Slides from Aug 24, 2012 concussion seminar at Saint Brigid of Kildare school, presented by Dr. Mickey Collins and Dr. Jonathan French. Slides are proprietary material, and are for viewing ONLY. No downloads, embedding or sharing allowed without permission.

1. Evidence-Based Management of
Sports Concussion: What Are
We Learning?
University of Pittsburgh Medical Center
UPMC Department of Orthopaedic Surgery
UPMC Sports Medicine Concussion Program

2. Disclosure Statement
Micky Collins, PhD is Vice
President, Chief Clinical Officer, and Co-
Founder of ImPACT Applications, a
computerized neurocognitive test battery
designed to assess sports concussion
and Mild Traumatic Brain Injury.
Copyright © 2011

3. Objectives
Discuss pathophysiology of sports-related
concussion/mTBI.
Present data pertaining to neurocognitive
outcomes from sports concussion and risk
factors/profiles that predict protracted recovery.
Discuss appropriate in-office clinical evaluation
for sports concussion/mTBI management.
Present a case study of sports concussion
management
Copyright © 2011

4. Copyright © 2011

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16. Neurometabolic Cascade
Following Cerebral Concussion/MTBI
500
(Giza & Hovda, 2001)
Calcium
400
% of normal
300 K+
200 Glucose
Glutamate
100
50
2 6 12 20 30 6 24 3 6 10
0 hours days
minutes
Cerebral Blood Flow
UCLA Brain Injury Research Center
Copyright © 2011

21. Concussion Management: Areas of Focus
Rule out more serious intracranial pathology
• CT, MRI, neurologic examination primary diagnostic tests
Prevent against Second Impact Syndrome
Prevent against cumulative effects of injury
• Less biomechanical force causing extension of injury
Prevent presence of Post-Concussion Syndrome
Copyright © 2011

22. Most Commonly Reported Symptoms
– 1-7 days following concussion
SYMPTOM PERCENT
#1 Headache 75%
#2 Difficulty Concentrating 57 %
#3 Fatigue 52 %
#4 Drowsiness 51 %
#5 Dizziness 49 %
#6 Foggy 47 %
#7 Feeling Slowed Down 46 %
#8 Light Sensitivity 45 %
#9 Balance Problems 39 %
# 10 Difficulty with Memory 38 %
Kontos, Elbin, French Collins, Data Under Review; N = 1,438
Copyright © 2011

23. Post-Concussion • More emotional
Symptom •
•
Sadness
Nervousness
Groups • Irritability
• Headaches • Attention Problems
• Visual Problems • Memory dysfunction
• Dizziness • “Fogginess”
• Noise/Light Sensitivity • Fatigue
• Nausea • Cognitive slowing
• Difficulty falling asleep
N=327, High School and
University
• Sleeping less than usual
Athletes Within
7 Days of Concussion
(Pardini, Lovell, Collins, et al. 2004)
Copyright © 2011

24. The Evolving Definition of Concussion
CDC Physicians Toolkit 2007
A concussion (or mild traumatic brain injury) is a complex pathophysiological
process affecting the brain, induced by traumatic biomechanical forces
secondary to direct or indirect forces to the head. Disturbance of brain function
is related to neurometabolic dysfunction, rather than structural brain injury, and
is typically associated with normal structural imaging findings (CT Scan, MRI).
Concussion may or may not involve a loss of consciousness. Concussion
results in a constellation of physical, cognitive, emotional, and sleep -related
symptoms. Recovery is a sequential process and symptoms may last from
several minutes to days, weeks, months, or even longer in some cases.”
Copyright © 2011

25. Management of MTBI:
Topics of Concern
Grading systems ineffective/not evidenced based.
CT and MRI insensitive to neurometabolic effects of
injury.
Variability in management recommendations.
Inadequate/Improper recommendations from
ED/Trauma Departments/clinician offices.
“Rest” does not cure all concussions.
Lack of education and awareness of injury.
Self-report predicating management directives.
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26. 26
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27. Return to Play Following mTBI:
In some cases (not all), athletes will minimize difficulties
Athletes are naïve to the subtleties of the injury
Young athletes lack insight into self-assessment of MTBI
symptoms
Relying on subjective status of a patient with brain injury
Studies suggest that up to 50% of athletes experience
concussion symptoms per year but only 10 % report having an
injury
Need for comprehensive understanding of athletes recovery
status
Copyright © 2011

28. Computer-Based Neurocognitive Testing
Cogsport (Axon)
Headminders (CRI)
ANAM
CNS Vital Signs
ImPACT
Copyright © 2011

29. ImPACT
Immediate Post-Concussion
Assessment and Cognitive Testing
Computerized Neurocognitive Testing
Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery
Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery
Joseph Maroon, MD - UPMC Dept. of Neurological Surgery
Copyright © 2011

30. ImPACT: Post-Concussion Evaluation
Demographic / Concussion History Questionnaire
Concussion Symptom Scale
 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)
8 Neurocognitive Measures
 Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores
Detailed Clinical Report
 Outlines Demographic, Symptom, Neurocognitive Data
Internal baseline validity checks built into program
Desktop and On-Line Versions Available
 Extensive normative data available from ages 11-60
On-line and In-Person training workshops available to learn interpretation
Over 100 peer-reviewed research articles/books/chapters, published since
2000
 Extensive data published on reliability, validity, sensitivity/specificity, added
value, prognostic ability of test
Copyright © 2011

32. Computer-Based Neurocognitive Testing
Reaction Time Processing Speed
Visual Memory Verbal Memory

33. Pre-season 1-3 Days
First Follow-up
Baseline Testing
Follow-
Testing
Concussion Up as needed
Supervised Remove Evaluation Return to Play
at School From Play
Or clinic
Copyright © 2011

34. Show Baseline Video
Copyright © 2011

35. ImPACT Testing: What it is and Isn’t
IS a tool to help determine recovery from injury.
IS a tool to help manage concussion (e.g. return to
academics, return to exertion, return to play).
IS a tool to help communicate post-concussion
status to coaches, parents, clinicians.
IS NOT a substitute for clinical evaluation
Copyright © 2011

36. Sensitivity and Specificity of
Computerized Neurocognitive Testing
Schatz P, Pardini J, Lovell MR, Collins MW. Sensitivity and specificity of the ImPACT
test battery in athletes’ concussion status. Archives of Clinical Neuropsychology
2005:21;91-99.
N = 138 controls/
concussed athletes
Discriminate Function Analysis
Statistical classification of Concussed (physician dx)/Control subjects
No Clinician Input
Testing completed within 3 days post injury
Positive Predictive Value (90%)
(Probability that that a concussion is present when test is positive)
Negative Predictive Value (82%)
(Probability that a concussion is not present when test is negative)
Copyright © 2011

37. Comparison of Preseason, Midseason and Post-Season
Neurocognitive Scores in Uninjured Collegiate
Football Players
Miller, Adamson, Pink, Sweet, AJSM, 2007
Compared ImPACT results for 78 non-concussed, collegiate football
players at preseason, midseason and post season.
All athletes engaged in contact practices/games
Found no statistical differences in test performance across the three
evaluations
“ImPACT test scores are not significantly altered by a season of
repetitive contact in uninjured collegiate football athletes”
“Impairment of ImPACT scores in concert with clinical
symptoms/findings should be interpreted as evidence of a
post-concussive event”
Copyright © 2011

38. Unique Contributions of Neurocognitive
Assessment to Concussion Management
Symptomatic Asymptomatic Control
100
Testing reveals 95
cognitive deficits 90
85
in asymptomatic 80
athletes within 4 75
70
days post-concussion 65
60
55
N=215, MANOVA 50
p<.000000 Verbal Visual
Memory Memory
Copyright © 2011

39. Concussion Management Programs
ImPACT Computerized Neurocognitive Testing
NFL (All Teams Mandated)
NHL (All Teams Mandated)
MLB (All Major/Minor League Teams/Umpires Mandated)
Major League Soccer (all teams)
US Ski/Snowboarding Teams
NASCAR, IRL, CHAMP Racing Leagues
USA Rugby/US Lacrosse
USA Soccer
Cirque de Soleil
Irish National Rugby
New Zealand Rugby Football Union
South African Rugby
European Professional Soccer
World Wrestling Federation
US Military (All four branches/National Guard)
Over 900 Colleges/Universities
Over 6,000 high schools
Over 800 Primary Care and Pediatric Clinics
Copyright © 2011

40. Measuring
Neurocognitive
Recovery from Sports
mTBI
How Long Does it Take?

41. Authors Sample Population Tests Utilized Total Days Cognitive Total Days Symptom
Size Resolution Resolution
Lovell et al. 95 Pro (NFL) Paper and Pencil NP 1 day 1 day
2005
McCrea et al. 94 College SAC 1 Day 7 days
2003
McCrea et al. 94 College Paper and 5-7 days 7 days
2003 Pencil NP
Echemendia 29 College Paper and Pencil NP 3 days 3 days
2001
Guskiewicz et al. 94 College Balance 3-5 Days 7 Days
2003 BESS
Bleiberg et al. 64 College Computer 3-7 days Did Not
2005 NP (ANAM) Evaluate
Iverson et al. 30 High School Computer 10 days 7 Days
2006 NP (ImPACT)
McClincy et al. 104 High School Computer 14 days 7-10 Days
2006 NP (ImPACT)
Lovell, Collins et al 208 High School Computer 26 days 17 Days
2008 NP (ImPACT)
Covassin et al 72 High School Computer 21 days 7 Days
2011 NP (ImPACT)
Maugans et al 12 Ages 11-15 Computer 30 days 14 Days
2011 NP (ImPACT)
Copyright © 2011

42. Three-year prospective study in Western PA.
17 high school football teams
134 athletes with diagnosed concussion (6.2%)
All athletes referred for evaluation at UPMC
Recovery determined by “Back to Baseline”
on computerized neurocognitive test scores
and symptom inventory
Determined by Reliable Change Index Scores-RCI’s)
Copyright © 2011

43. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5
100
90
80
70 80%
RECOVERED
60
50 60%
40 RECOVERED N=134 High School
Male Football Athletes
30
20 40%
10 RECOVERED
0
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
Copyright © 2011

44. Examining Relevance of
“Grade 1” Concussions in High
School Athletes
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004
Copyright © 2011

45. 64 high school athletes with “mild” concussion
Two groups compared in terms of outcome
 Athletes with <5 min of signs/symptoms
 Athletes with 5-15 min of signs/symptoms
No athlete in sample sustained LOC
All athletes met AAN Grade 1 criteria
No athlete returned to contest
ImPACT evaluation obtained at baseline, day 2,
day 4, and day 7 post-injury
Copyright © 2011

46. ImPACT Memory Composite Scores
Brief versus Prolonged On-field Mental Status Changes
5-15 min < 5 min
90
85 P<.04
P<.02 P<.004
N = 64 80
High
75
School
Athletes 70
65
60
Baseline 36 Hours DAY 4 DAY 7
ImPACT Memory-Percent Correct
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004
Copyright © 2011

47. ImPACT Symptom Scale Scores
Brief versus Prolonged On-field Mental Status Changes
5-15 min < 5 min
40
P<.003
35 P<.061
30
N = 64
25
High School NS
20
Athletes NS
15
10
5
0
Baseline 36 hours DAY 4 DAY 7
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54, 2004
Copyright © 2011

48. Copyright © 2011

49. “Bell-Ringer” Summary
First studies to challenge assumption that Grade 1 or mild
concussion in high school athletes is associated with rapid
and complete recovery
 Findings contrary to most grading systems (AAN)
 Recovery from concussion may not be linear process
 Replication needed with college/professional athletes
 Should high school athletes diagnosed with concussion
be allowed to return to play in same contest?
Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003
Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004
Copyright © 2011

50. Prognosticating Protracted
Concussion Outcomes:
An Evidence-Based Analysis

51. Helps to set up clear communication to player, coaches, and
medical personnel regarding recovery expectations
May help to alleviate some pressure on RTP issue
May help to immediately provide individualized clinical
management recommendations (e.g. need for academic
accommodations/physical rest, etc)
Begins to create a risk profile for sports concussion and
may set stage to effectively research treatment and
rehabilitation strategies.
Copyright © 2011

52. Which 0n-Field
Symptoms Predict
Protracted
Recovery?
Lau B, Kontos A, Lovell MR, Collins MW.
AJSM.Vol. 39(11):2311-18; 2011
Copyright © 2011

53. Which On-Field Symptoms Increase Risk of
Post Concussion Syndrome in High School Football Players?
176 Male HS Football Players (Mean Age = 16.2 years)
Athletes had baseline computerized NP testing
All followed until clinical recovery (Mean = 4.1 evaluations)
Within RCI of baseline on ImPACT for neurocognitive/symptom scores
32% of sample required < 7 days until recovery (N =56) “Rapid
Recovery” (Mean = 4.9 days)
39% of sample required 7-14 days until recovery (N = 68)
17% of sample required > 21 days until recovery (N = 31) “Protracted
Recovery” (Mean = 33.2 days)
MANOVA used to determine differences between rapid/> 3 week recovery
ATC’s documented on-field markers (e.g. LOC, Amnesia) and on-field
Symptoms (e.g. headache, dizziness, etc)
Copyright © 2011
Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011

54. Which On-Field Markers/Symptoms Predict 3 or More Week
Recovery from MTBI In High School Football Players **p<.01
On-Field Marker N Chi2 P Odds 95% Confidence
Ratio Interval
Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42
Retrograde Amnesia 97 .120 0.729 1.179 0.46-3.00
Confusion 98 .114 0.736 1.164 0.48-2.82
LOC 95 2.73 0.100 0.284 0.06-1.37
On-Field Symptom N Chi2 P Odds 95% Confidence
Ratio Interval
Dizziness** 98 6.97 0.008 6.422 1.39-29.7
Headache 98 0.64 0.43 2.422 0.26-22.4
Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63
Visual Problems 97 0.62 0.43 1.400 0.61-3.22
Fatigue 97 0.04 0.85 1.080 0.48-2.47
Balance Problems 98 0.28 0.59 0.800 0.35-1.83
Personality Change 8 0.86 0.35 0.630 .023-1.69
Vomiting 97 0.68 0.100 0.600 0.18-2.04
The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of
missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects
for whom data were available for each category. Markers of injury are not mutually exclusive.
Copyright © 2011 Lau, Kontos, Collins, Lovell , AJSM 2011

55. Which Subacute
Symptoms
Predict Protracted
Recovery?
Lau B, Lovell MR, Collins MW; Pardini J;
CJSM 2009 (3):216-21
Copyright © 2011

56. 108 concussed high school football players
Athletes had baseline computerized NP testing and were revaluated
within 3 days of injury (Mean = 2.2 days)
All followed until clinical recovery
43.5% of sample recovered < 10 days = “Quick”
Mean = 5.9 Days
56.5% of sample required >10 days until recovery = “Protracted”
Mean = 29.2 Days
MANOVA conducted on which individual symptoms and symptom
factors predicted “quick” versus “protracted” recovery
Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21
Copyright © 2011

57. Current Symptoms
 Headache
 Nausea
 Vomiting
 Balance Problems
 Dizziness
 Fatigue
 Trouble falling asleep
 Sleeping more than usual
 Sleeping less than usual
 Drowsiness
 Sensitivity to light
 Sensitivity to noise
 Irritability
 Sadness
 Nervousness
 Feeling more emotional
 Numbness or tingling
 Feeling slowed down
 Feeling mentally foggy
 Difficulty concentrating
 Difficulty remembering
 Visual problems (blurry or double vision)
Copyright © 2011

58. FOGGY DIFF CONC VOMIT DIZZY
NAUSEA HEADACHE SLOWNESS BALANCE
LIGHT SENS NOISE SENS NUMBNESS
2
1.5
1
0.5
0
Expressed as Effect Sizes (Cohen’s D). Only includes symptoms
with large (greater than .80) effect sizes.
Sample is composed of 108 male HS football athletes.
Copyright © 2011

59. “It is like going from a high definition TV
world to standard TV world”
“Feeling one step removed from my
surroundings”
“It is like my vision is impaired, but it isn’t”
“Feeling like I am underwater”
Copyright © 2011

60. Determination of
Neurocognitive Cutoff
Scores that Predict
Protracted Recovery
(at 2 days post injury)
Lau B, Collins MW, Lovell MR
Neurosurgery 2012;Feb 70(2):371-79.
Copyright © 2011

61. 108 concussed HS and Collegiate Athletes
Athletes had baseline computerized NP testing
All followed until clinical recovery
43.5% of sample recovered < 10 days = “Quick”
Mean = 5.9 Days
56.5% of sample recovered >10 days = “Protracted”
Mean = 33.0 Days
ImPACT composite cutoff scores statistically calculated at 75%,
80%, and 85% sensitivity to predict protracted recovery (i.e., on
average, 1 month or longer for clinical recovery)
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
Copyright © 2011

62. Cutoff Values of ImPACT Neurocognitive Scores
at 2 Days Post Injury That Predict Protracted
Recovery
75% 80% 85%
Sensitivitity Sensitivity Sensitiviity
Neurocognitive
Domain Cutoff Cutoff Cutoff
Verbal Memory 66.5 64.5 60.5
Visual Memory 48 46 44.5
Processing Speed 24.5 23.5 22.5
Reaction Time 0.72 0.78 0.86
Sensitivity is defined as the ability of the cutoff to accurately identify
protracted recovery (Mean Recovery Time = 1 month) in an athlete.
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
Copyright © 2011

63. Iverson G. CJSM; 2008
Predicting Quick versus Protracted Recovery from
Sports mTBI
At three days post-injury, if athlete exhibit three or more RCI
changes on ImPACT cognitive composite scores (relative to
baseline), there is a 94.6% chance that recovery will require
>10 days.
Exhibiting a high symptom score did not improve classification
accuracy over neurocognitive test scores in isolation.
Athletes with prior history of concussion were not statistically more
likely to have “protracted” recovery from concussion.
Copyright © 2011

64. Use of Computerized Neurocognitive Testing
In High School Athletes (Meehan et al, Pediatrics 2011)
 41.2% of US High Schools that employ at least 1 ATC utilized
computerized neurocognitive testing during 2009-2010 academic
year (25.7% in 2008-2009 year)
 93% use ImPACT
 100% of schools utilizing testing reported that scores were
utilized in making RTP decisions
 86% of these schools performed baseline testing
 Athletes who underwent computerized NP tesing were less likely
to be returned to play within 10 days of injury (38.5% vs 55.7%, p
< .01) and were more likely to be returned to play by a physician
(60.9% vs 45.6%, p <.01)
Copyright © 2011

65. Established (?) Constitutional Risk Factors
For More Complicated Recovery
Age - Field, Lovell, Collins et al. J of Pediatrics, 2003
- Pellman, Lovell et al. Neurosurgery, 2006
- Mihalik, Collins,Lovell et al, J Neurosurgery, 2006
Migraine History &
Symptoms
Learning Disability - Collins, Lovell et al, JAMA, 1999
- Kontos, Elbin, Collins, Data submitted for publication
Repetitive - Collins, Lovell et al, Neurosurgery, 2004
- Iverson et al, CJSM, 2004
Concussion? - Moser et al, JCEN, 2011
- Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009
Gender? - Covassin et al, CJSM, 2009
Copyright © 2011

66. Summary
Outcomes are highly variable
Vestibular-related symptoms following injury predict
more protracted recoveries
Migraine-type symptoms (and potentially preexisting
history of migraine) may place individuals at increased
risk of injury and longer recovery
Neurocognitive testing is valuable in determining
prognosis and recovery in sports-related mTBI
Clinical management key to preventing poor outcomes
The “mild” injuries may become severe and the
“severe” injuries may become mild
Copyright © 2011

67. Scientific Evolution and Building
Consensus: Where are we Headed?
Copyright © 2011

68. Recommended Sports Concussion Management
Post-Injury Management
Removal from contest if concussion suspected-no RTP in same game
No return to play while symptomatic or if symptomatic with exertion
Carefully monitored and graded increase in exertion over time
Need to be mindful of cognitive exertion on role of recovery
Need for conservative management in children/adolescents
Neurocognitive testing recommended for athletes sustaining concussion
Criteria for Return to Play
1. Symptom-Free at Rest
2. Symptom-Free with Cognitive/Physical Exertion
3. Normal Neurocognitive Data/Objective Evaluation
Copyright © 2011

69. - Education necessary- Dept of Education will post concussion
educational information; Student/parents must sign form prior to
participation that they have reviewed concussion fact sheet.
Coaches must complete concussion management training course
on yearly basis. Informational school meetings are encouraged
that educate on concussion management and importance of
baseline assessments that can aid in evaluation and management
of injury.
- Any athlete exhibiting signs/symptoms of concussion shall be
removed from practice/game and no RTP on day of injury.
Medical clearance must occur from: Physician trained in
concussion management OR licensed physician designee
trained in concussion management, OR licensed
neuropsychologist (fellowship trained) who has specific
training in concussion management. Penalties occur with any
infraction.
Copyright © 2011

70. Clinical Implementation:
Concussion
Management

71. The UPMC Sports Concussion Program
ATC from
Pediatric
Contracted
Practices
Schools
Emergency Primary Care
Departments Physicians
UPMC
Concussion
Program
(Neuropsych)
Parents Vestibular /
/Schools /
Parents Neuro Orthopaedic Behavioral
PM & R Physical
School Radiology /Neuro Neuro-
Therapy Surgery Optometry

72. UPMC Typical Evaluation
Detailed Clinical Interview
Vestibular Screening
Computerized Neurocognitive Testing
Same day patient feedback
 Severity of Injury?
 Prognosis for Recovery?
 Neuroimaging indicated?
 Level of Physical Exertion Allowed?
 Level of Cognitive Exertion
Allowed?
 Academic Accommodations?
 Return to Play?
Communication to ATC, Team
Physician, Referring Physician, etc.

73. Clinical Evaluation
 Clinical Interview
 Vestibular & Ocular Screening
 Computerized Neurocognitive
Testing
Copyright © 2011

74. Factor Analysis,
Post-Concussion • More emotional
Symptom Scale • Sadness
• Nervousness
(Pardini, Lovell, Collins
• Irritability
et al. 2004)
• Headaches • Attention Problems
• Visual Problems • Memory dysfunction
• Dizziness • “Fogginess”
• Noise/Light Sensitivity • Fatigue
• Nausea • Cognitive slowing
N=327, High School • Difficulty falling asleep
and University • Sleeping less than usual
Athletes Within
7 Days of Concussion
Copyright © 2011

75. Symptom Evaluation/Clinical Interview: What is Asymptomatic?
IS NOT “How are you feeling?” or “Do You Have a Headache?”
IS a series of questions inquiring about subtleties of injury
“Do you have a pressure in your head that increases as day progresses?”
“Do you feel more fatigued than normal at the end of the day?”
“Do busy environments cause you to feel foggy, anxious, tired?”
“Do you become dizzy when looking up/down, turning head, standing quickly?”
“Do you have blurred or fuzzy vision while reading or difficulty reading?”
“ Do you feel a frontal pressure in your head when reading/computer work?”
“Do you feel more distractible in school than normal?”
“Are you having more significant difficulty in Math and Science?”
“Do you have difficulty falling/staying asleep?”
“Have you or your parents noticed that you are more irritable than normal?”
Copyright © 2011

76. Acute Concussion
Evaluation
Gioia, Collins 2006
CDC Toolkit for
Physicians
Copyright © 2011

77. Copyright © 2011

78. Copyright © 2011

79. Cutoff Values of ImPACT Neurocognitive Scores
at 2 Days Post Injury That Predict Protracted
Recovery
75% 80% 85%
Sensitivitity Sensitivity Sensitiviity
Neurocognitive
Domain Cutoff Cutoff Cutoff
Verbal Memory 66.5 64.5 60.5
Visual Memory 48 46 44.5
Processing Speed 24.5 23.5 22.5
Reaction Time 0.72 0.78 0.86
Sensitivity is defined as the ability of the cutoff to accurately identify
protracted recovery (Mean Recovery Time = 1 month) in an athlete.
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
Copyright © 2011

80. ImPACT Domain Mean RCI 90% Confidence
Interval
ImPACT Verbal Memory Score
Time 1 88.6 8.75
Time 2 88.8
ImPACT Visual Memory Score
Time 1 78.7 13.5
Time 2 77.5
ImPACT Processing Speed Score
Reliable change methodology
Time 1 40.54 4.98 is designed to identify cutoffs
Time 2 42.24 that can be used for
meaningful comparisons of
ImPACT Reaction Time Score test scores that are
Time 1 .543 .06 independent of practice
effects and other sources of
Time 2 .536 variance
ImPACT Symptom Score
Time 1 5.23 9.6 Iverson et al, TCN 2005
Time 2 5.79
Copyright © 2011

81. Clinical Evaluation
 Clinical Interview
 Vestibular-Ocular Screening
 Computerized Neurocognitive Testing
Copyright © 2011

82. Vestibular-Ocular Screening
• Ocular-Motor:
– “H-Test”- Smooth Pursuits
– Vertical/Horizontal Saccades
• Any dizziness, blurriness, over/under shoots?
• Vestibular-Ocular:
– Vertical/Horizontal Gaze Stability (focus on stationary object
while moving head up and down/side to side)
– Any observable nystagmus, provocative dizziness/blurriness,
slowed movements?
– VOR Cancellation
– Ocular Convergence and Accommodation
• In high school/college aged athletes, near point < 6-8 cm
• Balance Examination
• Romberg, Compliant Foam-eyes open/eyes closed
Copyright © 2011

83. Vestibular-Ocular Screening
Expected Symptoms/Environmental Triggers
Domain Symptoms Main Environmental Quote from Patients
Triggers
Saccadic Eye Movements- Headache, Fatigue, Computer Work, “Its like my eyes are
Vertical and Horizontal Difficulty Reading, Watching playing a slow game of
concentrating Action Movies, Video ping pong”
Games
Gaze Stability-Vertical and Fogginess, Headache, Note Taking, Busy “It feels like I am outside
Horizontal Fatigue, Dizzy, Anxiety Environments, Hallways, myself, one –step behind,
Running, Gymnasiums, and the world is in slow
Busy Weightrooms motion”
Ocular Convergence Headache (frontal), Reading, Computer Work, “I feel like two fat men
(Convergence Insufficiency) Fatigue, Irritability Texting, Math and with two fat asses are
Chemistry, sitting on my eyes”
VOR Cancellation Nausea, Headache, Car Rides, “While at the mall, I feel
Fogginess, Fatigue, Supermarkets, Busy like I am looking out the
Depersonalization, Environments, Wide side window of a high-
Anxiety Open Spaces speed car…I just want to
get out of there and it
freaks me out”
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84. Copyright © 2011

85. 15 year old, Sophomore
Honors student, High Average standardized
testing
No other medical history-no prior
concussion
Strong migraine history in maternal family
In retrospect, difficulties with concussion
started on September 11, 2009
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86. Initial injury in video caused bilateral blurred
vision, dizziness, photo/phonphobia, nausea, difficulty with play calls
No LOC, amnesia or mental status change
Never reported hit or symptoms to ATC, though told teammates
Second event in video worsened symptoms
That evening, told parents of symptoms (minimized difficulties)
No other medical intervention
Played remainder of season
Symptoms ebbed/flowed depending upon exertion and contact to head
Grades dropped during course of season (Straight A’s to C range)
Symptoms persistent throughout entire season
Sustained “another” concussion 10/30/09 (2nd to last game)-posterior blow
• Reported to ATC week after game/Referred to UPMC
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87. November 16, 2009 Evaluation (2 Months after initial event)
Headaches daily in school (7/10-generalized pressure), moderate
fatigue, “feeling slow”, fogginess, general dizziness, distractible,
short term memory difficulty
Discussed inherent pressure of playing quarterback, team culture
of playing through injury, pressure from coaches/family/friends
“Knew it was concussion, but nothing serious”
“Would be fine in long run”
“Good time to report injury given break from conditioning-no football responsibilities”
Father nonchalant, mother very concerned-discussed
team/community culture of football
Physical evaluation indicated convergence insufficiency, provocative
dizziness with horizontal/vertical saccades and gaze stability,
balance WNL
ImPACT Testing
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88. Vestibular-Ocular Screening
• Ocular-Motor:
– “H-Test”- Smooth Pursuits
– Vertical/Horizontal Saccades
• Any dizziness, blurriness, over/under shoots?
• Vestibular-Ocular:
– Vertical/Horizontal Gaze Stability (focus on stationary object
while moving head up and down/side to side)
– Any observable nystagmus, provocative dizziness/blurriness,
slowed movements?
– VOR Cancellation
– Ocular Convergence and Accommodation
• In high school/college aged athletes, near point < 6-8 cm
• Balance Examination
• Romberg, Compliant Foam-eyes open/eyes closed
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90. Cutoff Values of ImPACT Neurocognitive Scores
at 2 Days Post Injury That Predict Protracted
Recovery
75% 80% 85%
Sensitivitity Sensitivity Sensitiviity
Neurocognitive
Domain Cutoff Cutoff Cutoff
Verbal Memory 66.5 64.5 60.5
Visual Memory 48 46 44.5
Processing Speed 24.5 23.5 22.5
Reaction Time 0.72 0.78 0.86
Sensitivity is defined as the ability of the cutoff to accurately identify
protracted recovery (Mean Recovery Time = 1 month) in an athlete.
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
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91. Recommended formal Vestibular Evaluation (UPMC-
Eye and Ear Institute/Center for Rehabilitation
Services)
Patient strongly desired to remain in school
Allowed ½ days for 2 weeks
Provided full academic accommodations-including no tests for
3 weeks, ½ work assignments, books on tape if possible,
extensions on all assignments, leaving class early, avoiding
high stimulus areas, excused absences from school-
recommended meeting with all teachers
Return evaluation in 2 weeks to monitor status
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92. November 30 Evaluation
Vestibular Therapy initiated
Home-Based program outlined, Patient compliant
Symptoms not improved and persistent
Patient vocalized concerns over injury, response from
coaching staff, etc.
“Play through pain culture”
Both parents understanding and concerned
Teachers helpful at providing accommodations
Father trying to “educate” others regarding injury
Vestibular screening improved, but remained abnormal
ImPACT Testing
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94. Continued Vestibular Therapy-no exertion
until WNL
Recommended homebound instruction
Recommended medication referral
Dr. Camiolo-Medical Advisor-UPMC Sports
Concussion Program
Amantadine 200mg
Follow up in 2-3 weeks
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95. Factor Analysis,
Post-Concussion • More emotional
Symptom Scale • Sadness
• Nervousness
(Pardini, Lovell, Collins
• Irritability
et al. 2004)
• Headaches • Attention Problems
• Visual Problems • Memory dysfunction
• Dizziness • “Fogginess”
• Noise/Light Sensitivity • Fatigue
• Nausea • Cognitive slowing
N=327, High School • Difficulty falling asleep
and University • Sleeping less than usual
Athletes Within
7 Days of Concussion
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96. Emotionality
SSRIs
Escitalopram (Lexapro)
Somatic Sertraline (Zoloft)
Symptoms
Therapy
Headaches Prophylaxis Cognitive Symptoms
 Propranolol* Neurostimulants
 Verapamil* Amantadine*
 Amitriptyline*
Methylphenidate*
 Escitalopram (Lexapro)
Sleep Atomoxetine (Strattera)*
 Sertraline (Zoloft)
Disturbance
Vestibular Therapy
Melatonin
Trazodone
NOTE:
*Off-label use
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98. December 18, 2009 (3 months post-injury)
Headaches 1/7 days (1/10, 20 minute duration), mild
perceived difficulty with short-term memory
No other symptoms reported
Discharged from Vestibular therapy-all WNL
Started Exertional Physical Therapy
Sean Learish,PT-Center for Rehab Services-Director of
Exertional PT- UPMC Sports Concussion Program
ImPACT Testing
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99. 5 Stage Post-Concussion Exertion Program
Target Exertion calculated by Karvonen’s equation:
[ {Max. H.R. (220-Age) – Resting H.R.} X Target % ] + Resting H.R.
Stage Activity
Stage 1
- Very light aerobic conditioning
Target Heart Rate : 30-40% of maximum exertion
- Sub-max strengthening
Recommendations: 10-15 minutes of cardio exercise; low
stimulus environment; no impact activities; balance and - ROM/ Stretching
vestibular treatment (prn); limit head movement/ position - Very low level balance activities
change; limit concentration activities
Stage 2 - Moderate aerobic conditioning
- Light weight strength exercise
Target Heart Rate : 40-60% of maximum exertion
- Stretching (active stretching initiated)
Recommendations: 20-30 minutes of cardio exercise;
exercise in gym areas; use various exercise equipment; - Low level balance activities
allow some positional changes and head movement; low level
concentration activities
Stage 3 - Moderately aggressive aerobic exercise
- All forms of strength exercise (80% max)
Target Heart Rate: 60-80% of maximum exertion
- Active stretching exercise
Recommendations: any environment ok for exercise (indoor,
outdoor); integrate strength, conditioning, and balance / - Impact activities running, plyometrics (no
proprioceptive exercise; incorporate concentration challenges contact)
Copyright © 2011 - Challenging proprio-balance activities

100. 5 Stage Post-Concussion Exertion Program
Target Exertion calculated by Karvonen’s equation:
[ {Max. H.R. (220-Age) – Resting H.R.} X Target % ] + Resting H.R.
Stage Activity
Stage 4 (Sports Performance Training) - Non-contact physical training
Target Heart Rate: 80-90% of maximum exertion - Aggressive strength exercise
Recommendations: continue to avoid contact activity, - Impact activities/ plyometrics
resume aggressive training in all environments - Sports specific training activities
Stage 5 (Sports Performance Training) - Resume full physical training
activities with contact
Target Heart Rate: Full exertion
- Continue aggressive strength/
Recommendations: Initiate contact activities as
conditioning exercise
appropriate to sport activity; full exertion for sport
- Sport specific activities
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101. Show JB Video
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103. December 18 recommendations
Return to full school, minimal accommodations
(breaks from class if needed, tutoring in difficult
classes, extensions all assignments)
Progress with exertional therapy to Stage 3-4
No contact sports
Continue Amantadine
Follow up 1 month
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104. January 11, 2010 (4 months post-injury)
Off Amantadine
Reported circumscribed short term memory difficulties
Doing well in school-full curriculum
No other symptoms reported
Stage 4 Physical Exertion-no difficulties
Vestibular screening WNL
ImPACT Testing
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106. January 11, 2010 Recommendations
Continue Exertion as tolerated
Follow up in February for monitoring of status
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107. February 22, 2010 Evaluation
100% asymptomatic-no difficulties reported
Full physical and cognitive exertion
Grades returned completely to normal
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109. February 22, 2010 Recommendations
Full clearance back to all sports, including football
Quotes from Family:
Both “Felt educated about injury”
Strong desire to “educate others”
Reported misperceptions of others
Concussion is always repetitive and cumulative
Son has “permanent damage”
Son would “never” return to football
Son would “never be the same cognitively or physically”
Son should “never play football again” (from same people who
questioned veracity of injury to begin with)
“Poor education throughout community-from coaches to
clinicians”
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110. Thank You
Micky Collins, Ph.D.
collinsmw@upmc.edu
412-432-3668 (Direct) or 412-432-3681 (Secretary)
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