“Evaluation and Management of Sport-Related Concussion in Youth: Clinical,

Research & Public HealthStrategies”

Gerard A. Gioia, Ph.D.Gerard A. Gioia, Ph.D.Pediatric NeuropsychologistPediatric Neuropsychologist

Chief, Division of Pediatric NeuropsychologyChief, Division of Pediatric NeuropsychologyDirector, Safe Concussion Outcome, Recovery & Education (SCORE) Director, Safe Concussion Outcome, Recovery & Education (SCORE) ProgramProgram

ChildrenChildren’’s National Health Systems National Health SystemProfessor, Pediatrics and Psychiatry & Behavioral MedicineProfessor, Pediatrics and Psychiatry & Behavioral Medicine

George Washington University School of MedicineGeorge Washington University School of MedicineWashington, DCWashington, DC

Disclosure Statement

Psychological Assessment Resources, Inc.Psychological Assessment Resources, Inc.Test AuthorTest Author

Behavior Rating Inventory of Executive Function Behavior Rating Inventory of Executive Function (BRIEF) (BRIEF) Tasks of Executive Control (TEC)Tasks of Executive Control (TEC)

Objectives

Describe history and evolving state of mild TBI/ Describe history and evolving state of mild TBI/ concussion as related to sportsconcussion as related to sportsDescribe clinical and public health methods for Describe clinical and public health methods for evaluation of sportevaluation of sport--related concussionrelated concussionDiscuss traditional and newer models of Discuss traditional and newer models of managementmanagementIdentify key areas of research need in pediatric mild Identify key areas of research need in pediatric mild TBITBI

Concussion/ mTBI 10-15 Years Ago

Little understanding of mTBILittle understanding of mTBIFew treating healthcare providers Few treating healthcare providers Few medical tests or toolsFew medical tests or toolsMinimal research/ fundingMinimal research/ fundingLittle public awareness of risksLittle public awareness of risksNo rules to protect kidsNo rules to protect kids

Basic Underlying AssumptionsThe Brain is complex!The Brain is complex!Brain injury is complex!Brain injury is complex!Brain injury does not manifest in a single domain Brain injury does not manifest in a single domain of functioning of functioning No singleNo single score, test/ measure, discipline, person score, test/ measure, discipline, person can answer ALL the complex clinical questions.can answer ALL the complex clinical questions.Understanding brain injury requires a synthesis of Understanding brain injury requires a synthesis of multiple data sources and perspectives.multiple data sources and perspectives.NO MAGIC BULLET!

A Concussion is a Brain Injury

Brain Motion...

Joel Stitzel, jstitzel@wakehealth.ed

Concussion/ mTBI Definition

A concussion (or mild traumatic brain injury)A concussion (or mild traumatic brain injury)is defined as a is defined as a

complex complex pathophysiologicpathophysiologic process affecting process affecting the brain,the brain,induced by traumatic induced by traumatic biomechanical forcesbiomechanical forcessecondary to direct or indirect forces to the secondary to direct or indirect forces to the head.head.

CDC Heads Up: Brain Injury in Your Practice (2007)

Concussion/ mTBI Definition

Disturbance of brain function is related to: Disturbance of brain function is related to: neurometabolicneurometabolic dysfunction, rather than dysfunction, rather than structural injurystructural injurytypically associated with typically associated with normal structuralnormal structuralneuroimaging findings (i.e., CT scan, MRI). neuroimaging findings (i.e., CT scan, MRI).

Changes brains electrochemical Changes brains electrochemical ““softwaresoftware””functionfunctionConcussion may or Concussion may or may notmay not involve a loss of involve a loss of consciousness (LOC). (10consciousness (LOC). (10--20%)20%)

CDC Heads Up: Brain Injury in Your Practice (2007)

Concussion/ mTBI Definition

Concussion results in a Concussion results in a constellation of symptomsconstellation of symptoms::physical, cognitive, emotional and sleepphysical, cognitive, emotional and sleep--related. related.

Duration of symptoms are Duration of symptoms are variablevariable may last for as may last for as short as several minutes and last as long as short as several minutes and last as long as several days, weeks, months or even longer in several days, weeks, months or even longer in some cases.some cases.

CDC Heads Up: Brain Injury in Your Practice (2007)

Effects of Concussive Forces on the Brain

Typically, the Typically, the ““softwaresoftware”” of the brain is of the brain is affected affected

Neurometabolic/ neurochemical processesNeurometabolic/ neurochemical processesPhysiologicalPhysiological

Not the Not the ““hardwarehardware””Structure Structure

Neurometabolic Cascade FollowingTraumatic Brain Injury

2 6 12 20 30 6 24 3 6 10minutes hours days

500

400

300

200

0

50

100

% o

f nor

mal K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

Anatomical Timeline of a ConcussionDefining the Key Factors

LOC<10%

Antero-grade

Amnesia25-40%

CONCUSSIONCONCUSSION

Pre-InjuryRisks

Retro-grade

Amnesia20-35%

Neurocognitive & Balance dysfx &

Post-Concuss Sx’s

Sec-Hrs Hours - Days - Weeks+Sec-MinSec-Hrs

A. Injury Characteristics B. Symptom AssessmentC. Risk Factors

Signs of a Concussion(what you observe)

CognitiveCognitiveAppears dazed/stunnedAppears dazed/stunnedConfused about events Confused about events

(assignment or position)(assignment or position)

Answers questions more Answers questions more slowlyslowly

Repeats questions/ forgets Repeats questions/ forgets instruction or playinstruction or play

CanCan’’t recall events prior to or t recall events prior to or after the hit/fall after the hit/fall

PhysicalPhysicalVomitingVomitingLoses consciousnessLoses consciousnessBalance problemsBalance problemsMoves clumsily Moves clumsily DrowsyDrowsy

Behavior/Emotion•Behavior or personality changes

Symptoms of a Concussion(what they feel and report)

PhysicalPhysicalHeadacheHeadacheFatigueFatigueVisual problems Visual problems (blurry/(blurry/““doubledouble””))

Nausea/vomitingNausea/vomitingBalance problems/ dizziness Balance problems/ dizziness Sensitivity to light/noiseSensitivity to light/noiseNumbness/tinglingNumbness/tingling

Cognitive Cognitive Mental fogginess Mental fogginess Difficulty concentrating Difficulty concentrating Difficulty rememberingDifficulty rememberingFeeling slowed downFeeling slowed down

Emotional•More emotional•Irritable•Sad•Nervous

Sleep •Sleeping more/less•Trouble falling asleep•Drowsiness

Neuropsychological Impairment• Concussion produces impairment of

neuropsychological function in children and adults:

- Attention- Memory- Speed- Executive function- Emotional response

Assessments-Brief cognitive measure (SAC)-Paper & Pencil Battery-Computer-based Battery-Questionnaire/ Ratings

Criteria for RecoveryWhen Return to Full Activity?

No longer have any No longer have any symptomssymptomsNo longer need medicine to control symptoms.No longer need medicine to control symptoms.

Neurocognitive functionNeurocognitive function & & balancebalance back to preback to pre--injury injury ““normal.normal.””

At RestAt RestAfter Gradual activity (exertion)After Gradual activity (exertion)

Cleared by medical professional to begin gradual Cleared by medical professional to begin gradual Return to ActivityReturn to Activity

Recovery From Concussion:How Long Can it Take?

0102030405060708090

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Preparing the Team on the Field

HomeBackyardNeighborhoodSchoolPlaygroundAthletic FieldRoadWoods…

Injury

ParentTeacherNeighborCoachFriendTeammateBystander…

“Job”Recognize & Respond1+2 “When in Doubt, Sit Them Out”

EMTEmergency Dept.Urgent CarePrimary CareSchool HealthAthletic HealthSpecialty Care

Injury Setting Non-Medical Medical Provider

“Job”Diagnose & Treat

Identification

Public Health Model

Public Health Focus: Empower Responsible Public Health Focus: Empower Responsible Persons with Persons with Public HealthPublic Health Knowledge AND Knowledge AND Skill/ ToolsSkill/ Tools

ParentsParents TeachersTeachersYouthYouth CoachesCoaches

Public Health EffortsPublic Health EffortsCDC relationship (Heads Up): toolkit CDC relationship (Heads Up): toolkit developmentdevelopmentEducation & TrainingEducation & TrainingSmartphone apps, paperSmartphone apps, paper--basedbased

Knowledge to

Recognize

Once recognized, what do I do (Respond)?

Public Health Challenge

Concussion/ mTBI = Invisible Injury

Child / Teen(Student, Athlete,

Son/Daughter,Friend)

Public HealthFour Corners Approach to Concussion Care

Family

Sports/Recreation

Medical

School

CNM_PPT_PB2012_temp.potx

Public Health Toolkits ConcussionEducational Materials

Heads Up: Concussion in High School Sports

Heads Up: Concussion in Youth Sports

Heads Up: Concussion in Your Practice

Heads Up to Schools: Know your Concussion ABCs

www.cdc.gov/concussion

Empower with Recognition & Response

Blow / Force to Head / Body

Teach Concussion Recognition

Change in Function /   Behavior / Performance

Post-Concussion Signs & SymptomsPhysical Cognitive Emotional SleepHeadache Concentrate Irritability MoreFatigue Memory Emotional LessBalance/ Speed of control CannotDizziness Thinking Sadness

Post-Concussion Signs & SymptomsPhysical Cognitive Emotional SleepHeadache Concentrate Irritability MoreFatigue Memory Emotional LessBalance/ Speed of control CannotDizziness Thinking Sadness

1 2

“I SUSPECT!”

Teach Proper Response

ResponseProtect from further risk

Removal‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Medical EvaluationRestrict Risk Activities

Rest / Recovery

“When in Doubt, Sit Them Out”

Empower with Recognition & Response Multimodal Clinical Pediatric Concussion Model

••Injury CharacteristicsInjury Characteristics••History VariablesHistory Variables

1. Symptoms: Child, Parent1. Symptoms: Child, Parent2. Neurocognitive Testing2. Neurocognitive Testing3. Cognitive Exertion Effects3. Cognitive Exertion Effects4. Balance4. Balance

Predicting:•Diagnosis•Recovery Outcomes

Return to Life•Return to Play•Return to School

+

Development

Development

Children’s National Research ActivityDevelopment of outcome measuresDevelopment of outcome measuresInjury recovery trajectoriesInjury recovery trajectoriesAge/ developmental differences in recoveryAge/ developmental differences in recoveryGender differences in recoveryGender differences in recoveryEffects: Effects:

School, cognitive exertionSchool, cognitive exertionEmotional outcomesEmotional outcomes

Treatments:Treatments:Active symptom managementActive symptom managementActive Rehabilitation (Slow to Recover) Active Rehabilitation (Slow to Recover) –– aerobic activityaerobic activity

Roots: force profiles, genetics, neuroRoots: force profiles, genetics, neuro--imagingimaging

Clinical Tools

Acute Concussion Evaluation (ACE)Acute Concussion Evaluation (ACE)ACE Care Plan, Home/School InstructionsACE Care Plan, Home/School InstructionsPostPost--Concussion Symptom Inventories (PCSI)Concussion Symptom Inventories (PCSI)Multimodal Assessment of Cognitive & Symptoms Multimodal Assessment of Cognitive & Symptoms (MACS) for Children(MACS) for ChildrenExertion Effects Rating Scales (EERS)Exertion Effects Rating Scales (EERS)Behavior Rating Inventory of Executive Function (BRIEF)Behavior Rating Inventory of Executive Function (BRIEF)Tasks of Executive Control (TEC)Tasks of Executive Control (TEC)Concussion Recognition & Response (CRR) appConcussion Recognition & Response (CRR) appConcussion Assessment & REsponse (CARE) appConcussion Assessment & REsponse (CARE) app

Clinical Tools

ACE is a ACE is a clinical protocolclinical protocol to assist diagnosis of to assist diagnosis of mTBI/ concussion in medical settingsmTBI/ concussion in medical settingsAges 4Ages 4--adultadultElements of clinical assessment protocol are Elements of clinical assessment protocol are evidenceevidence--basedbasedLink to followLink to follow--up care via up care via ACE Care PlanACE Care Plan

Acute Concussion Evaluation (ACE)

Since June 2007Emergency Care

What’s My Clinical Protocol?What Tools Do I Have?

Acute Concussion Evaluation Acute Concussion Evaluation Emergency Dept. (ACEEmergency Dept. (ACE--ED) ED)

Acute Concussion Evaluation Emergency Dept. (ACE-ED)

EmergencyDepartment

Pediatrician

Standardized Acute mTBI Instructions for Home and School

Urgent Care

CDC Emergency Dept. study (CNMC, CHP), age 5-21

Objective: determine whether the Acute Concussion Evaluation (ACE) tools, modified for ED use, improved patient follow-up and post-injury behaviors

Follow-up care was improved at 1, 2 and 4 weeks

(32% vs. 61% at Week 4, p<0.001).

Parental recall of discharge instructions was significantly increased

Student received greater academic assistance

Patient’s mean total post-concussion symptom score was significantly higher

Report of return to normal activity was significantly longer.

Patient/ Family Evaluation & Mgt.in the Emergency Dept.

CDC Award U49CE001385NIH # M01RR020359, P30/HDO40677-07

Primary CareWhat’s My Clinical Protocol?

Acute Concussion Evaluation (ACE)Acute Concussion Evaluation (ACE)A.A. Define Define Injury CharacteristicsInjury CharacteristicsB.B. Assess for Assess for Symptoms (22)Symptoms (22) (Lovell & Collins, 1998)(Lovell & Collins, 1998)C.C. Identify Identify Risk FactorsRisk Factors for Prolonged Recoveryfor Prolonged RecoveryD.D. Red FlagsRed Flags for Neurological Deterioration for Neurological Deterioration E.E. Establish the Establish the DiagnosisDiagnosisF.F. Plan Plan FollowFollow--UpUp Action / ReferralAction / Referral

Acute Concussion Evaluation (ACE) Key Elements

Acute Concussion Evaluation (ACE)A. Injury Characteristics

Injury DescriptionCause

Amnesias (retrograde, anterograde)Loss of Consciousness (LOC), Seizures

Early Signs

basketball

Sept. 7, 2008Fell to ground, hit head on ground, kneed in right temporal region; dazed initially but

continued to play with bad headache. Felt sluggish and confused.

Acute Concussion Evaluation (ACE)B. Symptom Checklist

5

4

1

2

12

Acute Concussion Evaluation (ACE)C. Risk Factors for Protracted Recovery

Research findings have linked these risk factors to longer periods of recovery

Acute Concussion Evaluation (ACE)D. Red Flags for Neurological Deterioration

Physicians and parents/ patients need to be aware of signs that signal the need for

emergency care.

Cognitive FunctionMultimodal Assessment of Cognition &

Symptoms (MACS) for Children

Subtests measuring memory, attention, speedSubtests measuring memory, attention, speed

DevelopmentallyDevelopmentally--appropriateappropriateTask instructionsTask instructions

Test stimuli (pictures, words)Test stimuli (pictures, words)

Developed for age 5Developed for age 5--12 12 6 subtests, 5 alternate forms6 subtests, 5 alternate forms

CDC Award U17/ CCU323352NIH M01RR020359, P30/HDO40677-07

Multimodal Assessment of Cognition & Symptoms (MACS) for Children Psychometric Analyses -MACSNormative development n=705Normative development n=705Developmental trendsDevelopmental trendsSex differences minimalSex differences minimalReliability: Internal consistency, testReliability: Internal consistency, test--retest (.74retest (.74--.93).93)Form Equivalence Form Equivalence –– 3 forms (2 addit rsch)3 forms (2 addit rsch)Validity: Validity:

Construct (factor analysis)Construct (factor analysis)Relationship to other measures (concurrent, discriminant)Relationship to other measures (concurrent, discriminant)Detecting group differences (longitudinal: repeated measures Detecting group differences (longitudinal: repeated measures ANOVA, growth curve modeling)ANOVA, growth curve modeling)Detecting clinically meaningful intraDetecting clinically meaningful intra--individual differencesindividual differences

Reliable change (from normal, back to normal)Reliable change (from normal, back to normal)Detecting reliable change across test administrations (BaselineDetecting reliable change across test administrations (Baseline--Post)Post)

Classification Analyses: Likelihood Ratio, Sensitivity/ SpecificClassification Analyses: Likelihood Ratio, Sensitivity/ Specificity, Hit ity, Hit RateRate

Neurocognitive Recovery (Speed)

Response Speed Composite and Subcomposite Scores at Visits 1, 2 and 3 for Children with Concussions Seen within 14 Days

Neurocognitive Recovery (L&M)

Learning & Memory Accuracy Composite and Subcomposite Scores at Visits 1, 2, 3 for Children with Concussions Seen w/n 14 Days

Symptom Assessment

British Journal of Sports Medicine (2009)

Symptom ReportsPostPost--Concussion Symptom Inventory (PCSI)Concussion Symptom Inventory (PCSI)

Age 5Age 5--7: 5 items (Physical, Cognitive, Emotional)7: 5 items (Physical, Cognitive, Emotional)Age 8Age 8--12: 17 items (Physical, Cognitive, Emotional, Fatigue)12: 17 items (Physical, Cognitive, Emotional, Fatigue)Age 13Age 13--18: 21 items (Physical, Cognitive, Emotional, Fatigue)18: 21 items (Physical, Cognitive, Emotional, Fatigue)Parent: 20 items (Physical, Cognitive, Emotional, Fatigue)Parent: 20 items (Physical, Cognitive, Emotional, Fatigue)

Behavior Rating Inventory of Executive Function Behavior Rating Inventory of Executive Function (BRIEF), concussion monitoring form(BRIEF), concussion monitoring form

Working memory/ attention, planning/organization, initiation, Working memory/ attention, planning/organization, initiation, emotional control, inhibitionemotional control, inhibition

YES NO

Over the past dayOver the past day……Have you had headaches? Has Have you had headaches? Has

your head hurt?your head hurt?

PCSI age 5-12

A Little? A Lot?

How much?How much?

Over the past dayOver the past day……

Have you had headaches? Has Have you had headaches? Has your head hurt?your head hurt?

Symptom Recovery Rptd. Meas. MANOVA

Mean PCSI Symptom Ratings for Physical, Cognitive, Emotional, Sleep and Total Symptoms at Visits 1, 2 and 3 for Children with Concussions Seen within 14 Days

Emotional Symptomatology after mTBI (w/ & w/o comorbid Anxiety or Depression)

F=131.4, p <.001, eta2 =.19n= 469 (No Dx)

n= 93 (Dx Anx/ Dep)

Cognitive ExertionWhy Do we Care?

Exertional Effects = Symptom exacerbation Exertional Effects = Symptom exacerbation following following physicalphysical or or cognitivecognitive activityactivitySignalSignal that the brainthat the brain’’s dysfunctional s dysfunctional neurometabolism being pushed beyond its neurometabolism being pushed beyond its tolerable limitstolerable limitsChildChild’’s sensitivity to symptom exacerbation / s sensitivity to symptom exacerbation / exertional effects is hypothesized to be one more exertional effects is hypothesized to be one more indicator of its injury status.indicator of its injury status.Possible treatment implicationsPossible treatment implications

Measuring Exertional Effects

1 5

1

63

5

2 0

Exertion Effects Index Difference Score = 16- 6 =10

Cognitive Exertion EffectsAge x Sex

Cognitive Exertion

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Pre Post

Tota

l sco

re

Uninjured F 5-12Uninjured F 13-18Uninjured M 5-12Uninjured M 13-18mTBI F 5-12mTBI F 13-18mTBI M 5-12mTBI M 13-18

Boys & girls no different at BASELINE

Age x sex interaction: Adolescent girls most pronounced with exertional effects.

Similar pattern with general symptom report

Validating Exertion Effects Index

• Exertion Effects Index difference score of 4 points or greater significantly differentiates concussion from matched controls at80% Confidence Interval.

Testing the model

n above % Total n %

1-tailedControls 40 10.5 40 10.5Concussion 118 30.9 118 30.9

Normal Control n = 382; Concussion = 382; Male n=259 Female n=123Age 5-18; seen w/in 30 days of injury

“New” Management Strategies“Active” Rehabilitation

• No additional forces to head/ brain

• INITIALLY, resting the brain & getting good sleep (days)

• Individualized moderated, monitored symptom management– Managing/ facilitating physiological recovery; teaching symptom 

monitoring, exertion concepts

– Find the activity “sweet spot”

– Optimized activity w/o over‐exertion; Not too much BUT not too little 

– Plan of graduated physical and cognitive activation 

Ways to over‐exert• Physical• Cognitive (concentration)• Emotional (stress)

“New” Management Strategies“Active” Rehabilitation

• Aerobic Activation (Gagnon et al., 2009; Leddy et al, 2010)• Structured and monitored subsymptom threshold exercise to facilitate healing.

• Progressive “controlled” exercise below level that produces symptom occurrence or worsening. 

Return to SchoolKid’s Major “Job”

• New Learning/ Acquiring Knowledge– Academic– Social

• Practicing incompletely learned knowledge

• Mental/ Cognitive exertion is essential to new learning/ practice

Concussion’s Effects on School Learning & Performance

• 216 students (Gr. 4‐12) with concussions• “Which specific types of problems are you experiencing in school?”

• Students reported an average of 3.4 problems below. • Headaches interfering  66%    (HS‐68%) • Too tired  54%    (HS‐58%) ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐• Can’t pay attn in class  58%    (HS‐62%) • HW taking much longer  49%    (HS‐54%) • Difficulty studying for test/quiz  42%    (HS‐47%) • Diffic understanding material  44%    (HS‐46%) • Difficulty taking notes  27%    (HS‐32%) 

Gradual Return to School Where Are We Today?

Increased public awarenessIncreased public awarenessSignificant increase in recognition of sportSignificant increase in recognition of sport--related mTBI/ concussionrelated mTBI/ concussionExpanding our research knowledgeExpanding our research knowledgeImproving our understanding of the injuryImproving our understanding of the injuryTraining more healthcare providers, clinicsTraining more healthcare providers, clinicsDeveloping more clinical tests and toolsDeveloping more clinical tests and toolsImplementing rules to protect kidsImplementing rules to protect kids

What we still need to know

The brainThe brain’’s individual response to forces s individual response to forces (concussive, subconcussive)(concussive, subconcussive)Reasons for variability in risk for injuryReasons for variability in risk for injuryReasons for variability in recovery outcomesReasons for variability in recovery outcomesLongLong--term effects of single, multiple, complex term effects of single, multiple, complex injuriesinjuriesIndividualized treatment predictors, protocolsIndividualized treatment predictors, protocolsPREVENTIONPREVENTION

Let’s Put Kids First!

“Their Brains are The Future”

Thank You!