. Conversely, cortical blows may potentially result in a set of symptoms characterized more by amnesia, “fogginess,” personality changes, and ongoing deficits with complex attention and memory. As such, less severe injuries will often produce circumscribed symptoms, whereas more severe trauma will produce a constellation of symptoms. Insights into prognosis, expected recovery time, and severity of biomechanical force related to injury can be gleaned thru a detailed symptom interview and understanding of the functional aspects of injury. Signs of Concussive Injury

Appropriate acute care and management of the concussed athlete begins with a detailed and accurate assessment of the severity of the injury. As with any serious injury, the first priority is always to evaluate the athlete’s level of consciousness and ABCs (airway, breathing, and circulation). Loss of Consciousness

Upon ruling out more severe injury, the acute evaluation continues with assessment of concussion. First, the clinician should establish whether a loss of consciousness (LOC) has occurred. By definition, LOC represents a state of brief coma in which the eyes are typically closed and the athlete is unresponsive to external stimuli. LOC is relatively rare in sports concussion and occurs in less than 10% of injuries. Moreover, prolonged LOC (<1-2 minutes) in sports-related concussion occurs much less frequently. Athletes with LOC are typically unresponsive for only a brief period of time, sometimes only one to two seconds, which may at times make LOC difficult to diagnose, as it often takes medical personnel at least several seconds to get to the injured athlete on the field, rink, or court. Any athlete with documented LOC should be managed conservatively and return to play in the same game is contraindicated. Confusion

A more common form of mental status change following concussion involves confusion and amnesia. Confusion (i.e. disorientation), by definition, represents impaired awareness and orientation to surroundings, though memory systems are not directly affected. An athlete demonstrating post-injury confusion will typically appear stunned, dazed, or “glassy-eyed” on the sideline or playing field. Confusion is often manifested in athletes who do not remove themselves from play in the form of difficulty with appropriate play-calling, failure to correctly execute their positional assignment during play, or difficulty in communicating game information to teammates or coaches. Amnesia

Amnesia is emerging as perhaps the most important sign to carefully assess following concussion. Amnesia following concussion may present as retrograde amnesia (difficulty with memory of events prior to the injury) or post-traumatic/ anterograde amnesia (difficulty with memory for events following the injury). Both forms of amnesia should be assessed thoroughly and taken very seriously in the evaluation and management of sport-related concussion. Athletes who present with one or both types of amnesia may initially have difficulty recalling large spans of time either before or after the injury (or both), though these larger periods of amnesia will frequently shrink as the injury becomes less acute. The presence of amnesia, even if for only 10 BRAIN INJURY PROFESSIONAL

Table 1

Signs/Symptoms of Sports Concussion

SIGNS OBSERVED BY COACHES, PARENTS, MEDICAL STAFF

SYMPTOMS REPORTED BY ATHLETE

Appears to be dazed or stunned

Headache (Pressure related)

Is confused about assignment

Nausea

Forgets plays

Balance problems or dizziness

Is unsure of game, score or opponent

Double or fuzzy vision

Moves clumsily

Sensitivity to light or noise

Answers questions slowly

Feeling sluggish

Loses consciousness (even temporarily)

Feeling foggy

Shows behavior or personality change

Change in sleep pattern

Forgets events prior to hit (retrograde)

Concentration or memory problems

Forgets events after hit (anterograde)

Fatigue

a few seconds, has been found to be predictive of post-injury cognitive deficits and post-concussion symptoms (Collins et al., 2003). Symptoms of Concussion Headache

Headache is the most commonly reported symptom of concussion and has been reported in up to 70% of athletes with this injury. However, the absence of headache does not rule out a diagnosis of concussion, highlighting the importance of a thorough assessment of all symptoms. Assessment of postconcussion headache may be complicated by the presence of musculoskeletal headaches and other preexisting headache syndromes. However, any presentation of headache following a blow to the head or body should be managed conservatively. Most frequently, a concussion headache is described as a sensation of pressure in the skull that may be localized to one region of the head or may be generalized in nature. In some athletes (particularly athletes with a history of migraine), the headache may take the form of a vascular headache, may be unilateral, and is often described as throbbing or pulsing. Most commonly, post-concussion headache is worsened with physical exertion. Thus, if the athlete complains of worsening headache during exertional testing or return to play, post-concussion headache should be suspected and conservative management is indicated. Headaches due to concussion may not develop immediately after injury, and in fact, may not develop until many hours after injury, again underscoring the need to assess symptoms at multiple time points post-injury. It should be stated that the quality and location of the reported concussion headache seems to be consistent across the duration of recovery, and will infrequently “move” in terms of location or change in terms of quality (e.g. pressure type feeling in head). Other Common Symptoms

In addition to headache, many other symptoms may emerge as the result of a concussive injury. Balance problems, incoordination, or dizziness may also be reported. Moreover, an athlete may report increased fatigue, feeling slowed down (cognitively or physically), or feeling lethargic. Fatigue is especially common in concussed athletes in the days following injury, and from a clinical perspective, seems to occur almost as frequently as headache. Often athletes may report brief changes in vision as a result of concussion. These changes may include blurred vision, changes in peripheral vision, or seeing “spots” or “lines,” among

other visual disturbances. Additionally, athletes may report cognitive changes, including problems with attention, concentration, short-term memory, learning, and multitasking. Another frequently reported symptom which has gained recent research attention is a reported sensation of feeling “foggy” following concussion (Iverson et al., 2004). Such data has shown that the presence of “fogginess” post-injury may result in a more severe presentation of difficulties and more protracted recovery. Significant Advances in Assessment and Management of Sports Concussion: The Utilization of Neurocognitive Testing

Perhaps the most significant advancement in the field of sports concussion has been the transition from a standard “grading scale” approach of managing injury to a more individualized and data-driven approach. In short, attempting to manage concussive injury with a “cookbook” approach is insufficient, as there is tremendous variability in injury presentation, outcomes, and associated risk factors. Thus, in discussing the current “paradigm shift” in managing sports concussion, perhaps the most significant advancement in the field is the development and clinical implementation of neurocognitive testing programs that allow for a reliable and valid approach to quantifying the injury, tracking athletes in terms of recovery, and providing a dependent variable to effectively research individual factors in recovery. Because concussion is a “functional” rather than “structural” brain injury, neurocognitive testing has recently been deemed the “cornerstone” of proper concussion management through the implementation of baseline testing (pre-season/pre-injury) and subsequent post-injury evaluations conducted until recovery is complete (Concussion in Sport Group, 2002). During the initial stages of recovery from sports concussion, computer-based neurocognitive testing procedures have a number of advantages and relatively few disadvantages when compared to more traditional (i.e., “paper and pencil” tests) neuropsychological testing procedures. First, the use of computers allows for the evaluation of large numbers of student athletes with minimal manpower. This promotes the baseline assessment of an entire athletic team within a reasonable time period using minimal human resources. Second, data acquired through testing can be easily stored in a specific computer or computer network, and can therefore be accessed at a later date (e.g. following injury). Not only does computerized testing promote the efficient clinical evaluation of the athlete, but it also greatly expands the possibilities for research. Third, the use of the microcomputer promotes the more accurate measurement of cognitive processes such as reaction time and information processing speed. In fact, computerized assessment allows for the evaluation of response times that are accurate to 1/100 of a second while traditional testing only allows for accuracy up to 1-2 seconds. Fourth, the utilization of the computer allows for the randomization of test stimuli that may help to improve the reliability of data across multiple administration periods, minimizing the “practice effects” that naturally occur with multiple exposures to the stimuli. Lastly, computer-based approaches allow for the rapid dissemination of clinical information into a coherent clinical report that can be easily interpreted by the sports medicine clinician. In summary, there are many benefits derived from a computer-based approach insofar as the technology has appropriate sensitivity, reliability, and validity to measuring the subtle aspects of concussive injury. It should be noted that more comprehensive neuropsychological

testing may be indicated in the post-acute management of injury as well as for athletes who exhibit protracted and complicated recoveries. Some clinicians even utilize a “hybrid” approach of both computerized and paper and pencil test batteries to better delineate an athlete’s status. Table 2 outlines recent studies examining acute outcomes from sports concussion where a baseline/post-injury methodology is employed. Such data highlight that the type of test employed (computerized versus paper/pencil testing), as well as age, may play significant roles in measured outcomes and length of recovery from injury. The only potential disadvantage of computer-based neuropsychological testing involves its inappropriate utilization as a “stand-alone” diagnostic instrument. This approach fails to recognize the complexity of the injury and may not incorporate other pertinent data, such as a detailed clinical interview, overall symptom presentation, medical/concussion history and the results of other diagnostic studies (e.g. balance testing, vestibular assessment, etc). At the current time, there are several computer-based management approaches that have been developed and validated to help determine management and return to play issues following concussive injury. Specifically, four computer-based models have been detailed in the scientific literature. These include ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), CogState, Headminders, and ANAM (Automated Neuropsychological Assessment Matrices). Each of these test batteries have examined important aspects of reliability and validity in their approach to measuring concussive injury and specific computerized test batteries have published additional data examining sensitivity/specificity of their test battery, as well as the “added value” of their assessment tool when compared to the assessment of symptoms in isolation (Schatz et al., 2006; van Kampen et al., 2006; Fazio et al., In Press). The adoption of computerized neurocognitive testing programs has now reached wide-scale implementation across all levels of sport participation. For example, the National Football League, as well as the National Hockey League have mandated baseline/post-injury computerized neurocognitive testing for their athletes. Moreover, computerized concussion management programs are now being utilized across major professional sports organizations, such as Major League Baseball, US Lacrosse, USA Rugby, USA Soccer, and across all four branches of the United States Military. Statewide programs are even occurring at high school levels of sport participation (see accompanying article by Savage et al.), and up to 2,000 high schools nationally conduct baseline and post-injury computerized neurocognitive testing. The implementation of these programs, as well as more general educational efforts by the Centers for Disease Control (see accompanying article) have led to an all-time high regarding general increased awareness and appreciation of sports concussive injury. Innovations in Treatment and Rehabilitation

There is also a shift in focus on treatment and rehabilitation with the concussed athlete. Recent factor analytic work done by our group at the University of Pittsburgh has highlighted four distinct symptom factors in a large scale of concussed athletes. These findings are depicted in Figure 2. Specific treatment recommendations (see article by Reddy and Lombard) may also include pharmacologic interventions based upon symptom clusters (i.e. concussion subtypes) that the BRAIN INJURY PROFESSIONAL

Factor Analysis, Post-Concussion Symptom Scale (Pardini et al. 2004)

figure 2

Emotionality • More emotional • Sadness • Nervousness • Irritability

Cognitive Symptoms • Attention Problems • Memory dysfunction • “Fogginess” • Fatigue • Cognitive slowing

Somatic Symptoms • Visual Problems • Dizziness • Balance Difficulties • Headaches • Light Sensitivity • Nausea

Risk Factors for Protracted Recovery

Sleep Disturbance • Difficulty falling asleep • Sleeping less than usual

N=327, High School and University Athletes Within 7 Days of Concussion

Recovery Rates Vary by Age/Dependent Measure

Table 2 Authors

Sample Size

Population

Tests Utilized

Total Day Cognitive Resolution

Total Days Symptom Resolution

Lovell et al 2005

Pro (NFL)

Paper and Pencil

1 day

Echemendia 2001

College

Paper and Pencil

2 days

McCrea et al. 2003

College

Paper and Pencil

5-7 days

7 days

Guskiewicz 2003

College

Balance BESS

3-5 Days

7 Days

Bleiberg et al. 2005

College

Computer ANAM

3-7 days

Did Not Evaluate

Iverson et al. 2006

High School

Computer ImPACT

10 days

7 Days

McClincy 2006

104

High School

Computer ImPACT

14 days

7 Days

Table 3

WEEK 4

WEEK 3

WEEK 5

WEEK 2

Recent research has also highlighted specific risk factors that appear to result in more protracted recovery in athletes sustaining concussive injury. Such factors include a preexisting history of learning disability (Collins et al., 1999) prior history of concussive injury (Guskiewicz et al., In Press; Collins et al., 2002), and, as outlined previously, younger age (Field et al., 2003). Moreover, recent and other forthcoming published research indicates that athletes experiencing post-traumatic migraine-type symptoms (e.g. pressure headache with photo/phonophobia, nausea, visual changes, dizziness, and/or vomiting) exhibited longer recovery and that the issue of migraine plays a significant role in recovery (and perhaps treatment strategies) (Mihalik et al., 2005). Additionally, a recent paper has examined the role of exertion on recovery from injury, and such data clearly indicates the need for moderation of physical and cognitive exertion during the acute stages of recovery (Majerske et al., In Press). Criteria for Return to Play

In terms of clinical practice, there are now data-driven protocols available to help manage an athlete following sports concussion injury and, fortunately, many informed clinicians are practicing these protocols. Prevailing standards of care require an athlete to satisfy three general conditions before returning to play. First, the athlete must demonstrate that he/she is completely symptom free at rest. Once asymptomatic at rest, the athlete is then progressed through increasing non-contact physical exertion, until he/she has demonstrated asymptomatic status during heavy non-contact physical exertion and non-contact sport-specific training. It is important to clarify that the athlete should also be completely asymptomatic with cognitive exertion (as well as physical). Third, there is increasing evidence and agreement that the athlete should demonstrate intact neurocognitive functioning prior to return to sport participation.

No Previous Concussions

N=134 High School athletes Based upon ImPACT Test Results

38 40 +

33 35 37

27 29 31

23 25

17 19 21

13 15

All Athletes

9 11

The three prevailing criteria for return to play are as follows: 5

Recovery From Concussion How it Takes for Athletes How Long Does it TakeLong in Athletes?

WEEK 1

100 90 80 70 60 50 40 30 20 10 0

ma, though 20% will have “protracted” recovery. If these athletes have associated functional deficits with school, severe symptoms, and other difficulties, pharmacologic intervention may be indicated. Moreover, given the strong relationship between exertion and recovery, there has been a focus by our group and others to create specific concussion rehabilitation protocols that focus on graded exertional protocols from both a physical and cognitive perspective. Research is forthcoming regarding this issue.

1 or More Previous Concussions

Collins et al. Neurosurgery, 2006

athlete may be experiencing. One may hypothesize that severity of concussive injury may be predicated upon the overlap and degree of these symptoms clusters. From a treatment standpoint, it has been our philosophy to avoid pharmacologic intervention until the athlete is at three weeks or longer into recovery and there is some functional disability as it relates to the experienced symptoms (difficulties in school, severe symptoms, etc). Table 3 highlights a recent study utilizing baseline and post-injury ImPACT testing and typical rates of recovery in a concussed high school population. Based upon this data, one can see that 80% of athletes will spontaneously recover within three weeks of trau12 BRAIN INJURY PROFESSIONAL

1. Asymptomatic Status at Rest

Separately or in conjunction with administration of a neurocognitive test battery, the athlete should complete a symptom inventory or symptom interview both on the sideline (may be brief ) and serially throughout recovery. Before progressing to any significant level of physical exertion, the athlete should report being completely asymptomatic at rest. If the athlete’s report of asymptomatic status is suspected to be false, a careful discussion of the importance of reporting all symptoms should be initiated with the athlete. Moreover, such cases should certainly be augmented with formal neurocognitive testing. 2. Asymptomatic Status with Physical Exertion

As an athlete demonstrates being asymptomatic at rest, he or she should begin a graduated return to physical (and cognitive) exertion prior to contact participation, as post-concussion dif-

ficulties may evolve with increased metabolic demands. International consensus recommendations have suggested a graduated exertional protocol. Such a protocol may involve the athlete successfully moving through the following exertional stages: (1) light aerobic exercise (walking, stationary biking), (2) sportspecific training (ice skating in hockey, running in soccer- typically moderately exertional), and (3) non-contact training drills (heavily exertional, including heavy weight training, sprints, all positional maneuvers, etc). If the athlete’s previously resolved post-concussion symptoms return at any point during the graded return to physical exertion, the athlete should return to the previous exertion level at which they were last asymptomatic. In addition to physical exertion, cognitive exertion should be closely monitored along with its overall relationship to symptoms. It should be noted that physical and cognitive exertion may have different effects on symptoms and resolution of difficulties under both conditions should be met (especially in student athletes). Clearly, considerations according to prior history of concussion and outcome from previous concussion, as well as any suspected deception in the athlete’s symptom reporting may influence return to participation and management directives. 3. Intact Neurocognitive Functioning

Post-injury assessment in the form of neurocognitive testing should also be considered to help determine overall management and return-to-participation issues. Cognitive recovery is considered achieved when the athlete’s performance either returns to baseline levels or, in the absence of baseline, is consistent with premorbid estimates of functioning when the test data are compared to normative values (clinicians should utilize test batteries that have readily available athlete-specific norms). As described above, a pre-season or baseline neuropsychological assessment would be a helpful tool against which to compare post-injury functioning to “normal” functioning for the injured athlete. Many practitioners prefer to complete acute and serial follow-up evaluations in order to gain insight into the extent and type of cognitive impairment created by the injury. Such data can help with prognosis (Iverson et al., 2007), help to determine when the athlete may return to exertion, and may also help to provide academic recommendations and accommodations. Once the athlete has been cleared medically, is symptom free at rest and with physical exertion, and within expected levels on cognitive testing, he/she may return to full-contact training, and then to competition. Such evidence-based parameters are becoming the “gold standard” for return to sport participation following concussion and are becoming widely implemented at all levels of sports participation. Summary

The field of sports concussion management has evolved rapidly over the past several years. There has been more data published regarding this injury in the past 10 years, than the previous 100 combined. Management has seemingly evolved to much more individually-driven management protocols that have been formulated through scientific evidence and the labors of many researchers across the world. The days of generally grading a concussion at the time of injury, and then having the athlete sit out a week, or perhaps two (or even perhaps going into the same game), is being replaced with safer and more prudent evidence-based management parameters. Relatedly, data is now available to better understand the phenomenology of sports concussion, risk factors, typical outcomes, effects of repetitive

injury, subtypes of concussive injury, and even treatment and rehabilitation protocols. In short, we as a field have learned a tremendous amount over the past several years and, yes, we are in the midst of a “paradigm shift” for managing and treating this injury. Notably, however, research on paradigm shifts have elucidated that it takes, on average, 17 years for shifts to occur from the inception of the idea to true standard medical practice. As if not challenging enough to provide evidence-based management protocols, we as a field also bear the responsibility of educating parents, coaches, athletes, and, perhaps most important, clinicians regarding these management advances. It is an exciting time to be involved in the “subspecialty” of sports concussion management, though much more work needs to be done. About the Author

Michael Collins, PhD, a nationally renowned sports concussion clinician and researcher, joined the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program as assistant director when the program was established in September 2000. The program encompasses an ongoing clinical service and research team whose focus is providing the best possible evaluation and management of sports-related concussions in athletes of all levels. Referencess Langlois JA, Rutland-Brown W, and Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma Rehabilitation. 21(5): 375-8, 2006. Congress of Neurological Surgeons. Committee on Head Injury Nomenclature: Glossary of Head Injury. Clinical Neurosurgery. 12:386–94, 1966. Quality Standards Subcommittee, American Academy of Neurology. Practice parameter: the management of concussion in sports. Neurology. 48:581-5, 1997. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the first International Conference on in Sport, Vienna 2001. Clinical Journal of Sports Medicine. 12(1):6-11, 2002. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the second International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine. 39:196-204, 2005. Giza CC and Hovda DA: The neurometabolic cascade of concussion. Journal of Athletic Training. 36:228–235, 2001 McAllister TW, Sparling MB, Flashman LA, et al. New developments in management of sports concussion: Neuroimaging Findings in Mild Traumatic Brain Injury. Journal of Experimental and Clinical Neuropsychology. 23(6):775-791, 2001. Cantu RC and Voy R. Second impact syndrome: a risk in any contact sport. Physician and Medicine. 23:27-34, 1995. Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sports Medicine. 13:222-229, 2003. Iverson GL, Gaetz M, Lovell MR, et al. Relation between subjective fogginess and neuropsychological testing following concussion. Journal of the International Neuropsychological Society. 10(6): 904-906, 2004. Concussion in Sport Group: Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clinical Journal of Sport Medicine. 12:6-11, 2002. Schatz, P, Pardini, JE, Lovell MR, et al. Sensitivity and Specificity of the ImPACT Test Battery for Concussion in Athletes. Archives of Clinical Neuropsychology. 21, 91-99, 2006. van Kampen D, Lovell MR, Collins MW, et al. The “Value Added” of neurocognitive testing in managing sports concussion. American Journal of Sports Medicine. 34 (10), 1630-1635, 2006. Fazio V, Lovell MR, Pardini J, et al. The relationship between post-concussion symptoms and neurocognitive performance in concussed athletes. Neurorehabilitation (special issue). In press. Collins MW, Lovell MR, and McKeag DB. Current issues in Managing Sports-Related Concussion. Journal of the American Medical Association. 282(24), 2283-2285, 1999. Guskiewicz KM, McCrea M, Marshall SW, et al.: Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA concussion study. Journal of the American Medical Association, In Press. Collins MW, Lovell MR, Iverson G, et al. Cumulative effects of concussion in high school athletes. Neurosurgery. 51:1175-1181, 2002. Field M, Collins MW, Lovell MR, et al. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics. 142(5), 546-553, 2003. Mihalik J, Stump J, Collins MW, et al. Posttraumatic migraine characteristics in athletes following sports-related concussion. Journal of Neurosurgery. 102:850-855, 2005. Majerske CW, Milhalik JP, Dianxu R, et al. Concussion in sports: The effect of post-concussive activity levels on symptoms and neurocognitive performance. Journal of Athletic Training. In Press. Iverson G. Predicting slow recovery from sports-related concussion: the new simple-Complex distinction. Clinical Journal of Sport Medicine. 1731-37, 2007. BRAIN INJURY PROFESSIONAL

Ten Steps and Commitments for an Effective Youth Sports Concussion Program Gerard A. Gioia, PhD Concussions, or mild traumatic brain injuries (mTBI), are becoming a better recognized reality in sports. Early identification, diagnosis, and individualized management of an mTBI have arguably greater importance than any other sports-related injury. Effective management of concussions in youth sports is essential to reduce long-term negative outcomes. Yet organized concussion management systems in youth sports are infrequent compared with collegiate and professional sports. To address the need to establish effective concussion management systems in youth sports, we present a brief synopsis of ten programmatic steps and commitments. Three goals must be considered in a sports concussion program. First, safeguard the student-athlete; brain injuries require the highest level of caution and conservative decision-making. Second, facilitate speedy recovery and return to sports and other life activities through proper treatment; early identification, immediate individualized treatment, and careful recovery monitoring are paramount. Third, reduce the athletic program’s risk and liability; with current information regarding concussion management (e.g., Vienna statement, Aubry et al., 2002; NATA Position Statement, Guskiewicz et al., 2004; Lovell et al., 2004), there is no defensible argument for unawareness of risks of concussion to student-athletes (Osborne, 2001). Instituting a proper sports concussion program applying best practices is a reasonable means to safeguard student-athletes and reduce organizational risk.

Ten Steps in the Concussion Management Process 1. Pre-Injury Knowledge and Preparation: A preseason educational program, directed toward coaches’, players’ and parents’ informational needs (e.g., CDC Coaches and Physician’s Toolkits) is an essential first step. A basic understanding of the injury, its evaluation and treatment, promotes compliance and investment. 2. Preseason Baseline Testing: Baseline testing by properly trained professionals should be conducted for neuropsychological function, postural stability/ balance (Riemann & Guskiewicz, 2000), and pre-injury symptoms to serve as comparison with post-injury evaluation. Obtaining baseline symptom reports from parents is recommended for young athletes. 14 BRAIN INJURY PROFESSIONAL

3. Injury monitoring system: The most challenging step is instituting an active system for early recognition of concussion. Responsible person(s) must be defined for this role, ideally a certified athletic trainer (ATC) or, if unavailable, a trained alternative (e.g., parent or assistant coach). There are useful reference materials to assist recognition of signs/ symptoms (e.g., CDC Coaches/ Physician’s Toolkit sideline concussion cards). 4. Early On-Field/ Sideline Identification: Once a concussion is suspected, a protocol must be initiated to evaluate the player, including an effective sideline evaluation tool. A trained health professional should conduct the evaluation. If not available, the student-athlete is removed from play with referral to an appropriate health professional for evaluation. 5. Informed Decision: Evidence of concussion? Determining whether a concussion occurred is the first informed decision. Basic criteria include evidence of forcible blow to the head, and evidence of associated onset of signs or symptoms. With certain significant signs/ symptoms - loss of consciousness greater than several seconds, worsening level of consciousness, repeated vomiting, seizure, significant confusion – referral to the emergency room is warranted. 6. Post-Injury Clinical Evaluation: Following diagnosis, the post-injury clinical evaluation is conducted, providing an in-depth assessment of the student-athlete’s neurocognitive dysfunction (e.g., attention, working memory, new learning and memory, cognitive processing speed, reaction time), postural stability, and symptoms. The broad effects of injury upon school learning, home activity, social-emotional function, and sports participation must be evaluated. 7. Communication and Coordination: With early diagnosis and evaluation, treatment plan coordination among family, medical, athletic, and school systems is essential to facilitate consistent management and recovery. 8. Comprehensive Treatment: Appropriate recovery requires active management of the brain injury in all phases of the student-athlete’s life. Effective rest is the key to recovery. Written treatment plans guide physical and mental activity in all activities - sports, social/recreational, and academics. Neuropsychological testing guides individualized data-driven

recommendations for treatment. 9. Informed Decision: Return to Baseline Functioning?: Return to baseline decisions require explicit criteria for recovery, and consistent application to the student-athlete’s clinical condition. Published guidelines (e.g., NATA position statement, Guskiewicz et al., 2004; Aubry et al., 2002) define recovery as asymptomatic with return of neuropsychological and balance functions to pre-injury baseline levels, at rest and after the gradual exertional protocol. 10. Gradual Return To Play (RTP) protocol: With return to pre-injury baseline functioning at rest, an appropriately trained health care provider (e.g., athletic trainer) initiates the gradual RTP exertional protocol following established guidelines (e.g., Concussion in Sport Group, Aubry et al., 2002). Careful attention is paid to resumption of symptoms at each stage of exertion.

Ten Commitments to Program Success To implement effectively the ten programmatic steps, the youth sports program must commit to the following: 1. Top-down administrative commitment and support: Successful program implementation requires strong support from the leadership of the youth sports program. Programs will face inconsistent implementation, at best, without full administrative support. Appropriate time and personnel must be committed to the necessary tasks for an effective program. 2. Program buy-in at all levels of the organization: The sports concussion program is only as effective as its weakest link. Any compromise in implementation will result in reduced effectiveness and increased risk to the student-athlete. All athletes, family members, coaches, and athletic/personal health professionals must accept the program goals and follow the policies and procedures to meet the program goals successfully. 3. Modifying the “play with pain” culture: When an injury to the brain is concerned, the athletic culture must not promote the “play with pain” mentality. An effective program demonstrates positive reinforcement for players’ healthy reporting of concussion symptoms. Players are not viewed as weak for reporting concussion signs and symptoms. 4. Developing the sports concussion team: An effective program requires appropriate leadership, training and supervision from a team of healthcare and athletic professionals with expertise in managing sports concussions. This requires developing affiliations with athletic trainers, sports neuropsychologists, and sports medicine physicians, each providing an important and essential role to the evaluation and management of sports concussion. 5. Orientation and training of all personnel: All involved individuals participate in training in the knowledge and skills associated with their roles and responsibilities, including the student-athlete, family, athletic, academic, and medical personnel. 6. Defining clear roles, policies and procedures, and criteria for decision-making: Clearly written program policy and procedures are important to standardize the sports concussion program. Team member roles are clearly defined. Clear, specific criteria for decision-making are established for recognition/ diagnosis of concussion, removal from play, and recovery/return. 7. Communication among key parties and processes: An

effective program defines the appropriate means and timing of communications at various stages of recovery to clarify the student-athlete’s needs and associated plan for recovery for all involved. 8. Written documentation at each stage: Written documentation of findings, decisions, and treatment plans are necessary at each stage of the process to facilitate effective care and recovery. Standardized assessment protocols, treatment plans, and progress monitoring tools are important to facilitate documentation. 9. Definition and treatment of all post-concussion needs: While the primary focus of the student-athlete may be a speedy return to sports participation, an effective program must commit to a broader focus including academic and social-emotional functioning. 10. Program Evaluation: Systematic data collection and analyses of outcomes: An effective program evaluates its effectiveness in meeting goals, making program adjustments as needed. Evaluation can be directed at specific program steps (e.g., success of pre-season educational program, application of decision rules) and/or at a broader set of outcomes (e.g., total number of student-athletes identified, mean length of recovery time, parent satisfaction).

Summary Youth sports programs must take seriously the risks of traumatic brain injuries in student-athletes. Implementing an effective sports concussion management program is essential to safeguard young participants and reduce long-term risks. Toward this end, we describe ten steps and commitments necessary for an effective program. Management of this serious injury must consider the varied effects in the home, school, social, and sports environments. While specifics of program design and implementation may vary with the type of sport, age and level of the studentathlete, and availability of program resources, the ten steps and commitments will guide youth sports organizations in establishing early identification, diagnosis and coordinated, individualized management. About the Author

Gerard A. Gioia, Ph.D., Associate Professor, Director, Pediatric Neuropsychology Program, Director, Safe Concussion Outcome, Recovery & Education (SCORE) Program Children’s National Medical Center, Department of Pediatrics and Psychiatry, George Washington University School of Medicine.

References

1. Aubry, M., Cantu, R., Dvorak, J., et al., Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clinical Journal of Sport Medicine. 12: 6-11, 2002. 2. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Concussion in High School Sports. Atlanta (GA): Centers for Disease Control and Prevention; 2005. http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. 3. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Brain Injury in Your Practice. Atlanta (GA): Centers for Disease Control and Prevention; 2007. http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm. 4. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Concussion in Youth Sports. Atlanta (GA): Centers for Disease Control and Prevention; 2007. 5. Guskiewicz, K.M., Bruce, S.L., Cantu, R.C. et al., National Athletic Trainers’ Association Position Statement: Management of sport-related concussion. Journal of Athletic Training, 39, 280-297. 6. Lovell, M.R., Echemendia, R.J., Barth, J.T., & Collins, M.W. Traumatic Brain Injury in Sports: An International Neuropsychological Perspective. Exton, PA: Swets & Zeitlinger, 2004. 7. Osborne, B. Principles of liability for athletic trainers: Managing sport-related concussion. Journal of Athletic Training, 36: 316-321, 2001. 8. Reimann, B.L. & Guskiewicz, K.M. Effects of mild head injury on postural stability as measured through clinical balance testing. Journal of Athletic Training, 35: 19-25, 2000. BRAIN INJURY PROFESSIONAL

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Sports-Related Concussion: New Frontiers in Neuroimaging

Jamie E. Pardini, PhD, Mark R. Lovell, PhD, and Andrew Wroblewski, PhD

Recently, our understanding of sports-related concussion (SRC) has been enhanced through the implementation of research exploring the impact of the injury on physiological correlates of brain functioning. Particularly, functional MRI, PET, SPECT, and electrophysiological studies have provided insight into potential long-term and short-term sequelae of the injury that extend beyond descriptions of the symptomatic and cognitive impairment that mild brain injuries can produce. This is especially helpful, given that a concussion cannot be detected using traditional neuroimaging procedures, such as magnetic resonance imaging (MRI) or computerized axial tomography (CT scan). fMRI and SRC

To date, functional magnetic resonance imaging (fMRI) research has provided insight into the physiological consequences of SRC. Across research studies, changes in brain activation are observed in even mild cases of SRC, either when compared to controls (e.g., Chen et al., 2004; Jantzen et al., 2004) or pre-injury baseline neuroimaging (e.g., Jantzen et al., 2004). Patterns of activation on fMRI are often related to cognitive dysfunction on neuropsychological testing (e.g., Lovell et al., 2007; Chen et al., 2007). However, in many fMRI studies, even when concussed athletes’ performance on in-scanner cognitive tasks is equivalent to that of control athletes, they continue to demonstrate differential activation patterns, both diffusely and within specific regions of interest (e.g., Chen et al., 2004; Chen et al., 2007; Lovell et al., in press; Jantzen et al, 2004). Figure 1 depicts activation from a sample of concussed athletes, and Figure 2 illustrates a case example of concussion-related hyperactivation and resolution of hyperactivation with recovery from concussion in a motocross athlete, along with an example of typical activation in a control athlete. Furthermore, extent of hyperactivation in concussed athletes has recently been found related to clinical recovery time in one study (Lovell et al., 2007). In this sample of athletes who underwent fMRI scanning approximately 1 week after concussion, athletes who exhibited the greatest degree of hyperactivation took significantly longer to recover, when compared to the rest of the sample. fMRI and SRC studies have also examined the relation between functional activation and symptom status. Correlations between post-concussion symptoms and activation have been observed in concussed athletes (Chen et al., 2007; Lovell et al., 2007; Pardini et al., 2006). Recent research using athletes who had experienced “complex concussions” (as defined by Concussion in Sport Group 18 BRAIN INJURY PROFESSIONAL

at the 2004 Prague Conference; McCrory et al., 2005) and continued to experience symptoms at least 1 month, and on average 5 months, post-injury, found differences in task performance and functional activation when comparing athletes reporting low levels of post-concussion symptoms to those reporting moderate levels of symptoms (Chen et al., 2007). Overall, results of this study indicated that athletes with complex concussions and moderate levels of post-concussion symptoms were more inaccurate and slower on cognitive tasks, and demonstrated reduced activation in the frontal lobes while performing working memory tasks. Although athletes with lower levels of post-concussion symptoms demonstrated no differences in performance on cognitive testing when compared to a control group, they did show reduced activation in the prefrontal regions when compared to control athletes. Similarly, Lovell et al. (2007) found that lower activation in a posterior parietal network of brain regions while completing a working memory task was associated with higher report of cognitive and somatic symptom clusters in recently concussed athletes (mean 6.6 ± 4.7 days post-injury). Current research also suggests that, while an athlete is still experiencing symptoms of concussion, the brain may recruit regions outside of those typically associated with task performance in an un-injured brain (Chen et al., 2007; Pardini et al., 2006). This may represent a compensatory physiological mechanism for the successful completion of working memory tasks while the brain is injured. Electrophysiological data and SRC

In addition to fMRI, electrophysiological studies have demonstrated differential activation in concussed versus non-concussed athletes. Electroencephalographic abnormalities have been observed in athletes with concussion and mild head injury (e.g. Korn et al., 2005; Slobounov et al., 2002). Studies using eventrelated potentials have shown attenuated P300 (Gosselin et al., 2006; Lavoie et al., 2004), N1 (Gosselin et al., 2006), and P2 (Gosselin et al., 2006) amplitudes in symptomatic concussed athletes when compared to control athletes. Lavoie et al., 2004 found that symptomatic concussed athletes also demonstrated reduced P300 amplitudes when compared to asymptomatic concussed athletes. In contrast, the Gosselin study (2006) found that asymptomatic concussed athletes had reduced P300, N1, and P2 amplitudes when compared to control athletes. Furthermore, symptom severity was inversely related to P300 amplitude (Lavoie et al., 2004). Also, athletes with histories of 3 or more concussions demonstrated longer P300 latencies when

compared to athletes who had never experienced a concussion (Gaetz, Goodman, & Weinberg, 2000). Neuroimaging in non-athlete mTBI populations

Neuroimaging research examining consequences and correlates of mild traumatic brain injury and concussion has chiefly utilized non-athlete populations. From these studies, SRC clinicians and researchers have also gained insight about SRC injuries. Differential activation to working memory tasks using fMRI have been found in patients with mild head injuries when compared to healthy controls (Chen et al., 2003; McAllister et al., 1999; McAllister et al., 2001). Consistent with SRC neuroimaging studies, differences in activation can be seen in absence of task performance differences when comparing individuals with mTBI and controls (e.g., McAllister et al., 1999; McAllister et al., 2001). Cortical and subcortical abnormalities on PET (Umile et al., 2002) and SPECT (Agrawal et al., 2005; Umile et al., 2002) imaging have been observed in mTBI patients, and were found to be comparably sensitive to neuropsychological testing in detecting abnormalities due to mTBI (Umile et al., 2002). Electrophysiological research also reveals abnormal brain functioning in patients with mild brain injuries (e.g., Geets & de Zegher, 1985). Figure 1

fMRI data reveals hyperactivation in a sample of 13 concussed high school athletes.

Summary

Recent neuroimaging research has provided valuable insight into the physiological correlates of SRC, and has demonstrated relationships between these new tests and neuropsychological testing results and symptoms reported by the athlete. Future studies will likely further elucidate these relationships and increase their diagnostic specificity and clinical utility.

About the Authors

Jamie E. Pardini, Ph.D. is a neuropsycholgist and clinical researcher at the UPMC Sports Medicine Concussion Program. Dr. Pardini provides concussion evaluation and management for injured athletes, as well as brief psychotherapy services for athletes who experience emotional distress due to prolonged diffculty with sports-related head injuries. Mark R. Lovell, Ph.D., is an internationally recognized sports concussion expert and founding director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program. The program is the first and largest program of its kind to both clinically manage and scientifically study the neurocognitive effects of sports-related concussion and develop better methods of post-concussion evaluation to determine when it is safe for an athlete to return to sports following a concussion. Drew Wroblewski, Ph.D., is a senior at Bucknell University where he is majoring in biology and minoring in french. He spent the past summer as a research assistant with the UPMC sports concussion program in the department of orthopaedic surgery.

References

fMRI data

Figure 2 A

2A -- fMRI data from a concussed motocross athlete at 5 days post-injury (top) shows hyperactivation to a working memory task. When recovered at 20 days post-injury (bottom) hyperactivation has resolved. 2B -- fMRI data from a control subject scanned on two occasions demonstrates no evidence of hyperactivation to a working memory task at the Time 1 (top) or Time 2 (bottom) scans.

Agrawal, D., Gowda, N.K., Bal, C.S., Pant, M., & Mahapatra, A.K. Is medial temporal injury responsible for pediatric postconcussion syndrome? A prospective controlled study with singlephoton emission computerized tomography. Journal of Neurosurgery. 102: 167-171, 2005. Chen, J.K., Johnston, K.M., Frey, S., Petrides, M., Worsley, K., & Ptito, A. Functional abnormalities in symptomatic concussed athletes: an fMRI study. Neuroimage. 22: 68-82, 2004. Chen, J.K., Johnston, K.M., Collie, A., McCrory, P., & Ptito, A. (2007 March 19). A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. Journal of Neurology, Neurosurgery, & Psychiatry, DOI: 10.1136/jnnp.2006.110395. Retrieved from http://jnnp.bmj.com/cgi/content/abstract/ jnnp.2006.110395v1 Chen, S.H.A., Kareken, D.A., Fastenau, P.S., Trexler, L.E., & Hutchins, G. D. A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography. J Neurol Neurosurg Psychiatry. 74: 326-332, 2003. Gaetz, M., Goodman, D., & Weinberg, H. Electrophysiological evidence for the cumulative effects of concussion. Brain Injury. 14: 1077-1088, 2000. Geets, W., & deZegher, F. EEG and brain-stem abnormalities after cerebral concussion. Short term observations. Acta Neurologica Belgica. 85: 277-283, 1985. Jantzen, K.J., Anderson, B., Steinberg, F.L., & Kelso, J.A.S. A prospective functional MR imaging study of mild traumatic brain injury in college football players. American Journal of Neuroradiology. 25: 738-745, 2004. Korn, A., Golan, H., Melamed, I., Pascual-Marqui, R., & Friedman, A. Focal cortical dysfunction and blood-brain barrier disruption in patients with post-concussion syndrome. J Clin Neurophysiology. 22: 1-9, 2005. Lavoie, M.E., Dupuis, F., Johnston, K.M., Leclerc, S., & Lassonde, M. Visual P300 effects beyond symptoms in concussed college athletes. Journal of Continuing Education in Nursing. 26: 55-73, 2004. Lovell, M.R., Pardini, J.E., Welling, J.S., Collins, M.W., Bakal, J., Lazar, N., Roush, R., Eddy, WF., & Becker, J.T. Functional Brain Abnormalities Are Related to Clinical Recovery and Time to Return to Play in Athletes. Neurosurgery. 61:352-360, 2007. McAllister, T.W., Saykin, A.J., Flashman, L.A., Sparling, M.B., Johnson, S.C., Guerin, S.J., Mamourian, A.C., Weaver, J.B., and Yanofsky, N. Brain activation during working memory 1 month after mild traumatic brain injury: A functional MRI study. Neurology. 53: 1300-1308,1999. McAllister, T.W., Sparling, M.B., Flashman, L.A., Guerin, S.J., Mamourian, A.C., & Saykin, A.J. Differential working memory load effects after mild traumatic brain injury. Neuroimage 14: 10041012, 2001. McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M, Cantu, R., Dvorak, J., Graf-Baumann, T., Kelly, J., Lovell, M., & Schamasch, P. Summary and agreement statement of the 2nd international conference on concussion in sport, Prague, 2004. British Journal of Sports Medicine. 35(Supplement 1): 78-86, 2005. Pardini, J., Pardini, D., Roush, R., & Welling, J. (2006, June). Relation of Post-Concussion Symptoms to Functional Brain Activation in Concussed Athletes. Poster session presented at the annual meeting of the Organization for Human Brain Mapping Florence, Italy. Slobounov, S., Sebastianelli, W., & Simon, R. Neurophysiological and behavioral concomitants of mild brain injury in collegiate athletes. Clin Neurophysiology. 113: 185-193, 2002. Umile E.M., Sandel, E., Alavi, A., Terry, C.M., & Plotkin, R.C. Dynamic imaging in mild traumatic brain injury: Support for the theory of medial temporal vulnerability. Arch Phys Med Rehabil. 83: 1506-1513, 2002. BRAIN INJURY PROFESSIONAL

Pathophysiology of Sports Concussion: Are Kids Different?

Melvin Field, MD & Michelle Dolske, PhD

Introduction Perhaps in no other area of sports medicine is there more debate about the diagnosis and management of injured athletes than with sports-related concussions, also known as sports-related mild traumatic brain injury (mTBI). As more has been learned about mTBI in the athlete, an ever increasing number of centers of excellence have veered away from the previously used concussion scales and management algorithms and have turned towards neurocognitive analyses, balance testing, and detailed symptom analyses to diagnose, treat and determine return to play in the athlete. Despite significant advances, one of the common problems that remain in the management of sports-related concussion is an overwhelming percent of existing literature that assumes the mechanisms, symptoms, incidence, severity, recovery and longterm sequelae of concussion are age-independent. Of the nearly two thousand articles in the literature published over the past decade on mTBI and concussion, only 9 (0.46%) consider the possibility of age or development as variables when analyzing this condition. (Field and Dolske 2007) On the basis of the current common management strategies for sports-related concussion, it is assumed that the speed of recovery from injury is similar for all age groups. Recent research, however, is suggesting that like severe TBI, mild TBI may also be age dependent (Field et al 2003) (Pellman et al 2006). In an attempt to understand why sports-related concussion may be different based on age, this article will review the biomolecular and biomechanical differences between the developing child’s and the mature adult’s brain as pertaining to traumatic brain injury. Biochemical and Biomechanical Differences The exact underlying mechanisms that result in sports-related mTBI remain largely enigmatic, but current basic science models and clinical studies of severe TBI in humans provide clues to explain recently described age-related differences in recovery and severity seen in the athlete with sports-related concussion. 20 BRAIN INJURY PROFESSIONAL

For example, in 2002 Ommaya published his work demonstrating that brain tolerance to biochemical forces differs between adults and children. (Ommaya et al 2002) His study found that a 2-3 fold greater force of impact is needed to produce similar symptoms in children when compared to adults. Variations in the skull and brain with respect to geometry and size as well as constitutive structural properties of the head between an adult and child lead to these biomechanical differences. Differences in skull thickness, cerebrospinal fluid volume, brain tissue volume, water content, ventricular size and compensatory vascular channels biomechanically requires a greater impact force to induce concussive symptoms in the developing brain compared to the mature brain. (McCrory et al 2004). Research with respect to the brain’s biochemical response to injury also suggests theoretical differences between children and adults. Basic science research has shown that the immature brain may be up to sixty times more sensitive to excitatory amino acids (EAA) than the mature brain and that the resultant neurotoxic cellular calcium accumulation concentrations and durations of elevations after TBI are age-dependent (McDonald et al 1990) (McDonald et al 1988) (Osteen et al 2001). This hypersensitivity in the developing brain makes it more susceptible to the injurious effects of EAAs after TBI than the mature brain (Grundl et al 1994). In the developing brain, TBI also induces molecular changes to the receptors that bind EAAs, resulting in increased cellular vulnerability to these EAAs. These changes allow more calcium to enter the cell and potassium to leave the cell, impairing the function of the cell’s own mitochondria, the energy producing machinery of the cell. This hinders the cell’s ability to create energy at a time when it actually has increased energy needs to heal. The cell then becomes more deprived of energy and increased ischemia/ injury results. This is commonly referred to as secondary brain injury. The elevation of intracellular calcium also affects the tone of the vessels supplying blood, oxygen and nutrients to the injured brain. This is called dysautoregulation.

Dysautoregulation causes altered blood flow to the injured brain and results in even more injury to that area. Because of these age-related alterations in the brain’s cellular molecular mechanisms after trauma, the developing brain should have a more robust response to a concussion and resultant more prolonged recovery compared to the mature brain as is seen clinically in the severe TBI literature. In addition, these findings can explain a higher susceptibility to irreversible injury with additional stresses as is seen with second impact syndrome. Second impact syndrome (SIS) is thought to occur only in the developing brain. (Bruce et al 1981) (Snoek et al 1984) Of the nearly 50 cases described in the recent past, virtually all involve athletes of high-school age or younger. SIS occurs when an athlete suffers a relatively minor traumatic event to the head prior to fully recovering from a prior concussive injury. Rapid massive diffuse cerebral brain edema with ischemia develops followed most often by brain herniation and death. Biochemically, SIS is thought to occur when dysautoregulation becomes so severe that the brain can no longer adapt to the cell’s energy needs. The result is cell death. When the cell dies, more EAAs are released and adjacent cells become involved. A snow-ball effect can then ensue that is irreversible. In the adult brain, dysautoregulation is often less severe and prolonged presumably due to decreased cellular sensitivity to EAAs released after trauma. This may explain why SIS does not occur in adults.

Conclusions Sports-related concussion is a common injury in our youth. An increasing, yet small, body of evidence is suggesting that recovery from sports-related mTBI may be age-related. Pathophysiologically, this can be explained by an increased and prolonged sensitivity to the cellular mediators of brain injury in the developing brain relative to the fully developed brain which is seen in other models of brain injury. As a result, most experts in the field of sports-related mTBI are currently recommending increased caution when returning a child to play after concussion relative to recommended guidelines for the adult. About the Authors

Dr. Michelle Dolske is a practicing pediatric neuropsychologist with both clinical and research interests in sports-related concussion. Her undergraduate training was completed at the University of Georgia and her doctoral training was completed at the University of Alabama in Birmingham. Dr. Dolske practices pediatric neuropsychology in Orlando, Florida and is the current co-director of the Florida Sports Concussion Program in Central Florida. She is the associate director of Medical Psychology Associates at Florida Hospital Orlando and she is the director of rehabilitation and sports medicine for Florida Hospital Adventist Health System in Orlando. Dr. Dolske is well published in several peer reviewed medical journals and has given several talks, on various neuropsychology topics ranging from learning disabilities in children to recovery from mild traumatic brain injury in our youth. Her current research focuses on multidisciplinary team approaches to better manage and predict recovery in the athlete at risk for sports-related concussion. Dr. Melvin Field is a practicing neurosurgeon with both clinical and research interests in Sports-related neurosurgery. His undergraduate and medical training were completed at the University of Florida in Gainesville, FL and his post-graduate training in neurological surgery was done at the University of Pittsburgh Medical Center. Dr. Field practices neurosurgery in Orlando, Florida and is the current director of the Florida Sports Concussion Program in Central Florida. He is the NeuroCritical Care medical director for Florida Hospital Adventist Health Care System and he is a clinical Associate Professor at the University of Central Florida’s Burnett College of Biomedical Sciences Department of Biomolecular Sciences. He is a current partner of Orlando Neurosurgery and is the founder

of Callosum Enterprises. Dr. Field has numerous publications in peer reviewed medical journals and has given several talks, both nationally and internationally, on neurosurgical topics ranging from minimally invasive neurosurgery for brain tumors to age-related differences in recovery from mild traumatic brain injury. His current research focuses on sports-related neurological injury in the golfer and identifying diagnostic and therapeutic tools to better evaluate, manage and predict recovery in the athlete at risk for sports-related concussion.

References

Bruce DA, Alavi A, Bilaniuk L, et al. Diffuse cerebral swelling following head injuries in children: the syndrome of ’malignant brain oedema’. J Neurosurg. 54:170-178, 1981 Field M, Collins MW, Lovell MB, Maroon JC. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J of Pediatrics. 142:546-553, 2003 Field M, Dolske M. NeuroDevelopmental Issues in the Management of Mild Traumatic Brain Injury in the Athlete; Third International Meeting on Minor Traumatic Brain Injuries “mTBI” in Sports; March 12, 2007 Grundl PD, Biagas KV, Kochanek PM, et al. Early cerebrovascular response to head injury in immature and mature rats. J Neurotrauma. 11:135-148, 1994 McCrory P, Collie A, Anderson V, Davis G. Can we manage sport related concussion in children the same as in adults? Br J Sports Med. 38:516-519, 2004 McDonald JW, Johnston MV. Physiological pathophysiological roles of excitatory amino acids during central nervous system development. Brain Res Rev. 15:41-70, 1990 McDonald JW, Silverstein FS, Johnston MV. Neurotoxicity of N-methyl-D-aspartate is markedly enhanced in developing rat central nervous system. Brain Res. 459:200-203, 1988 Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 16:220-242, 2002 Osteen CL, Moore AH, Prins ML, Hovda DA. Age-dependency of 45calcium accumulation following lateral fluid percussion: acute and delayed patterns J Neurotrauma. 18:141-62, 2001 Pellman EJ, Viano DC, Tucker AM, Casson IR, Waeckerle JF. Concussion in Professional Football: Reconstruction of Game Impacts and Injuries. Neurosurgery. 53;799-814, 2003 Snoek JW, Minderhoud JM, Wilmink JT. Delayed deterioration following mild head injury in children. Brain. 107:15-36, 1984

conferences 2008 FEBRUARY 6-9 - 36th Annual International Neuropsychological Society Meeting,Waikoloa, Hawaii. Contact www:.the-ins.org 20-22 - International Stroke Conference, New Orleans, LA. Contact: www. strokeassociation.org. APRIL 9-12 – The International Brain Injury Association’s 7th World Congress on Brain Injury, Pestana Palace Hotel, Lisbon, Portugal. Contact: congress@internationalbrain.org, www.internationalbrain.org. JUNE 4-7 - European Congress on Physical Medicine & Rehabilitation, Brugge, Belgium. Contact: www.medicongress.com. SEPTEMBER 18-21 – 7th Mediterranean Congress of Physical Medicine & Rehabilitation Medicine, Potorose, Slovenia. Contact: marincek.crt@mail.ir-rs.si. 24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr.co.uk. OCTOBER 22-25 - National Association of Neuropsychology Annual Meeting, New York, NY. Contact: www.nanonline.org. 15-19 ACRM-ASNR Joint Educational Conference, Delta Chelsea Hotel, Toronto, Ontario, Canada. Contact: gclason@acrm.org, www.acrm.org BRAIN INJURY PROFESSIONAL

A Neurologist’s Perspective of Sports Related Concussion Advancements in Management Ellen Deibert, MD

Introduction

It is estimated that at least 85% of 1.5 million traumatic brain injuries in the United States per year are mild, i.e. concussions.1 This is a substantial increase from prior estimates and as a result neurologists will have an increasing role in the management of these athletes. Due to a growing body of evidence supplied by neuropsychological testing, there is concern that the traditional grading system approach to concussion management may be inadequate and a trend toward an individualized treatment approach is emerging.

Pitfalls in Concussion Grading Scales

There are several concussion grading scales available and all avoid placing the symptomatic athlete back into the contest. Although this is not based on Class I evidence, this concept has been supported by the American Orthopedic Society for Sports Medicine and the Concussion in Sport Group.2;3;4 Increasing evidence regarding lingering symptoms of concussion and potential vulnerability of younger players has placed into question the management of concussion using these scales. Grading scales often ignore age, gender, and skill level of the athlete.5 In addition, they emphasize loss of consciousness (LOC) by designating these athletes with more severe grades. Prolonged LOC may certainly indicate a serious head trauma and appropriate evaluation is essential.6 Alternatively, however, minimal LOC at the time of the injury has not been shown to be related to neurospsychological sequelae following a mild traumatic brain injury.7 Importantly, neuropsychological testing has been demonstrated to be a sensitive measure in detecting continued cognitive symptoms post concussion that are not picked up by history, neurological examinations, or routine Neuroimaging.8;9 This observation has called into question the emphasis of LOC in concussion grading scales and the potential for them to mislead neurologists in return to play decisions. The American Academy of Neurology (AAN) guidelines for 22 BRAIN INJURY PROFESSIONAL

concussion (currently under revision) are widely accepted by neurologists and other physicians.2 Publication of these guidelines increased awareness of concussion and is believed to have improved overall care of the injured athlete. One concern, however, with the AAN Grading System is the recommendation for return to play of the athlete who has suffered a Grade I concussion. An AAN Grade I concussion occurs when an athlete suffers transient confusion without LOC, and concussion symptoms or mental status abnormalities on examination that resolve in less than 15 minutes. The recommended management is to allow the athlete to return to play in the same contest.2 This approach is problematic. Evaluation on the sideline may not be adequate secondary to possible loss of objectivity of the coach, spectators, media, and even the athlete who may deny symptoms in order to return to play.2;9 Also, an assumption is made that the athlete who has symptoms that resolve in 15 minutes will remain asymptomatic. In fact, a recent study of 43 high school athletes with AAN Grade I concussions found an increase in self-report of symptoms and decline in memory processes when given a computerized neuropsychological test battery 36 hours post injury.10 Indirect evidence suggests that returning a symptomatic athlete to a contest the same day increases the risk of more severe neurological injury. It is known that an athlete who has suffered one concussion is at risk to suffer a second concussion.11 Also an athlete who plays with slowed reaction time could certainly place himself at further risk of injury as suggested by Ivenson.12 Studies in mice have shown an increase vulnerability to the brain after a second insult within 24 hours with increased blood brain barrier breakdown and axonal injury.13 Second Impact Syndrome (SIS) may be a clinical corollary to this. Second Impact Syndrome is a condition in which diffuse brain swelling occurs after an athlete has suffered a “second impact” while still symptomatic from an initial concussion.14 The second impact need not be severe. The morbidity is estimated to be 100% and mortality at 50%. The exact incidence is not known, but there is

an estimated 35 cases documented in the literature.15 Neurologists managing these athletes need to understand the rare but real risk of SIS and avoid returning athletes to the contest with symptoms.14,15

The Young Athlete

Recent literature has revealed an increased susceptibility in younger athletes to concussion.11 One study of 35 athletes ages 14-19 revealed that asymptomatic athletes reporting two or more past concussions had raw scores on an attention neuropsychological test battery similar to those athletes that suffered a concussion within one week of the test.16 A second study with 371 college athletes and 183 high school athletes found that high school athletes with concussion had measurable impairments in memory up to 7 days, while college athletes revealed similar deficits for only 24 hours.17 Finally, a study of 223 high school athletes found that those athletes who reported greater than two concussions had a significantly lower cumulative grade point average.18 These studies suggest that younger athletes may recover slowly from concussion adding to the concern that the rigid application of grading scales for return to play decisions is not appropriate.

Current Management Recommendations History and Physical Examination

Athletes with a concussion may be seen by a neurologist at any point in time post injury. A thorough history, physical examination, and review of neuroimaging are essential. In particular, the history should include a recount of the events of the most recent concussion, type of contest, mechanism of impact, protective equipment utilized, and the athlete’s initial symptoms. A concussion symptom check list should be utilized to determine the athlete’s ongoing symptoms.3 Important medical history includes current medications, migraine headache, attention deficit disorder, learning disabilities, prior head trauma, substance abuse, psychiatric conditions, and seizure disorders. Many of these disorders confound the clinical presentation and affect overall management. The general physical exam needs to evaluate the musculoskeletal and vascular systems of the neck. Mild neck injuries may be detected with evidence of paraspinous muscle spasms, point tenderness along the cervical spine, and decreased range of motion. Carotid bruits may raise concern for a carotid dissection. The neurological exam needs to emphasize the mental status, cranial nerve, coordination, and vestibular components. Persistent symptoms or focal neurological findings may warrant further investigation with imaging to ensure a structural lesion has not developed.

Neuropsychological Evaluation and Management

Neuropsychological testing can facilitate the detection of mild cognitive changes after concussion which can alert the neurologist to unsuspected symptoms.8 Abbreviated computer based tests are available that can be utilized in the clinic. Formal neuropsychological testing with a referral to a neuropsychologist may be necessary if a concussion presentation is complicated by a history of multiple prior concussions, attention deficit disorder, a psychiatric disorder, and/or learning disability. Cognitive symptoms such as poor attention, memory, or reaction time can be serious and affect school performance. Tutoring, extended time on homework and/or exams, and rest periods

may be necessary to allow time for healing and prevent worsening concussion symptoms. During this period, the athlete is not cleared for exertion in gym or sports.

Return to Play

In order to return to play, the athlete must be clinically asymptomatic and their neuropsychological testing, if available, needs to return to the expected baseline. Once asymptomatic, a gradual return to exertional activity in a stepwise fashion is recommended. As long as the athlete remains asymptomatic he will be able to resume normal activity within a short period of time. If, however, concussion symptoms remain, the athlete is counseled to drop down a level of activity until symptoms subside.4

Conclusions

Considering the recent data it seems clear that concussion is a far more complex and potentially dangerous entity than previously thought. It is imperative that neurologists be aware of the emerging data, recognize the pitfalls of grading scales, and develop an individualized approach to the concussed athlete. If concussion management is performed correctly, return to play decisions will be different for every athlete seen in clinic. About the Author

Ellen Deibert, MD, is an Assistant Professor of Neurology at the University of Massachusetts Medical School. She is fellowship trained in Neurological Critical Care and Board Certified in Neurology.

References

1. Bazarian JJ, McClung J, Shah, MN , et al. Mild traumatic brain injury in the United States, 1998-2000. Brain Injury. 19 (2): 85-91, 2005. 2. Practice Parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. American Academy of Neurology. Neurology. 48: 581-585, 1997. 3. Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clinics in Sports Medicine. 23: 421-441, 2004a. 4. Aubry M, Cantu R, Dvorak J, et al. concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clinical Journal of Sports Medicine.12 (1): 6-11, 2002. 5. McClincy Mp, Lovell MR, Pardini J et al. Recovery from sports concussion in high school and collegiate athletes. Brain Injury. 20 (1): 33-39, 2006. 6. Kelly, JP. Loss of consciousness: pathophysiology and implications in grading and safe return to play. Journal of Athletic Training. 36 (3): 249-252, 2001. 7. Lovell MR, Iverson GL, Collins MW, et al. Does loss of consciousness predict neuropsychological decrements after concussion? Clinical Journal of Sports Medicine. 9: 193-198, 1999. 8. Schatz P, Zillmer EA. Computer-based assessment of sports-related concussion. Applied neuropsychology. 10: 42-47, 2003. 9. Van Kampen DA, Lovell MR, Pardini JE, et al. The “value added” of neurocognitive testing after sports-related concussion. American Journal of Sports Medicine. 34 (10): 1630-1635, 2006. 11. Buzzini SR, Guskiewicz KM. Sport-related concussion in the young athlete. Current Opinion in Pediatrics. 18: 376-382, 2006. 10. Lovell MR, Collins MW, Iverson GL, et al. Grade 1 or “Ding” concussions in high school athletes. American Journal of Sports Medicine. 32 (1): 47-54, 2004b. 12. Iverson GL, Gaetz M, Lovell MR, et al. Relation between subjective fogginess and neuropsychological testing following concussion. Journal of the International Neuropsychological Society. 10: 904-906, 2004. 13. Laurer Hl, Bareyre, FM, Lee VMYC et al. Mild head injury increasing the brain’s vulnerability to a second concussive impact. Journal of Neurosurgery. 95: 859-870, 2001. 14. Mori T, Katayama y, Kawamata T. Acute hemispheric swelling associated with thin subdural hematomas: pathophysiology of repetitive head injury in sports. Acta Neurochir. 96 (supplement): 40-43, 2006. 15. Cantu RC. Second Impact Syndrome. Clinics in Sports Medicine. 17 (1): 38-45, 1998. 16. Moser RS, Schatz P. Enduring effects of concussion in youth athletes. Archives of clinical neuropsychology. 17: 91-100, 2002. 17. Field M, Collins MW, Lovell MR et al. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics. 142: 546553, 2003. 18. Moser RS, Schatz P, Jordan BD. Prolonged effects of concussion in high school athletes. Neurosurgery. 57(2): 300-306, 2005. BRAIN INJURY PROFESSIONAL

A Treatment Paradigm for Sports Concussion

Cara Camiolo Reddy, MD and Lisa A. Lombard, MD

It should be noted in this text we mention the use of several medications in indications that are not currently FDA approved. Clinicians should educate themselves of potential benefits and side effects of all medications before prescribing. Introduction In recent years, the management of sports concussion has been an active topic in the media and medical literature. Considerable energy and resources have been devoted to the development of return to play guidelines. Despite these efforts, a void still exists in guidelines for treating individuals with persistent post concussion symptoms. Here, we present our clinical views on the management of persistent mild traumatic brain injury (mTBI) symptoms. Acute Management Management of mTBI should begin immediately after the injury is sustained. While athletes who have sustained loss of consciousness often are seen in emergency departments, the majority of persons sustaining mTBI from athletic contests are evaluated by athletic trainers or primary care physicians. In the initial days following injury, individuals should be instructed on the benefits of proper sleep hygiene, physical rest, and cognitive rest. Avoiding physical and cognitive exertion when individuals are symptomatic is of utmost importance when recovering from mTBI. The majority of athletes will recover within 3-4 weeks post-injury, as demonstrated by improvement on self-reported symptom scales and neurocognitive testing (Yang et al., 2007; Collins et al., 2006). Unfortunately, approximately 10-15% will have prolonged symptoms. It is in this group of individuals that postconcussion symptoms can become functionally limiting and disabling. Persons with prolonged or worsening symptoms greater than 3 weeks or more warrant further medical evaluation. 24 BRAIN INJURY PROFESSIONAL

Postconcussion Symptoms The diagnosis of postconcussion syndrome is controversial in the medical community, as the symptoms associated with mTBI can appear quite vague and be mistaken for other clinical issues. Despite this debate, distinct symptom clusters and neurocognitive deficits following mTBI have been identified (Potter et al., 2006). For this discussion, we take a clinical approach that identifies symptoms consistent with concussive injury and tailor intervention accordingly. A detailed history is imperative for evaluation and treatment of mTBI, including mechanism of injury, location of the impact, length of loss of consciousness (if present), presence of retrograde and/or anterograde amnesia (lack of memory before or after the event, respectively), initial symptoms and treatment. A comprehensive review of ongoing symptoms should be undertaken. Symptoms consistent with mTBI fall into four categories: cognitive (difficulty with short term memory, poor concentration, taking longer to think, feeling foggy), somatic (body centered complaints, including headaches, dizziness, nausea, sensitivity to light and noise, blurred or double vision), emotional (irritability, frustration, depression, anxiety), and sleep disturbance (difficulty falling and/or staying asleep, too much or too little sleep). Cognitive Neuropsychological testing has provided objective data illustrating the multitude of cognitive derangements following mTBI. Clinically, these individuals may complain of feeling foggy, not being able to think quickly or not being able to focus attention to complete everyday tasks. Students will often complain of declining academic performance. Short term memory deficits and prolonged reaction times are also apparent. There is clear evidence that the cognitive deficits following TBI are improved with the addition of neurostimulant medications (Warden et al.,

2006). Most of this data has been found in the more severe brain injury populations; however, the improvement in neurocognitive testing is compelling. Anecdotally, substantial clinical improvements have been noted in our individuals treated with methylphenidate, amantadine or atomoxetine. (As mentioned above, these are off-label indications for these medications.) Somatic Headaches are one of the most common symptoms after mTBI. Getting specific information regarding the character of the headache is important, as posttraumatic headaches can be due to multiple underlying causes including musculoskeletal, vascular, neuropathic and iatrogenic. A thorough history and physical examination will help to narrow down these potential causes and will help to dictate a treatment plan. Some varieties of posttraumatic headaches have been found to be amenable to the same treatment guidelines available for primary headaches and migraines (Lew, et al., 2006). Prophylactic treatment with beta-blockers, calciumchannel blockers, antidepressants (both tricyclic and selective serotonin reuptake inhibitors [SSRIs]) and anticonvulsants can all play a role. Infrequent posttraumatic migraines may also benefit from abortive medications such as triptans. Musculoskeletal or tension headaches can be further identified both by the complaint of pain at the temples and tender spots and decreased neck range of motion on physical examination. Of particular note, some individuals will complain of headaches that occur only in the setting of “cognitive exertion.” For example, persons with mTBI may complain of headaches that occur and worsen with activities such as paying bills, walking in a supermarket, taking notes in class or test taking. Often these individuals will endorse significant cognitive symptoms as well, as discussed above. These headaches will be associated with those symptoms of “feeling foggy” or difficulty concentrating. We have dubbed such headaches as “cognitive-fatigue” headaches: those that occur in a clear relationship with cognitive exertion. For this subtype of headache, treating the cognitive symptoms (rather than the headaches themselves) may prove to be more efficacious. It is our experience that neurostimulants may also aid in headache management by improving the cognitive deficits that act as their trigger. Dizziness is also a very common complaint after mTBI and may be the most common symptom present in the days immediately following injury. For prolonged symptoms (>3 weeks), referral to a vestibular therapist should be considered as medications can mask symptoms without treating a potential underlying cause. One common cause of post-traumatic dizziness is benign paroxysmal positional vertigo (BPPV), which can be treated through a series of maneuvers performed by a trained clinician. Emotional Prolonged, unresolving cognitive and somatic symptoms may cause many individuals to become frustrated and anxious. In addition, mood disorders, including depression, are frequently seen after TBI. These emotional disturbances may worsen perception of cognitive impairment or pain. Initiation of SSRIs has been shown to be particularly helpful, and may also have an added benefit of headache prevention. Sleep Disturbance Disorders of sleep are also well documented after TBI. While individuals may initially complain of hypersomnia, several weeks after injury they will often complain of difficulty falling asleep or

staying asleep. Normal sleep-wake patterns can quickly become dysregulated. Proper sleep hygiene, including going to bed/waking at the same time daily, limiting caffeine intake, reducing daytime naps, eliminating TV watching in bed should be advocated. Medications, such as trazodone, amitriptyline, or melatonin, can be used to improve the quality and quantity of sleep. Benzodiazepines and nonbenzodiazepine hypnotics should be avoided due to their amnestic qualities and potential worsening of cognitive functioning. Returning to Physical/Cognitive Exertion When symptoms resolve at rest, individuals should begin a slow return to activity and sports in a step-wise pattern. First, light aerobic activity should be attempted with a gradual increase to more intense activity and eventual return to full exertion. Individuals should never advance to the next stage if they develop symptoms with their current level of activity. It is only when the athletes are symptom-free with full exertion may they be considered for a return to competitive play. These decisions are best made in a team approach, including physician, neuropsychologist, athletic trainer and athlete. A similar step-wise plan for returning to cognitive activity, whether work or school, should also be advocated. Individuals should consider return to work or school only when asymptomatic at rest. A gradual return, including doing light reading or work-related activities at home, should be performed first. When this is able to be done without exacerbation of cognitive symptoms or headaches, the athlete can consider returning parttime with a progression to full-time work or school. Conclusion In conclusion, there is a dearth of research addressing treatment of persistent postconcussion symptoms. Treatment can be optimized when comprehensive medical evaluation is used in conjunction with neurocognitive testing. It is our recommendation that athletes with persistent mTBI symptoms are best managed by an organized catalogue of symptoms, dividing them into the appropriate categories and treatments as outlined above. In addition, withholding activity until the athlete is symptom free, and careful monitoring of symptoms as activity is resumed gives the best possibility for a satisfactory recovery. About the Authors

Cara Camiolo Reddy, MD, is an Assistant Professor specializing in Traumatic Brain Injury in the Department of Physical Medicine & Rehabilitation at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania. Lisa A. Lombard, MD, is an Assistant Professor specializing in Traumatic Brain Injury in the Department of Physical Medicine & Rehabilitation at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania.

References

Collins MW, Lovell MR, Iverson GL, et al. Examining Concussion Rates and Return to Play in High School Football Players Wearing Newer Helmet Technology: A Three-Year Prospective Cohort Study. Neurosurgery. 2006, 58(2): 275-284. Lew HL, Lin PH, Fuh JL, et al. Characteristics and Treatment of Headache After Traumatic Brain Injury: A Focused Review. Am J Phys Med & Rehab. 2006, 85(7): 619-627. Potter S, Leigh E, Wade D, et al. The Rivermead Post Concussion Symptoms Questionnaire: A Confirmatory Factor Analysis. J Neurol. 2006, 253:1603-1614. Warden DL, Gordon B, McAllister TW, et al. J Neurotrauma. 2006, 23(10): 1468-1501. Yang CC, Tu YK, Hua MS, et al. The Association Between the Postconcussion Symptoms and Clinical Outcomes for Patients with Mild Traumatic Brain Injury. J Trauma. 2007, 62(3): 657-663. BRAIN INJURY PROFESSIONAL

bip expert interview Michael Matheny Please describe how you sustained your concussion and the factors that led to the injury becoming potentially more severe. The final concussion that I sustained was from a baseball fouled off my catcher’s mask. This was approximately the sixth foul ball that I received that week. The factors leading up to that were numerous “dings” from the age of 6 until current. I had many so called concussions that I was told to wake up every three hours ( of which I never did) and told to “keep an eye on it.” I am estimating that in the past 17 years of professional baseball that I was run over at the plate at least 2 times a year and a maximum of six that I can remember. Almost every occurence, the trainer would have me watch his finger as he moved it back and forth and then tell me that I “JUST had a mild concussion, and I would be fine to play the next day.” At age 6 I started playing football, and the head to head contact always seemed to bother me more than the other kids but I didn’t say much because I thought that I was just being soft. I continued to play football until I graduated from high school. My position was quarterback, and strong safety.

Pittsburgh where they specialized in concussion. I was tested, analyzed and then informed about what had happened to my brain. I never associated concussion with brain. I thought I was just going through a formality and then I was going to jump on a plane and catch a game that night in New York. Little did I know then that I had just played my last game. I would have tried to play, but I could hardly concentrate on my hand in front of my face, and my reactions felt like I was moving under water.

Michael Matheny is a former baseball catcher, playing for four different teams during his thirteen years in the major leagues. Matheny was considered one of the best defensive catchers in the major leagues and played for the Milwaukee Brewers from 1994 to 1998, the Toronto Blue Jays in 1999, and the St. Louis Cardinals from 2000 to 2004. He was signed by the San Francisco Giants to a three-year contract on December 13, 2004. During his career, he won four golden glove awards and was one of only three catchers to play 100 games without a single error. Matheny went on the disabled list on May 31, 2006 and on February 1, 2007, Matheny announced his retirement from Major league baseball due to his on-going symptoms of post-concussion syndrome.

Can you please describe the specific symptoms that you experienced with your concussion? Football collisions always gave me a temporary blackout, not enough to lose consiousness, but enough to physically see black and then a warm tingling in my head. I don’t remember having any fogginess after those hits, just headaches. My last concussion started with fogginess, confusion, brief nausea, forgetfulness, dizziness, localized pain to the left top of the head, trouble keeping my eyes open, sensitivity to light, and light headedness. I may be forgetting some of the other symptoms, but they are well documented somewhere.

not see. I am wondering now if there were instances leading up to that where I was either involved in a home plate collision, or had a foul ball off the mask. As a catcher, I was taught to always stay out of the trainer’s room, and never show pain, especially after collisions.

How many times in your past had you experienced similar symptoms, and how did these symptoms affect your baseball performance? I never recognized the relation of my fogginess and the trouble that I would go through seeing the ball, but there were specific times every year that I could just

Did you receive any treatments or evaluations and, if so, what was done? Do you feel that you were educated properly about your condition, prognosis, and the overall injury of concussion? The only treatment I received was after the final concussion, and I was sent by my trainer (against my will), to the U of

26 BRAIN INJURY PROFESSIONAL

What, if any, are the lingering symptoms you now experience, nearly 18 months after the injury? Nearly 18 months after injury, I still am limited to the amount of physical activity that I can do. If I get my heart rate up too high I get the localized pain and have about a day of foggy vision and thinking. I have found that it is most difficult to multi-task. After I work too hard I will find myself walking into a room and forgetting why I went in there. I will drive down the road and forget where I was trying to go. In all, things are much better. I can do most normal everyday activities that I could not do before, but I am still reminded whenever I try to do more than I should. What would you recommend in terms of better management and treatment of concussion? I believe that education at the grass roots level is essential. Trainers and coaches need to be made aware of the serious nature of this issue and to be told of the early signs and symptoms. I equate it to the changed opinion of football coaches after a couple of dehydration deaths. Water used to be withheld for punishment and motivation until the ideology was changed by tragedy. I would hate to have a tragedy be the reason for immediate change. The thought process that being tough and fighting through this sort of injury needs to be changed at the beginner levels as well as the advanced. Do you feel there is an appropriate awareness and understanding of concussion within Major League Baseball and other professional sports leagues? I believe that hockey and football have

had to attack this issue because it is so common. These sports have seen long term damage when the proper steps to prevention and treatment are not taken. Unfortunately, baseball has not had many reported cases, and the number of head injuries are so few that even after a player has a concussion, the likelihood of another concussion during the healing phase is even more minimal. I am proof that it is possible to have multiple head injuries in the sport of baseball, and if the proper precautions are not taken, less severe impacts will eventually end careers. My summary is this: I am very grateful for athletic trainers that think outside the box like Stan Conti. Stan directed me to Dr. Mickey Collins and the professionals at the University of Pittsburgh who got me the treatment I needed. I don’t think that I could have physically played, but if I had, and if I would have had some sort of collision, I hate to think of what the result could have been. This is a very real injury that has nothing to do with the “toughness” of an athlete. Parents and coaches need to take a long hard look at the facts that relate to this issue and come to the conclusion that if there is any doubt... why take the chance. It is not “JUST” a concussion. It is a brain injury.

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Traumatic Brain Injury in Sports: An Update from the Centers for Disease Control and Prevention Marlena M. Wald, MPH, Jane Mitchko, Med, Kelly Sarmiento, MPH, Jean A. Langlois, ScD

Physical activity in leisure time can provide important health benefits. Recent estimates for the United States indicate that approximately 38 million children and adolescents participate in organized sports1 and approximately 170 million adults participate in some type of non-work-related physical activity.2 While such activities may improve health and contribute to disease prevention,3 they may increase the risk for injuries including traumatic brain injury (TBI).4 Traumatic brain injury is caused by a bump, blow, or jolt to either the head or the body that disrupts the function of the brain.5 Concussions or mild TBI (mTBI) are a type of TBI and can have serious long-term health effects so that a seemingly mild ‘ding’ or a bump on the head should be cause for concern.6,7

How many sports and recreation concussions occur each year? An estimated 1.6 to 3.8 million sports- and recreation-related concussions occur in the U.S. each year, including those for which no medical care is sought.8 This range includes both concussions with and without loss of consciousness (LOC) and is based on studies that suggest that injuries involving LOC may account only for between 8%9 and 19.2%10 of sports concussions. This estimate supersedes that from an earlier CDC study that reported 300,000 sports- and recreation-related concussions per year which was based only on those injuries with LOC.11 A recent CDC report of nonfatal traumatic brain injuries from sports and recreation activities found that during the years 2001-2005, children and youth ages 5-18 years had the highest rates of sports- and recreation-related TBI, accounting for 2.4 million emergency department (ED) visits annually, of which 6% (135,000) involved a concussion.4 Within this age group, the highest rates of sports-related ED visits occurred among 28 BRAIN INJURY PROFESSIONAL

those aged 10-14 years, and the rate for males was 2.6 times that for females.4 (See Table)

In what sports are concussions most often reported? For the years 2001-2005, among children and youth ages 5-18 years, the five leading sports or recreational activities that accounted for concussions included bicycling, football, basketball, playground activities, and soccer.4 With regard to gender differences among those ages 5-18 years, the leading sports or activities associated with TBI-related ED visits for males were football, bicycling, basketball, playground activities, and baseball.12 Among females, the leading sports were bicycling, playground activities, basketball, soccer, and gymnastics (including cheerleading and dance).12 In organized high school sports, concussions occur most often in competitive sports, with football accounting for more than 60% of concussions.13 While football is the leading cause of high school sports concussion in males, soccer is the leading cause in females.13 What sports concussion resources are available from CDC? The Children’s Health Act of 2000 charged CDC to implement national education and awareness campaigns regarding TBI. In response to this charge, the National Center for Injury Prevention and Control at CDC has developed a series of concussion/ mTBI tool kits regarding concussion/mTBI. The first, designed for health care providers, was developed with input from experts, as well as government, professional medical, sports, and voluntary organizations. Entitled “Heads Up: Brain Injury in Your Practice,” this tool kit was developed to provide physicians with a more individualized assessment of mTBI and to help guide the

Estimated annual rate of nonfatal, sportsand recreation-related traumatic brain injuries treated in emergency departments (United States, 2001-2005)

Table 1

Age (yrs) 0-4 5-9 10-14 15-19 20-24 25-29

Sex

Number

Rate

41,294

81.5

24,161

49.9

124,153

244.8

53,256

110.0

197,737

367.0

72,089

140.5

186,484

352.7

61,850

123.6

49,150

92.9

20,731

41.5

29,668

60.3

11,352

24.0

Age (yrs) 30-34 35-39 40-44 45-49 50-54 ≥55

Sex

Number

Rate

19,766

38.1

11,313

22.2

19,295

35.8

10,783

20.1

19,919

35.0

11,439

19.8

14,242

26.7

8,918

16.2

8,440

18.0

7,269

14.8

21,927

15.5

13,834

7.8

Source: CDC. National Electronic Injury Surveillance System—All Injury Program

management and recovery of patients with mTBI. It includes a booklet with information on diagnosis and management of patients with mTBI, a patient evaluation tool, an information sheet for patients who recently sustained a mTBI, a palm card with information about on-field management of sport-related mTBI, patient education materials in English and Spanish, and a CD-ROM with downloadable tool kit materials and additional resources. First published in 2003, a second, revised version was released in 2007. To date, over 200,000 of these tool kits have been disseminated. Health care provider feedback led next to the development of a tool kit for high school athletic coaches entitled “Heads Up: Concussion in High School Sports”. The goal of this tool kit was to educate coaches about sports-related concussions and the need to prevent, recognize, and manage concussions appropriately. Developed and piloted with the assistance of fourteen national organizations and research centers, the kit includes a concussion guide for coaches; a wallet card for quick reference; fact sheets in English and Spanish for athletes as well as their parents; an educational video and DVD for athletes, parents, and other school staff; and a CD-ROM with additional resources. Since its publication in 2005, more than 35,000 tool kits have been distributed nationwide and over 19,000 web hits were tracked within the first three months of the tool kit launch. During 2006, an evaluation of the tool kit was conducted revealing that 50% of coaches reported viewing concussions more seriously after using the tool kit, 38% reported changing how they prevented and managed concussion (including placing more emphasis on training techniques and safety equipment that minimize risk), and 68% reported using the tool kit to educate others about concussions.14 During the evaluation of the high school sports tool kit, development of a similar resource for youth sports coaches and administrators was recommended. Again, working in partnership with leading medical, sports, and educational organizations, a tool kit entitled “Heads Up: Concussion in Youth Sports” was developed and launched in July, 2007. This tool kit includes fact sheets for coaches, athletes, and parents in English and Spanish; a clipboard with concussion assessment information; and a quiz to test coaches’, athletes’, and parents’ concussion knowledge.

Summary Sports- and recreation-related concussion is an important public health problem especially among young people. CDC is com-

mitted to educating professionals and the public about prevention and management of these potentially disabling injuries. References 1.

4. 5.

6. 7. 8. 9. 10.

11. 12. 13. 14.

National Council of Youth Sports. Reports on trends and participation in youth sports. Stuart, FL National Council on Youth Sports; 2001. [cited 8 Aug 2007]. Available at: http:// www.ncy.org/pdf/marketresearch.pdf Centers for Disease Control and Prevention. 2006 Behavioral Risk Factor Surveillance System. [cited 8 Aug 2007]. Available at: http://apps.nccd.cdc.gov/brfss/display.asp?cat=ex&yr =2006&qkey=4347&state=ub US Dept. Health and Human Services. Chapter 22: Physical activity and fitness. Healthy People 2010. [cited 8 Aug 2007]. Available at: http://www.healthypeople.gov/Documents/ tableofcontents.htm#Volume2 Centers for Disease Control and Prevention. Non-fatal traumatic brain injuries from sports and recreation activities – United States, 2001-2005. MMWR. 2007;56(29):733-37. US Dept. Health and Human Services. National Institutes of Health. NIH consensus statement: rehabilitation of persons with traumatic brain injury (October 26-28, 1998). Ragnarsson KT, editor. Washington (DC): Government Printing Office; 1999. Centers for Disease Control and Prevention. Sports-related recurrent brain injuries—United States. MMWR. 1997;46(10):224-27. Buzzini SRR, Guskiewicz KM. Sport-related concussion in the young athlete. Curr Opin Pediatrics. 2006;18:376-82. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-78. Schultz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors for concussion in high school athletes, North Carolina, 1996-1999. Am J Epidemiol. 2004;160(10):937-44. Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptoms deficit following sports-related concussion. Clin J Sport Med. 2003;13(4):222-29. Thurman DJ, Branche CM, Sniezek JE. The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. J Head Trauma Rehabil 1998;13(2):1-8. Centers for Disease Control and Prevention. National Electronic Injury Surveillance System. Unpublished data. 2007. Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. JAMA. 1999;282(10);958-63. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Heads Up: Concussion in High School Sports, Final Report. Atlanta (GA): Centers for Disease Control and Prevention; 2007.

FREE ‘HEADS UP’ TOOL KIT

Physicians Tool Kit www.cdc.gov/ncipc/tib/Physician_Tool_Kit High School Coaches Tool Kit www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm Youth Sports Coaches Tool Kit www.cdc.gov/ConcussionInYouthSports For more information on traumatic brain injury visit: www.cdc.gov/injury

About the authors

All of the authors are employed by the Division of Injury Response at the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention in Atlanta, Georgia. Marlena M. Wald, MPH, MLS, is an Epidemiologist, Jane Mitchko, MEd,CHES, and Kelly Sarmiento, MPH, are Health Communication Specialists, and Jean A. Langlois, ScD, MPH is a Senior Epidemiologist. BRAIN INJURY PROFESSIONAL

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The Role of the Athletic Trainer in the Proper Management of Sports Concussion Kevin Guskiewicz, PhD, A.T.C.

Whether on the sideline, athletic training room, or clinical/hospital environment, a thorough approach to evaluating athletes suspected of a concussion will aid in improving clinical diagnoses and return to play decisions. In the high school, collegiate, and professional sports setting, the certified athletic trainer is often on the front-line in the management of concussion. The certified athletic trainer is a licensed health care provider involved in the prevention, recognition, treatment and rehabilitation of athletic injuries such as concussion. While they work under the supervision of a licensed physician, they are often required to make quick decisions in the absence of other consulting medical personnel. Athletic trainers serve as the liaison between the physician and the athlete, parent, coach and/or athletic administrators. They are responsible for establishing the emergency action plan with input from the team physician and athletic administrators. This emergency action plan should include procedures for managing head injuries and accessing advanced medical personnel. The athletic trainerâ&#x20AC;&#x2122;s most important job is to identify a concussion has occurred, to rule out potentially catastrophic injuries (i.e. subdural or epidural hematoma), and to make decisions regarding appropriate referrals and return to play.

On-Field Evaluation Head trauma in an athletic situation requires immediate assessment. In many cases, this will involve an athlete-down scenario, where the concern goes beyond that of a concussion. Under these circumstances, a primary survey involving basic life support should be performed first. This is easily performed in a matter of 10-15 seconds, as respiration and cardiac status are 32 BRAIN INJURY PROFESSIONAL

assessed to rule out a life-threatening condition. Once this has been ruled out, the secondary survey can begin by first conducting a thorough history. The goal is to gain as much information as possible about any mental confusion, loss of consciousness, and amnesia. Confusion can be determined rather quickly by noting facial expression (dazed, stunned, â&#x20AC;&#x153;glassy-eyedâ&#x20AC;?) and/or any unusual behavior. If the athlete is unconscious or regaining consciousness but still disoriented and confused, the injury should be managed similar to that of a cervical spine injury. In this case, the athlete should be transported on a spine board with the head and neck immobilized. Vital signs should be monitored at regular intervals (1-2 minutes), as the athletic trainer talks to the athlete as he/she regains consciousness. If loss of consciousness lasts less than 1 minute and the remainder of the exam is normal, the athlete can be observed on the sideline. Prolonged unconsciousness lasting 1 minute or longer requires immobilization and transfer to an emergency facility for a more thorough neurological examination. The athletic trainer can perform amnesia testing by first asking the athlete simple questions directed toward recent memory and progressing to more involved questions. Asking the athlete about the injury and the events immediately following the injury will test for length of post-traumatic amnesia. Asking about events occurring prior to the injury such as the score or opponent will test for retrograde amnesia. Retrograde amnesia is generally associated with a more serious head injury. Questions of orientation (name, date, time, and place) are not considered good indicators of concussion (Maddocks and Saling, 1991). The athletic trainer is the ideal person to identify other signs and symptoms critical to the assessment of the injured athlete because of the

unique relationship and daily contact they typically have with the athletes. The best approach to tracking an athlete’s symptoms is to utilize a graded symptom checklist as outlined in the National Athletic Trainers’ Association’s Position Statement on Management of Sports-Related Concussion (Guskiewicz, Bruce, Cantu, et al., 2004). Portions of the observation and palpation should take place during the initial on-field evaluation. The athletic trainer should observe for any deformities or abnormal facial expressions, speech patterns, respirations and movement of the extremities. Gentle palpation of the skull and cervical spine should be performed to rule out a fracture. If the athlete is unconscious, care must be taken not to move the head and neck. A helmet should only be removed at this time if it compromises maintenance of adequate ventilation. An adequate airway can be maintained by simply removing the face mask or strap. A quick cranial nerve assessment can be conducted, which includes checking visual acuity (CNII: optic), eye movement (CNIII & CNIV: oculomotor & trochlear), and equality of pupillary size and reaction to light. The development of an unusually slow heart rate or an increased pulse pressure (increased systolic and decreased diastolic) after the athlete has calmed down may be indicative of increasing intracranial involvement. The overwhelming majority of concussions will not reveal positive results for these tests; however, they are important considerations for detecting a more serious injury such as a hematoma. The athletic trainer must be capable of identifying deteriorating conditions warranting immediate advanced medical care.

Special Tests Research has demonstrated neuropsychological and balance testing provides objective information. Advanced neuropsychological assessment is strongly recommended and will be discussed in a companion paper within this volume. However, brief mental status tests such as the Standardized Assessment of Concussion (SAC), are sensitive measures often used by athletic trainers on the sideline and in the athletic training room during the initial 48 hours after the injury (McCrea, Guskiewicz, Barr, et al., 2003; McCrea, 2001). Balance testing is another important tool that athletic trainers should use when managing concussion. The Balance Error Scoring System (BESS) is recommended as a rapid, cost-effective method of objectively assessing balance in athletes following a concussion. Three different stances (double-legged, singlelegged, and tandem) are completed twice, once on a firm surf ace and again on a piece of medium-density foam (Airex, Inc) for a total of six trials. The BESS has been shown to be a reliable and valid assessment tool for managing concussion (Guskiewicz, Ross, and Marshall, et al., 2001; McCrea, Guskiewicz, Barr, et al., 2003). Comparing the concussed athlete’s postinjury scores to baseline scores, and tracking recovery is an effective way to help ensure a safe return to participation. Counseling the Athlete Following the initial evaluation, the athletic trainer should counsel the athlete by explaining the injury and the dangers of returning to play while still symptomatic. In the high school setting, this interaction should take place alongside the parent and coach. Emphasis should be placed on the potential of a more catastrophic injury such as Second Impact Syndrome and

the increased susceptibility for future concussions if not managed properly. Athletes who previously sustain a concussion are at a significantly higher risk for concussion compared to their non-concussed counterparts (Zemper, 2003; Schulz, Marshall, Mueller, et al., 2004; Guskiewicz, Weaver, Padua, et al., 2000; Guskiewicz, McCrea, Marshall, 2003), emphasizing the need for accurate and empirically-based return to play (RTP) decisions. Therefore, it is important for the athletic trainer to know the athlete’s concussion history, and to gain his or her trust and willingness to report concussive injuries.

Return to Play The athletic trainer now has an array of tools and techniques that should be used for the on-field management of concussion, and objectivity in RTP decisions. Symptomatology, neurocognitive function, and balance are all pieces contributing to the concussion puzzle and no one piece should be used to the exclusion of others. At the very least, all signs and symptoms should be resolved prior to considering a return to play. When same-day return to play is being considered, symptoms should be evaluated both at rest and after exertional maneuvers such as jogging, sit-ups, and push-ups. Athletes with a concussion history should be managed extra cautiously, because they often experience more serious symptomatology and slower recovery compared to those without prior concussion (Collins, Lovell, Iverson, et al., 2002; Guskiewicz, McCrea, Marshall, 2003). Youth athletes and those who experience loss of consciousness or amnesia should never be returned to participation on the same day. Athletic trainers should work with the team physician, and other medical personnel assisting in the management of the injury to establish a graded progression of physical and cognitive exertion once the athlete is asymptomatic. For example, light aerobic exercise is followed by sport-specific training (i.e. dribbling, shooting baskets, walkthroughs, etc), and noncontact training drills. These activities are followed by full contact drills, and then return to play. Progression from one level of exertion to the next is predicated on the absence of postconcussion signs and symptoms at the previous level. Concussion Prevention Prevention should begin with education, and the athletic trainer is responsible for initiating this. For sports involving high contact, the athletic trainer should have a conversation with the players and coaches prior to the start of the season. During this meeting, the athletic trainer should explain “concussion” in the context of signs and symptoms, as well as the potential negative consequences (i.e. Second Impact Syndrome, predisposition to future concussions, etc.) of not reporting a concussive injury. Educational materials, such as the Centers for Disease Control and Prevention toolkits are available and have proven to be very useful in educating young athletes (CDC, 2005; CDC 2007a, CDC 2007b). Once the athlete has a better understanding of the injury, they can provide a more accurate report of their injury as well as report on any prior concussions which is useful information when managing future injuries. Athletic trainers can also ensure the athlete is equipped with appropriately certified and properly-fitting protective equipment. The athletic trainer should work closely with the equipment manager to select and fit the athlete with the best available helmets. In many settings, the athletic trainer participates with BRAIN INJURY PROFESSIONAL

instruction alongside coaches and players to ensure proper tackling, blocking, or sport-specific techniques to prevent improper head contact that could result in concussion.

Conclusion The most important role the athletic trainer plays is to identify a concussion has occurred. This begins by conducting a sideline evaluation to rule out a more serious or potentially catastrophic injury such as a subdural or epidural hematoma, and to make decisions regarding appropriate referrals and RTP. When making a RTP decision, the athletic trainer must find a balance between what is safe, yet practical. Decisions about when and if a concussed athlete can return to competition have to be made on an individual basis, depending on the athlete’s concussion history, the severity of the injury, duration of signs and symptoms, time between injuries, and availability of experienced personnel to conduct and interpret repeated assessments of symptomatology, neurocognitive function and balance. About the Author

Kevin Guskiewicz, PhD, ATC has been at the University of North Carolina, Chapel Hill Department Exercise and Sport Science in July 1995, and was appointed Department Chair in July 2005. He heads up the sport concussion program at UNC, while also serving as the Director of the Sports Medicine Research Laboratory and Research Director for the Center for the Study of Retired Athletes. His research is focused on the assessment of sport-related concussion and the long-term effects of concussion. He has been the recipient of over 15 funded research grants on this topic, and has published over 45 journal articles and five textbook chapters related to concussion in sport.

REFERENCES:

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Concussion in High School Sports. Atlanta (GA): Centers for Disease Control and Prevention, 2005. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Brain Injury in Your Practice. Atlanta (GA): Centers for Disease Control and Prevention, 2007. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Heads Up: Concussion in Youth Sports. Atlanta (GA): Centers for Disease Control and Prevention, 2007. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes. Neurosurgery. 51:1175-1180, 2002.

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Guskiewicz, K.M., Bruce, S.L., Cantu, R.C., Ferrarra, M.S., Kelly, J.P., McCrea, M., Putukian, M., and Valovich McLeod, T.C. National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. J Athletic Training. 39:280-297, 2004. Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, Onate JA, Kelly JP. Cumulative Effects Associated with Recurrent Concussion in Collegiate Football Players: The NCAA Concussion Study. Journal of American Medical Association. 290(19):2549-2555, 2003. Guskiewicz, K.M., Ross S.E., and Marshall S.W. Postural stability and neuropsychological deficits following concussion in collegiate athletes. Journal of Athletic Training. 36(3) 263-273, 2001. Guskiewicz, K.M., Weaver, N., Padua, D.A., and Garrett, W.E. Epidemiology of concussion in collegiate and high school football players. American Journal of Sports Medicine. 28(5)643-650, 2000.

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Maddocks, D. & Saling, M. Neuropsychologial Sequelae Following Concussion in Australian Rules Footballers. J Clin Exp Neuropsychol. 13: 439-442, 1991. McCrea, M., Barr, W.B., Guskiewicz, K.M., Randolph, C., Marshall, S.W., Cantu, R.C., Onate, J.A., Kelly, J.P. Standard regression-based methods for measuring recovery after sport-related concussion. J. International Neuropsychological Society. 11:58-69, 2005. McCrea M, Guskiewicz KM, Barr W, Marshall SW, Randolph C, Cantu R, Onate JA, Kelly JP. Acute effects and recovery time following concussion in collegiate football players: The NCAA Concussion Study. Journal of American Medical Association. 290(19):2556-2563, 2003. McCrea M. Standardized mental status assessment of sports concussion. Clin J Sport Med. 11:176181, 2001. Shultz, M.R., Marshall, S.W., Mueller, F.O., Yang, J., Weaver, N.L., Kalsbeek, W.D., and Bowling, J.M. Incidence and risk factors for concussion in high school athletes, North Carolina, 19961999. Am J Epidemiol. 160:937-944, 2004. Zemper, E.D. Two-year prospective study of relative risk of a second cerebral concussion. Am J Physical Med & Rehabil. 82:653-659, 2003.

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Implementing a Statewide Concussion Management Program Caroline Leipf, Ron Savage, EdD, and David Gealt, DO

The Brain Injury Association of New Jersey (BIANJ), a state affiliate of the Brain Injury Association of America, has developed an entire campaign to increase public awareness and prevention education on sports-related concussions. Its message: Concussion is a brain injury, and should be taken seriously. BIANJ organized its Concussion in Sports Committee in October 2004. The committee is made up of a diverse group representing a range of disciplines related to youth sports, including physicians, certified athletic trainers, therapists, coaches, researchers, brain injury specialists, sports administrators, and education professionals. To explain the diversity of this committee, one need only look as far as the campaign’s target audience—a similar range of athletic, medical and educational professionals, plus young athletes and their parents. The Concussion in Sports Committee’s approach is made up of several components, all aimed to deliver information on concussion to a statewide audience of young athletes, coaches, parents, athletic trainers, school professionals, and related sports- and safety-minded organizations. The committee has implemented a program beginning with a consensus statement, organizing a summit, establishing a grant for high schools for baseline testing, and providing continued educational resources to increase awareness. It is a model that can be adapted by other states, or even adjusted for smaller communities or larger national organizations that want to address concussion head-on. Concussion Consensus Statement Not until recently has concussion been dissected and examined for sports-related concussion specifically involving the youth. Be36 BRAIN INJURY PROFESSIONAL

cause there have been over twenty published guidelines on diagnosis and treatment, concussion is not uniformly understood among the athletic, educational, and medical communities of professionals who work with youth. The first charge of the Concussion in Sports Committee was to develop a consensus statement that defines concussion, discusses the features of concussion, and outlines the issues involved in return to play decisions. Information and research considered when crafting the consensus statement included reports from the CDC, the First International Conference on Concussion in Sport (Vienna, 2001), and the Second International Conference on Concussion in Sport (Prague, 2004). Once penned, the Concussion in Sports Consensus Statement became a tool for spreading basic information in a top-down approach. BIANJ distributes the Concussion in Sports Consensus Statement to organized statewide groups with members in sports, education and medical fields. To date, the BIANJ Concussion Consensus Statement is endorsed by 23 organizations, including: American Academy of Pediatrics, NJ Chapter; American College of Emergency Physicians, NJ Chapter; Athletic Trainers’ Society of New Jersey; Brain Injury Association of America; Brain Injury Association of New Jersey; Medical Society of New Jersey; NJ Academy of Family Physicians; NJ Advisory Council on Traumatic Brain Injury; NJ Association for Health, Physical Education, Recreation and Dance; NJ Association of Osteopathic Physicians and Surgeons; NJ Education Association; NJ Emergency Medical Services for Children Advisory Council; NJ Football Coaches Association; NJ Hospital Association; NJ Neuropsychological Society; NJ Principal and Supervisors Association; NJ SAFE KIDS; NJ School Counselor Association; NJ State First Aid Council; NJ State Interscholastic Athletic Association; NJ State Safety Council; NJ State School Nurses Association; and NJ Trauma Center Council. Concussion in Youth Sports Summit The Brain Injury Association of New Jersey hosted its Concussion in Youth Sports Summit on February 24, 2006, in the Stadium Club at the NY Giants Football Stadium. Over 150 delegates from more than 65 statewide organizations attended. The Summit brought attention to the importance of properly identifying, measuring, monitoring and managing concussion in sports and provided delegates with a great deal of information and resources. It also allowed the attendees to discuss and identify specific concerns in sports-related concussions for the BIANJ to consider for future objectives. The Summit faculty was comprised of concussion experts including: Jill Brooks, PhD; Robert C. Cantu, MD; Phil Hossler, ATC; Stephen Rice, MD, PhD; Wesley Rutland-Brown, MPH; Ronald Savage, EdD., and two featured speakers, Katrina Majewski and David Showalter. These two young adults, had both sustained concussions playing collegiate sports, and live with lingering effects from their mild traumatic brain injuries. To make the Summit presentations available to a wider audience, the Association has posted them —complete with video and accompanying PowerPoint slides—online at http://bianj.blueskybroadcast.com. Baseline Testing Grant Initiative At the Sports Concussion Summit, the Brain Injury Association of New Jersey announced a first-of-its-kind grant initiative for New Jersey high schools to implement concussion baseline testing and management programs. This initiative, which is still

in progress, offers matching grants to up to 100 public or private high schools. Schools pay $650 of the program’s $1300 total cost and make a 3-year commitment to baseline and post-concussion test their student athletes. BIANJ contributes the matching $650. This grant is funded by the New Jersey Traumatic Brain Injury (TBI) Fund, which was created, in part, to provide for public education and prevention activities related to brain injury. BIANJ is partnering with ImPACT Applications, Inc. of Pittsburg, Pennsylvania to deliver its computerized concussion management program to grant recipients, along with training for the schools’ certified athletic trainers and team doctors. ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) was the first, and is currently the most widely used, computerized concussion evaluation system. It is used by several New Jersey colleges and universities, including Rutgers and Princeton. ImPACT has also been the concussion management tool of choice for several professional sports teams, and, effective this fall, will be used to baseline every NFL player in accordance with its new league guidelines for concussion management. In spring 2006, 35 high schools applied and were awarded matching grants by the Brain Injury Association of New Jersey. Another 28 grants were awarded the following spring. There are 72 high schools in New Jersey currently using ImPACT, 63 of which are doing so through this grant. Of those 72, only 16 schools have used ImPACT independently from the grant either prior to the grant or at present. The Association’s grant initiative has more than quadrupled the number of high school scholastic sports programs with ImPACT, increasing the percentage of New Jersey high schools that are baseline testing by 11% (based on total of 423 public and private high schools in New Jersey State Interscholastic Athletic Association sports). With funding for up to 100 high schools, BIANJ is eager to award a remaining 37 grants in the spring of 2008. The first data runs are also now being analyzed by the Committee. Concussion Materials & Resources An information-based campaign is not complete without resources. In determining what it would create, the Brain Injury Association of New Jersey took stock of what already existed. The Concussion in Sports Committee wanted to deliver information that was consistent with that being disbursed by the CDC (U.S. Centers for Disease Control and Prevention), and utilize

existing resources whenever possible. Its materials would complement existing ones, while promoting the New Jersey campaign. New Jersey’s resources include two posters, tear-off pads on concussion signs and symptoms, and a sports safety brochure. The Association also produces a quarterly newsletter, Game Plan, specifically on sports concussion that is distributed to attendees from the Summit and schools participating in the Baseline Grant Initiative. A binder of Association and outside resources was compiled for Summit attendees and remains available electronically. The CDC’s coaches’ toolkit, Heads Up: Concussion in High School Sports, was produced near the same time as this campaign launched, and so the Association coordinated with the CDC to distribute a copy to every attendee at the Concussion in Youth Sports Summit. Similarly, the campaign encourages people to obtain their copies of the latest CDC toolkits, Heads Up: Concussion in Youth Sports and Heads Up: Brain Injury In Your Practice. Above all these materials, the Brain Injury Association of New Jersey regards a website created for the Concussion in Sports Campaign to be most valuable. All of the components of its Concussion in Sports Campaign, including the Concus-

sion Consensus Statement, links to Summit presentations, Baseline Grant Applications, and resource materials, can be found on www.sportsconcussion.com. Moving Forward The Brain Injury Association of New Jersey Concussion in Sports Committee has found that developing a clear consensus statement; educating professionals, athletes and others about concussions; creating a partnership with a concussion management program (ImPACT); securing funds to enable schools to implement concussion assessment and management tools; and providing additional resources and outreach to partners have produced an effective sports concussion campaign. New initiatives are currently being investigated and new partners are being identified as the BIANJ Concussion in Sports Committee continues to expand its work. About the Authors

All three authors are members of the New Jersey Brain Injury Association’s “Sports Concussion Management Committee”. Ms. Leipf is also the Director of Communications for NJ BIA. Dr. David B. Gealt, D.O., is a medical orthopaedics and sports medicine specialist at Cooper Hospital-University Medical Center in Camden, NJ. Dr. Ron Savage is the President of NABIS.

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