BASIC PRINCIPLES OF CONCUSSION MANAGEMENT

Transcription

1 BASIC PRINCIPLES OF CONCUSSION MANAGEMENT INTRODUCTION: Knowledge about concussion has grown enormously in the past two decades. Public awareness and interest in concussion, based on its prevalence in the news media and in the scientific literature, has exploded in the past few years. The organizations and institutions responsible for professional, collegiate and high school sports have altered how concussions are recognized, managed and hopefully prevented; the NFL and the NHL have assumed leadership positions after acknowledging the cumulative deleterious effects of concussion over a lifetime of playing collision sports. Society has reached a tipping point, with a majority of states passing state laws regarding concussion in young interscholastic athletes (including New Jersey in December 2010) since the State of Washington enacted the Zackery Lystedt law in the spring of Its passage was prompted by an injury to a junior high school football player who suffered a concussion and subdural hematoma during the same game in This law has three components: (1) Educate coaches, athletes and parents about concussion; (2) Any athlete suspected of having a concussion should be removed from play immediately and not permitted to return to play that day; (3) Concussed athletes cannot return to activity until cleared by a licensed health care professional knowledgeable in the evaluation and management of concussion. In New Jersey, under the law that went into effect in September 2011, concussed athletes cannot return to activity until cleared by a physician knowledgeable in the evaluation and management of concussion. Further, after symptoms have cleared, the return-to-play process entails a multi-step protocol that takes approximately one week to complete. Accordingly, it is essential that physicians in New Jersey who care for concussed individuals are up-to-date and knowledgeable on this important injury. In this article I want to emphasize several key points for physicians and to provide a plethora of excellent resources that are available to you through the Internet and attached materials. Can you meet the criteria of being a health care professional knowledgeable in the evaluation and management of concussion in 2012? While many of the principles of understanding concussion and its management do not meet the highest levels of evidence-based medicine, this past decade has brought together three international consensus conferences on concussion. In addition to the finding of the consensus conferences, position statements on concussion have been developed by most professional organizations and societies dealing with sports medicine, neurology, athletes and children. These international consensus conferences (Vienna 2000, Prague 2004, Zurich 2008) demonstrated the speed with which information and knowledge advance. Grading scales are no longer used to assess the severity of concussions. While certain principles have

2 been consistent in the three documents, there has been a shift toward recognizing that properly managing concussions entails far more than merely controlling when an athlete is removed from play and permitted to return to the field of action. The concept of brain rest to maximize the speed of recovery from concussion is a new cornerstone of management. The position statements of the American Academy of Pediatrics (2010), The National Athletic Trainers Association (2004), the American College of Sports Medicine (2006), and the American Academy of Neurology (2010) have all advanced the field of knowledge, spreading essentially the same message to their constituencies. Further, the Centers for Disease Control and Prevention (CDC) have developed, promulgated and updated outstanding materials for use by physicians, athletic trainers, school nurses, schools, youth sports coaches, athletes and parents. From this vast consensus of expert opinion, health care providers and organizers of sports have a solid base and basis from which to develop sound evidence-based policies. DEFINITION from Zurich 2008 Consensus Statement: The current accepted definition of concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Included in the definition are five major features of a concussion. 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Loss of consciousness occurs in less than 10% of concussions. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies (CT or MRI) is seen in concussion. SIGNS AND SYMPTOMS: The signs and symptoms of concussion can occur in one or more of the following clinical domains (some examples given in parentheses): a. Physical/Somatic (headache, nausea, vomiting, dizziness, disturbed balance, vision problems, sensitivity to light or noise, loss of consciousness) b. Emotional (behavioral) changes (irritability, sadness, nervousness, odd behavior) c. Cognitive impairment (slowed reaction times, slowed speed of processing, feeling in a fog, difficulty concentrating, difficulty remembering, memory loss/amnesia) d. Sleep disturbances (drowsiness, trouble falling asleep, sleeping more, sleeping less) Mental confusion and fogginess are the hallmarks of concussion. Headache is the most common and often the most persistent symptom.

3 PATHOPHYSIOLOGY of Concussion: The brain is an obligate aerobic organ fueled by glucose delivered via the circulation of blood. The proportion of oxygen and glucose in the blood under normal circumstances is precisely what the brain requires for optimal function. If brain activity increases (through physical activity, cognitive thinking or absorbing the stimuli of the world around us), the blood flow to the brain increases. This coupled relationship of oxygen and glucose is vitally important to normal brain function. The advent of fmri and PET scans have permitted scientists to identify various parts of the brain responding to different outside stimuli. The research of Hovda in 1995 and 2001 at UCLA demonstrated that a laboratory-induced concussive force in rats produced several metabolic changes: (1) alterations in intracellular/extracellular glutamate, potassium and calcium; and (2) a relative decrease in cerebral blood flow in the setting of an increased requirement for glucose (i.e., increased glycolysis). More specifically, this research demonstrated that the concussive force produced the release of excitatory amino acids, such as glutamate, that resulted in changes in the permeability of calcium and potassium ions in the axonal membrane causing indiscriminate ion flux. Calcium enters the cells and potassium leaves the cells. The calcium flux causes a decrease in cerebral blood flow; however, to restore potassium to its appropriate location inside the cell, activation of the sodium/potassium ion pump mechanism is required which utilizes ATP to work the pump. ATP, however, is generated from the glycolysis of glucose. During these first few minutes following the concussive blow to the head when the oxygen/glucose relationship becomes uncoupled, the brain accomplishes critical task anaerobically, accumulating lactic acid over the first 10 to 30 minutes. Following restoration of potassium within the cell, glucose utilization in the brain decreases to levels commensurate with the decreased blood flow. This cascade of events, once initiated, takes several days to a week or more to completely recover metabolic equilibrium. Thankfully, the brain is capable of healing itself spontaneously over time if it is given the opportunity to do so. Conserving glucose for the purpose of repairing the functional brain damage is the key to rapid recovery. This mismatch in the metabolic supply and demand may potentially result in cell dysfunction and increase the vulnerability of the cell to a second traumatic insult or stress. Increasing cerebral blood flow during this time of crisis in the brain will delay recovery and may cause more serious permanent cellular and functional damage. This same pattern is thought to occur in humans as well. An important clinical point to consider is whether the blow to the head or body was sufficient to initiate this chemical cascade in the athlete: releasing excitatory amino acids, membrane permeability changes, indiscriminate ion flux, calcium entering cells (causing decreased blood flow) and potassium leaving cells (activating the potassium/sodium ion pump). Can someone identify a sub-clinical incident from a concussion? Those present when the injury occurs can best attest to the signs and symptoms noted; a sideline evaluation (SCAT2) has been

4 developed to assist athletic trainers and physicians at the sidelines in making that decision. By today s standards, however, the threshold for assuming a concussion is relatively low. KEY POINTS: If an athlete experiences head trauma and demonstrates the signs and symptoms of a concussion to those individuals present at the time of the injury, a concussion has almost certainly occurred. By law in New Jersey, anyone who meets these criteria must be removed from physical activity immediately and not permitted to return to physical activity that day. When in doubt, sit em out! No one should be permitted to participate in physical activity while still experiencing symptoms of a concussion. The athlete must then be evaluated by a health professional. No two concussions are identical. While there are good general guidelines to channel our care management, each concussion care plan must be individualized. However, returning an athlete to physical activity prudently requires following a graduated return to play protocol. In New Jersey, a concussed athlete cannot begin the graduated return to activity protocol until cleared by a physician knowledgeable in the evaluation and management of concussion. After the symptoms of concussion have cleared, this return-to-play process entails a multi-step protocol that takes approximately one week to complete. When the athlete is ready to engage in full contact practices and games, physician approval is again required. One of the most important tasks of a health professional (or lay person, such as a coach or parent) initially evaluating an individual who experienced head trauma and demonstrates signs and symptoms associated with a concussion is determining whether or not a more serious brain injury or intracranial hemorrhage has occurred. Generally, most symptoms of a concussion are at their worst immediately after the injury and improve as time elapses. As long as the athlete continues along that pathway, careful observation may suffice as appropriate management. However, sudden onset of any of the following red flags is an indication for immediate referral to an emergency department: headaches that worsen, seizures, focal neurological signs, slurred speech, repeated vomiting, looking very drowsy or cannot be awakened, unable to recognize people or places, increasing confusion or irritability, weakness or numbness in the arms and legs, neck pain, unusual behavioral changes, or change in state of consciousness. Because the emergency department is a venue teeming with considerable activity and stimuli of all kinds (lights, noises, action), it is not an atmosphere conducive to rapid recovery from concussion; accordingly, referral to the emergency department should be reserved only for those patients in whom there is a high suspicion for more serious brain injury.

5 A CT scan is not usually necessary for managing a concussion because the CT scan provides information primarily about anatomic structural injury, such as skull fractures and bleeding within the skull. The CT does not measure the functional deficits caused by concussion. Since a CT scan requires a significant amount of radiation (equal to about one year s worth of ordinary background radiation from our environment), a CT scan should be avoided unless absolutely necessary especially in children. Further, many parents assume incorrectly that a negative CT scan means that their child did NOT suffer a concussion. The resolution of symptoms within minutes or hours, coupled by a normal physical examination and normal neuroimaging studies, does not negate the fact that the athlete was symptomatic immediately following head trauma; in 2012, it is not appropriate for a health professional to state definitively that a concussion did not occur at a recent time in the past because there are no findings at the present time. INITIAL MANAGEMENT AND ADVICE The best advice is to go home, find a quiet and dark room, get as much sleep and rest as possible. This concept of cocoon therapy, espoused by Connecticut pediatrician Dr. Michael Lee, appears to set the stage for rapid resolution of symptoms since it minimizes the possibility for further insulting the injured brain as it tries to heal itself. Rest is medicine. (1) Refrain from participation in all physical activities while any symptoms are present. (2) Brain rest is the best method for keeping concussion symptoms to a minimum and speeding the process of recovery. This rest includes not only avoiding physical activity, but minimizing cognitive activity (using your brain to think and carry out mental tasks) and minimizing social activity (which also requires increased brain activity). Good advice: no texting, no video games, no Internet or computer use, no reading, no driving, no loud music, no ipod use, no walking the dog, no visits from friends, no television (initially). Do not attend your team s practice, next game or other social functions. Avoid hot tubs. (3) Sleep is beneficial the first few days; it is not necessary to awaken a concussed individual during the night; instead, do as a parent of a sleeping newborn baby would do: observe the individual for a normal breathing pattern. After the first 3 days, go to sleep at your normal time and wake up at your normal hour. While at home, takes brief naps as needed during the day of no more than 15 to 20 minutes. EMERGING FROM THE COMPLETE REST If light bothers the person, use sunglasses whenever going outside or inside in bright surroundings. The resolution of symptoms is the initial management goal; headache is the most important symptom to overcome. Commonly, the headache will be dull or achy. If the person engages in too much brain activity, however, the fogginess and head in the clouds feeling may increase and change the character of the headache towards a throbbing headache. Do not allow that to happen!! When the fogginess resolves completely, the headaches usually resolve shortly thereafter.

6 When the headaches have resolved completely, alternate reading with using the computer in gradually increasing increments. Read two pages, take a ten minute break, then use the computer (no videogames) for 10 minutes and take another ten minute break. Double the reading and increase the computer use by 10 minutes each session. If there are no symptoms after using the computer for an hour, the child may return to school the next day. Symptomatic children should be advised to stay home and not go to school until symptomfree. Because many brain functions are impaired during concussion, learning, too, is impaired. The school environment is often too stimulating for symptomatic children; these children are often unable to make it through an entire school day. Between noisy hallways and cafeterias as well as teachers trying to inculcate knowledge to a brain that is having trouble concentrating and is not able to store information properly, returning to school too soon simply increases the level of symptoms. Math class really can give a concussed child a headache since a great deal of concentration is required! When the child returns to school, it may be helpful to consider temporarily shortening the athlete s school day, reducing workloads in school and allowing the athlete more time to complete assignments or take tests. Taking standardized tests while recovering from a concussion should be discouraged, as lower than expected test scores may occur. Test scores obtained while the athlete is concussed are likely not representative of true ability. If the child becomes symptomatic during school, go to the nurse s office and lie down or simply put your head down at your desk for fifteen minutes. If the noisy cafeteria or crowded hallways cause worsening symptoms, eat lunch in a study hall, library or nurse s office; obtain permission to leave class a few minutes early to allow navigation of the hallways when empty. Communication with school nurses, guidance counselors, administrators and teachers regarding these academic accommodation recommendations is imperative. (See the CDC Acute Concussion Evaluation [ACE] Care Plan - School Version for guidance or the School Recommendations for concussed Student-Athletes adapted from Connecticut) RE-INTRODUCING PHYSICAL ACTIVITY Student-athletes should NOT re-enter physical education, competition, training, or partake in any athletic physical activities until: (1) all symptoms have cleared at rest and (2) medical clearance is obtained to begin a multi-step graduated return-to-play protocol. Children take longer to heal from a concussion than adults. The brain is believed to achieve full maturity at about age 23. The younger the child s brain, the more vulnerable it is to further insult and the longer it may take to heal. Accordingly, children in upper elementary and middle school (grades 5-8) should be treated more cautiously than adolescents in high school (grades 9-12); similarly, college students may recover more quickly than high school students. The Zurich consensus statement suggested that adding an extra buffer period of time from the end of symptoms until the re-introduction of physical activity may be appropriate for the youngest victims of concussion (grades 5

7 through 8). While no data guides the length of time for this extra rest period, one week seems to be the most commonly used buffer period. Graduated return to activity protocol The graduated return to play protocol is a series of physical exertional challenges the athlete must successfully complete (without increasing symptoms each day) to return to full activity one step per day. If symptoms recur, stop immediately and rest for that day and the next. Then retry the same activity two days later. Step 1: No symptoms at rest and able to tolerate a normal day of activity in school or social situations without increasing symptoms. (Obtain initial medical clearance to begin step 2) Step 2: Increase heart rate without any head movement (light aerobic exercise, such as walking or stationary exercise bicycle for 20 minutes at <70% of maximal heart rate); no strength training. Step 3: increase heart rate with full head and body movement (jogging or skating for 20 minutes at same level of intensity as Step 2). Step 4: Begin simple drills (e.g. for soccer: passing and moving but no heading, no sprinting, no scrimmages, and no games; for baseball fielding grounders, batting); may initiate strength training. Step 5: More complex drills and practice. (Obtain medical clearance to enter step 6) Step 6: Full practice with sprinting, heading, and scrimmage time. Limit all out sprinting. Step 7: Return to normal exertional and competitive activity. THE OFFICE-BASED MEDICAL EVALUATION (See the diagnostic tools listed below.) History Use the Acute Concussion Evaluation (ACE) Physician/Clinician Office Version sheet developed by the CDC to help record a focused history. Detail the specific characteristics and mechanisms of the injury, immediate early signs and symptoms of amnesia, loss of consciousness, confusion and cognitive deficits. Ask the athlete to complete the symptom score sheet for every day since the concussion until the day of evaluation and to continue to record symptoms daily until cleared for full activity. This is the single most valuable source of clinical status. The symptom checklist (22 items with a 7 point grading scale 0 to 6) is helpful; maximal score 132. Below 10 may be normal, under 20 marginal (probably symptomatic); greater than 20 convincing for symptomatic concussion; scores commonly run from 20 to 80s in symptomatic concussed athletes. Most athletic trainers use this technique to make an immediate assessment. Parents and student-athletes can do likewise at home to chart the progress. (See attached Post-Concussion Symptom Scale)

8 It is not uncommon, however, for children and adolescents to report a symptom score anywhere from 0 to 10 even when they have not experienced a traumatic head injury; keep this in mind when using the post-concussion symptom scale to determine that all symptoms are fully resolved. Consider asking all children and adolescents to complete a baseline symptom score during their annual check-ups or pre-participation physical examinations. Inquire about co-morbidities which may increase symptoms or delay recovery, such as prior concussions, history of headaches (especially migraines), the history of brain development problems, such as attention deficit or learning disorders (ADD, ADHD), and mental Illness (depression, anxiety, sleep disorders, etc). Physical examination Aside from the standard physical examination and neurological examination, include assessing these neurological features more thoroughly, such as: a. Balance testing (BESS) for postural stability. See paragraph below. b. Vestibular function (repeated alternating rapid eye movements horizontally, vertically, turning head side-to-side while focusing on stationary finger in front, lying supine on exam table with head extended over the edge of the table examiner extends and flexes neck passively positive test is presence of dizziness or vertigo (room spinning) c. Eye convergence (using eyes together to focus) blurriness should be <6 from nose d. Coordination (various finger-to-nose tests with eyes open and closed) Postural stability testing, as measured by the balance assessment test BESS (Balance Error Scoring System), is another reliable and valid tool for objectively measuring the motor domain of neurological functioning. Athletes are asked to stand with their eyes closed and hands on hips in three positions for 20 seconds: (1) feet together with both ankles touching; (2) standing on their non-dominant leg with the other leg bent at 30 degrees of hip flexion and 45 degrees of knee flexion; (3) feet in tandem position with their non-dominant leg behind the dominant leg. The test is performed standing on the floor in bare feet and standing on a dense foam pad. The NCAA website noted on the resource attachment to this article has a video demonstration of the BESS test. Neurocognitive Testing Within the first 48 hours after a concussion, the cognitive portions of Sideline Assessment Tool (SCAT2) are considered valid for assessing memory and processing. Computer-based neurocognitive testing is more sophisticated and an important tool but its significance is commonly misunderstood by athletes, parents and even health care professionals. (The SCAT2 form is attached to the end of 2008 Zurich Guidelines). The various available commercial products (ImPACT, Cogsport, Headminder, CNS Vitalsigns, ANAM) test four domains of brain function: Verbal Memory, Visual Memory, Speed of Processing, Reaction Time as well as attention span. For a student, verbal memory and visual memory are essential for learning in the classroom. For the athlete, speed of processing and reaction time are critical parameters on the playing field. Athletes constantly have to assess and interpret what is happening around them and then rapidly

9 take action. A reaction time of 0.72 seconds or slower is also an indication that it is unsafe to drive a car. About 100 New Jersey high schools currently have ImPACT testing within their school and have done pre-season baseline testing on their athletes, permitting a direct before and after comparison of the athlete against his or her own baseline test when healthy. The ImPACT system can also be placed in the physician s office and post-concussion neurocognitive testing carries it own CPT code to enable payment for test administration. Other computer-based neuropsychological test instruments for routine use in basic concussions are also very good, but not as widely used in New Jersey. Neurocognitive testing does not independently determine if an athlete has been concussed nor when they may safely return to play. Rather, both of those determinations are clinical decisions. The testing should be used as one tool, rather than the sole decision maker, for evaluating and determining return to play for an athlete. Athletes do not pass or fail these computer-based neurocognitive tests. The developers of ImPACT have conducted hundreds of research studies on concussed athletes and produced excellent data. It has been proven that the greatest cognitive deficits in concussed individuals occur on days 3 through 5. Even those individuals whose symptoms lasted only 5 or 15 minutes have demonstrable cognitive deficits at three and five days. While it is widely believed that a vast majority of concussed adolescents recover in 7 to 14 days, only 40% showed full recovery in all four domains at 7 days and 70% at 14 days on ImPACT testing. Do not use computer-based neurocognitive testing (e.g. ImPACT) while the athlete is significantly symptomatic (especially if a baseline test exists). The test is designed to be challenging and requires great concentration; it is likely to exacerbate symptoms. These tests are best done as symptoms remit and return toward normal or baseline. This test may be most useful at the first follow-up visit; some providers, however, prefer to test on about day 4, knowing that it may increase symptoms temporarily, in order to see if the individual is moderately or severely cognitive impaired. Severe impairments suggest prolonged recovery. Follow-up Follow up is essential to good management of a concussion. The timing of the next visit may depend on how soon the initial office visit occurred following the concussion and how symptomatic the patient is at the initial visit. Typically, a concussed individual should be seen about 10 days later (unless symptoms resolve completely sooner). If symptoms recur as increases in living activities resume, however, it will be necessary to scale back those activities so that the symptoms regress again. The managing physician must consider several factors regarding the timing of these follow-up visits to meet key landmarks.

10 1. School Readiness: Whether and when the person will be ready to go back to school (will academic accommodations be needed?). 2. Activity Readiness: When to begin the graduated return-to-play protocol. 3. Advancing in the return-to-play protocol from doing drills to actual full sports practice (including contact) and then full competition. 4. Returning to physical education. In many school districts, an athlete must be returned to physical education at the same time as return to practice for interscholastic sports. During the early stages of the return to play protocol (prior to return to full practice including contact), no physical education is most appropriate, since the athlete s rehabilitation should be under the supervision of the athletic trainer in the high school. One bout of activity per day rather than two (physical education and team sport practice) is preferable during recovery from concussion. Written approval and guidance by a physician is required at several of these steps. In some cases, communication with a school nurse or athletic trainer may help facilitate accomplishing these landmark steps. TELLING THE STORY OF CONCUSSION to patients and parents by analogy: The functional disturbances of concussion can often best be explained to parents and athletes by thinking about the old fashioned telephone switchboard, where operators would take a plug from the console and place it into the proper hole on the board, connecting the two parties. If the console is banged hard, however, all of the plugs may disconnect from the board and fall back into the console. Service is temporarily interrupted until the operator can replace the plugs into their correct location. It takes time to fully restore service. There is no permanent damage to the console, plug or board. Similarly, the brain is essentially a computer that works through chemistry rather than microchips and electricity. When the brain is concussed, it behaves like a computer with a virus or works with the Internet as it did when we used dial-up for our connection: slowly and inefficiently. Normal pathways may be blocked (like in a traffic jam) forcing the brain to use alternate pathways to accomplish tasks. Further, the concussed brain may not be able to store information properly, producing memory problems. Just as if you changed computer screens but failed to save your work, it is gone and not retrievable, the concussed person can work with something directly in front of him or her, but if the person goes on to another task, the prior information may not be saved and is totally forgotten. In one ear and out the other. POST-CONCUSSION SYNDROME VERSUS PROLONGED HEALING OF INITIAL CONCUSSION Much discussion has taken place regarding post-concussion syndrome. Symptoms that last for more than several weeks in a youth who has carefully followed all of the recommendations for rest, both physical and cognitive, raise a concern for possible postconcussion syndrome and probably should be referred to a neuropsychologist for a more complete evaluation and management. But in most cases, the prolongation of symptoms is more of a reflection of insufficient rest - not permitting the brain the opportunity to heal rather than actual post-concussion syndrome.

11 A few years ago, I saw a high school senior who was injured in the final game of his high school athletic career in early November. He was evaluated in the emergency room (twice), by his pediatrician and a neurologist. Since he was no longer playing sports, avoiding physical activity was not difficult. But no one mentioned anything about cognitive rest. He continued to try to go about his daily life in the usual fashion, but his symptoms never fully went away. His grades deteriorated as well. He came into my office in late January. He was truly a case of prolonged initial concussion rather than postconcussion syndrome. With weeks of rest, every symptom completely resolved and he felt like himself again. If the brain is given ample opportunity to heal itself before returning the athlete to participation in sports or to the challenging classroom environment, the likelihood of having an increased probability of future concussions with less forceful trauma may not be increased. Much of that phenomenon is probably related to prior insufficient management of initial concussions. Given our improved understanding about concussion and recovery today, it is hoped that the ultimate goal of good management, rapid complete recovery with no increased risk for future concussions because recovery was prompt and without complications or setbacks, can be achieved. Similarly, it is imperative to avoid the situation of multiple concussions in individuals who have not recovered from the prior concussions, leading to the negative consequences whereby less force produces more severe concussion with longer recovery time, resulting in a permanently damaged brain SUMMARY OF TREATMENT PRINCIPLES Each concussion and athlete should be treated individually. 1. Rest from physical activity, mental concentration, social stimulation 2. Goal to reduce symptoms to baseline levels as quickly as possible 3. Analogy to musculoskeletal injury RICE if you control swelling and pain properly and promptly, minimize lost time until able to return to play safely 4. At home, cocoon therapy may be wisest no physical activity, no reading, no screen time on computer, no video games, quiet and dark room, lots of sleep for the first few days, no driving (or even riding in a vehicle), no loud music, minimal television (no violence) 5. By day 3 of concussion, respect regular bedtimes at night and wake up at usual hour in the morning; take short naps (20 to 30 minutes) during the day as needed 6. Begin reading and computer screen time with brief bouts followed by rest breaks. Keep to a maximum of 15 to 20 minutes; longer bouts than that frequently lead to brain fatigue and increased symptoms; increase length of time gradually as tolerated. When the child is able to handle an hour of screen time or reading without an increase in symptoms, that child is likely ready to try to return to school. 7. If symptom score is over 25 to 30, probably best to avoid the school environment, since the stimulation level is high and the mental concentration required to learn is intense

12 8. Return to school no physical education initially (go to nurse s office to rest). May benefit from a variety of academic and social accommodations. Use the CDC school version form. Ask student to fill out his or her school schedule (including lunch period) to help figure out how best to organize the school days (when to fit breaks into schedule) 9. When able to handle school without increasing symptoms, may begin the graduated return to protocol (takes 5 to 6 days to complete) 10. Persistent dizziness and fogginess are indications of potential for delayed recovery 11. For some children, return to physical activity does not worsen symptoms, but mental concentration (intense school learning) exacerbates symptoms. Not all children recover academically before achieving normalcy during physical activity. 12. Follow-up 10 days after initial office assessment and/or at start of return to play protocol and/or at clearance point for return to full contact practice and game competition 13. However, if recovery (despite following recommendations) extends beyond two to three weeks, consider referral to a concussion expert, such as a neuropsychologist, sports medicine physician, neurologist, physical therapist experienced in vestibular function management 14. Final goal rapid complete recovery with no increased risk for future concussions because recovery was prompt and without complications or setbacks 15. Negative consequences (trying to avoid) less force produces more severe concussion with longer recovery time = permanently damaged brain Reminders: An individual with a possible concussion may return to physical activity only after release from a licensed medical doctor knowledgeable in concussion treatment and management AND after satisfying the graduated return to play protocol. Coordination and communication between the medical doctor and the athletic trainer are essential to smoothly navigate the return to full athletic participation efficiently and safely. Referral team Concussion Center Neurologist Neuropsychologist Vestibular Therapist Neurosurgeon RISK MANAGEMENT: THE MEDICAL-LEGAL ASPECTS OF THE NEW JERSEY CONCUSSION LAW (N.J.S.A. 18A: ) 1. Obligation for physicians to be knowledgeable and current about concussion management. The standard of care is changing as medical knowledge evolves and

13 advances. Because concussion is a hot topic, the public and the media are increasingly aware of these changes. Physicians must stay up-to-date, too, or be at risk for liability by managing cases using out-dated scientific protocols. 2. Physician Education is readily available. In addition to articles such as this one, there are position statements from major organizations, many lectures and grand round presentations occurring at CME and hospital departmental meetings throughout New Jersey. On-line education exists as well (with post-tests and certificates of completion): The Centers for Disease Control and Prevention (CDC) has produced an excellent free 20 minute on-line course for physicians, accessible through The Athletic Trainers Society of New Jersey (ATSNJ) has prepared a two-hour on-line educational course for physicians through its ConcussionWise series at a cost of $ School /Team Physician: The New Jersey Concussion Law (N.J.S.A. 18A: ) specifically states that school district physicians and/or team physicians must be knowledgeable and current in the management and treatment of concussion; the official New Jersey Department of Education Model Policy and Guidelines Document says: Each district board of education, board of trustees, and non-public school will adopt an Interscholastic Head Injury Training program to be complete by the School/Team Physician,. Pursuant to N.J.S.A. 18A: This is one of the requirements for policy content. 4. Patient Education has already been developed by both the Brain Injury Association of New Jersey (BIANJ) and the CDC. There are handouts for parents, athletes, coaches; toolkits for high school and youth sports coaches. The NCAA and National Federation of State High School Associations have produced handouts, toolkits and video/on-line courses for coaches, athletes and parents. 5. Documentation is critical to proper risk management and avoidance of liability. The numerous worksheets and forms that have been developed and available for free make this task manageable for physicians. It is not necessary to re-invent the wheel to be able to incorporate these items into your daily practice. There are even templates for dictations and electronic medical records for documenting the evaluation and treatment of patients who present with a concussion. 6. Physician Clearance Required to Return to Various Activities the New Jersey Concussion law expressly gives the responsibility for clearance to physicians; this clearance must be in writing, and receives written clearance from a physician trained in the evaluation and management of concussion to return to competition or practice. The physician obligation in the return to play process through the graduated return-to-play protocol developed in the 2008 Zurich Consensus document states that such clearance is needed to begin physical exertion (exercise bicycle riding). If the athlete successfully progresses toward full practice, written clearance is required again to permit full practice activity (including contact and then full competition). It has already been explained that physician clearance should also be invoked in determining when it is appropriate to return to school and with what academic accommodations (if needed). A medical note alone does not automatically allow an athlete to return to play completing the graduated return to play protocol is the only prudent way to manage

14 a concussion. The model school district policy and guidance document states medical clearance that is inconsistent with district, charter and non-public school policy may not be accepted and such matters will be referred to the school/team physician. Although the law has been actively in force only since the beginning of the school year, there is already some discussion as to whether other health professionals should also be permitted to provide written clearance for return to various levels of activity; a bill was introduced in the New Jersey Senate in December 2011 with the intent of allowing licensed athletic trainers and neuropsychologists to also have right to issue such clearances. Unless the physician community is prepared to step up and be able to stay current and knowledgeable as a group, this express responsibility for clearance may not remain only with physicians.

15 FORMS AND RESOURCES Items included at end of article: Graduated Return to Play Protocol (for high school athletes) Graduated Return to Play Protocol with 7 extra symptom-free days (younger athletes) School Class Schedule Post Concussion Symptom Scale School Recommendations for Academic Accommodations Head Injury Fact Sheet RESOURCES CDC ACE Physician Evaluation - Office Version* CDC ACE Physician Accommodations Recommendations - School Version** CDC ACE Physician Accommodations Recommendations Work Version *** Centers for Disease Control and Prevention Information for Physicians Facts for Physicians booklet [PDF 4.58MB] *Acute Concussion Evaluation (ACE) form [PDF 79KB] On-line educational physician course: ACE Care Plan **Work version ***School version [PDF 76KB] [PDF 78KB] 3. Concussion in Sports palm card [PDF 138KB] 4. Information for Patients Heads Up: Preventing Concussion fact sheet English Spanish [PDF 239KB] [PDF 219KB] To order bulk quantities of CDC s concussion resources free-of-charge and/or to learn how you can get involved to help keep all people safe from concussion, visit or contact CDC by (CDC-INFO@cdc.gov) or toll-free at CDC-INFO ( ). Brain Injury Association of New Jersey Website: SportsConcussion.com BIANJ Concussion in Sports Committee a held Concussion Summit in February 2006 at Giants Stadium and has been active in assisting 100 high schools in New Jersey to

16 obtain ImPACT at a reduced rate for a three year period. Producer of concussion posters for your office walls, information sheets for parents, athletes and coaches. Resource for information and leadership on concussion. coaches fact sheet.pdf NJ Department of Education 1. Policy for school boards 2. Student-Parent information sheet fact sheet and acknowledgement form.pdf Model policy and guidelines.pdf National High School Federation Free learning course on concussion designed for coaches, but is very good. A 20 minute Internet program presented by a sports medicine physician who heads the Federation Sports Safety Committee. Do not be intimidated by having to register and appear to pay for the course; it is FREE!! Consensus Statement on Concussion in Sport: 3 rd International Conference on Concussion in Sport Held in Zurich, November Clinical Journal of Sport Medicine 2009;19: Full text of the Consensus Statement and the SCAT 2 (Sideline Testing) including BESS Balance Test American Academy of Pediatrics Position Statement on Concussion Clinical Report: Sport-related Concussion in Children and Adolescents Halstead ME, Walter, KD and the Council on Sports Medicine and Fitness Pediatrics 2010;126(3): Computerized neuropsychological tests ANAM -- Cogsport -- CNS Vital Signs Headminder -- ImPACT

17 Name: Age: Date: Date of Concussion: CONCUSSION: GRADUATED RETURN TO PLAY PROTOCOL Advance to next step the following day only if symptoms do not return Step 1: No activity, complete physical and cognitive rest. The objective of this step is recovery. Goals are symptom level back to pre-concussion baseline and being able to complete one full day of normal activity without increase in symptoms (no athletic activity, however). Physician s signature for medical clearance: Date: Step 2: Light aerobic exercise, which includes walking, swimming, or stationary cycling, keeping the intensity <70% maximum percentage heart rate for about 20 minutes. No resistance training. The objective of this step is to increase heart rate (and blood flow to the brain) without head movement. Step 3: Sport specific exercise including skating, jogging and/or running drills; no head impact activities. No sprinting. The objective of this step is to add movement to increased heart rate activity. Step 4: Non-contact training drills involving progression to more complex training drills (e.g. passing drills in football, soccer, or lacrosse). The student-athlete may initiate progressive resistance training. Physician s signature for medical clearance: Date: Step 5: Following medical clearance, participation in normal training activities including contact in a non-competitive environment (practice and/or scrimmage). The objective of this step is to restore confidence in the athlete and for assessment of the athlete s functional skills by the coaching staff. Step 6: Return to play involving normal exertion or game activity.

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19 Name: Age/DOB: Date of Concussion: Post Concussion Symptom Scale No symptoms"0" moderate "3" Severe"6" Time after Concussion: Date and Day Number SYMPTOMS Date/Day # Date/Day # Date/Day# Headache Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling to sleep Excessive sleep Loss of sleep Drowsiness Light sensitivity Noise sensitivity Irritability Sadness Nervousness More emotional Numbness Feeling "slow" Feeling "foggy" Difficulty concentrating Difficulty remembering Visual problems TOTAL SCORE Use of the Post-Concussion Symptom Scale: The athlete should fill out the form, on his or her own, in order to give a subjective value for each symptom. This form can be used with each encounter to track the athlete s progress towards the resolution of symptoms. Many athletes may have some of these reported symptoms at a baseline, such as concentration difficulties in the patient with attention-deficit disorder or sadness in an athlete with underlying depression, and must be taken into consideration when interpreting the score. Athletes do not have to be at a total score of zero to return to play if they already have had some symptoms prior to their concussion.

20 HEAD INJURY FACT SHEET This is a medical follow-up information sheet for your health and safety. Please refer to the fact sheet you were required to sign prior to your pre-participation physical examination for additional details. Concussion is a traumatic brain injury that interferes with normal brain function (without structural damage). A concussion initiates pathophysiological and chemical changes in the brain that generally take at least several days to resolve. A concussion always produces symptoms immediately after the trauma; however, some symptoms of a concussion may appear hours later. Common symptoms include: Memory difficulties Neck pain Sensitivity to light or noise Headache Odd behavior Repeats the same answer or question Vomiting or nausea Irregular sleep patterns Nervous, anxious, more emotional Focus or concentration issues Slowed reaction Fatigue, low energy, drowsiness Balance problems Blurry vision Confusion, in a fog, don t feel right Please observe your child carefully and take the necessary precautions until a professional medical opinion from your regular health care provider can be obtained promptly in the next day or two. If your daughter or son starts to show signs of significant worsening of these symptoms as time elapses (instead of improving as time goes by), or there any other alarming symptoms you notice about the behavior or conduct of your son or daughter, you should consider seeking immediate medical attention at the emergency department of your hospital. These red flag warning signs include: severe headache, stiffening of the neck, blood or clear fluid dripping from the ears or nose, persistent ringing in the ears, decreasing consciousness, unequal pupils, weakness in either arm or leg, increasing pain in the head or neck. Please consider the following guidelines regarding your child: (1) Refrain from participation in all physical activities while any symptoms are present. (2) Brain rest is the best method for keeping concussion symptoms to a minimum and speeding the process of recovery. This rest includes not only avoiding physical activity, but minimizing cognitive activity (using your brain to think and carry out mental tasks) and minimizing social activity (which also requires increased brain activity). Good advice: no texting, no video games, no Internet, no reading, no driving, no loud music. Sleep is beneficial the first few days do not awaken your child during the night to check for symptoms. Attending school while still having a significant level of symptoms is counterproductive school is a very challenging and stimulating environment likely to delay resolution of symptoms (brain healing). (3) Refrain from taking any medicine unless (a) it is a current prescribed or authorized medicine that needs to be taken regularly, and/or (b) is newly prescribed by a licensed health care professional. If you are unclear and have questions about the above symptoms, please contact your licensed health care professional. Please be advised that a player who experiences a concussion may not return to play until there is a signed clearance note from a licensed medical doctor who is knowledgeable in concussion treatment and management AND after completing a multi-step graduated return-to-play protocol.