Concussions: A Region’s Playbook William Lewis, MD, Brittany Gusic, MD (PGY-2), Yusuf Khan, MD, Ryan Miller (MS-4) WVU Department of Family Medicine – Eastern Division FMEC 11/2/13

West Virginia's Eastern Panhandle O 15 – High Schools O 8 – counties O 1 – West Virginia Area Health Education Center (WV AHEC) O 1 – Division of WVU School of Medicine O 1 – Family Medicine Residency (Harpers Ferry Rural Family Medicine Residency)

Project ImPACT O Started 2008 to provide concussion testing in the eastern panhandle O Supported by our regional AHEC group O 10 High Schools now participating

Project ImPACT O 2011 O 1,014 baselines O 179 post-concussion tests O 2012 O 1,128 baselines O 154 post-concussion tests O 2013 O 1,337 baselines O 137 post-concussion tests

ImPACT testing O Piece of the overall concussion evaluation and management process O Neurocognitive tests O Symptom monitoring O Extensively researched O Used to track recovery following concussion O Not a tool for diagnose concussion or a substitution for medical evaluation

Symptom monitoring O Most recent concussion date O Hours slept last night O Current medications O Rate the current severity of 22 concussion symptoms on a 7-point Likert scale

Neurocognitive Tests O Baseline and Post-Injury Neurocognitive Tests 1. Word Discrimination O Evaluates attentional processes and verbal recognition memory utilizing a word discrimination paradigm 2. Design Memory O Evaluates attentional processes and visual recognition memory using a design discrimination paradigm 3. X's and O's O Measures visual working memory as well as visual processing speed and consists of a visual memory paradigm with a distractor task that measures response speed 4. Symbol Matching O Evaluates visual processing speed, learning and memory 5. Color Match O Represents a choice reaction time task and also measures impulse control and response inhibition. 6. Three Letter Memory O Measures working memory and visual-motor response speed

ImPACT Test Scores There are five ImPACT Test scores calculated from the neuropsychological tests and a symptom score 1. Verbal Memory Composite O Total memory percent correct O Symbol match (total correct hidden symbols) O Three letters (total percent of total letters correct) 2. Visual Memory Composite O Design memory (total percent correct score) O X's and O's (total correct memory score) 3. Processing Speed Composite O X's and O's (total correct (interference)) O Three-letters (average counted correctly) 4. Reaction Time Composite T O X's and O's (average correct RT (interference)) O Symbol match (average correct RT/3) O Color match (average correct RT) 5. Impulse Control Composite O X's and O's (total incorrect (interference)) O Color match (total commissions) 6. Total Symptom Composite O Total for all 22 symptom descriptors

Our testing program O Athletic trainers with support of AHEC conduct baseline testing O All contact sports athletes can receive baseline test O Usually repeat baseline every 2 years

Our testing program O Athletes with clinical concussion receive post injury test O Results sent to an ImPACT trained provider for interpretation O Can access results through web or app O Results can also be placed into PDF to be ed

Our testing program O First positive test repeat 1 week O Second positive recommend seeing physician O Trainer will notify teachers to adjust class work O Can not return to participation until ImPACT back to baseline AND symptom free for 1 week

Our data from 5 years of testing

Baseline testing vs. Post injury testing

Yearly Post-injury Testing # by School

5 Year Injury Rate by School

“Most Concussions Happen in Football…” Year % Football (Baseline) % Football concussions

Trends in the data

Berkeley Schools Prior to Changes

Jefferson Prior to 2012

Standardization O Expansion of tested sports O Education for Trainers O Physicians/residents/medicals student sideline to evaluate

Berkeley Co. Schools after Changes

Jefferson After 2012

WV Return to Play O “An athlete removed from a contest that shows signs/symptoms of a concussion shall be immediately evaluated by an appropriate health care professional. If no appropriate health care professional is available, the athlete shall not be allowed to RTP.” O “…if it is determined the athlete has suffered a concussion, the athlete shall not be permitted to RTP the same day as the concussion.”

WV RTP O “RTP shall be delayed until athlete is asymptomatic and has undergone a progression of tests to determine if they are able to RTP.” O No activity O Light aerobic activity O Sport specific exercise O Non-contact training drills O Full participation practice O RTP O If symptoms occur during progression, drop back to previous level after a 24 hour rest period.

What to do on the sideline

Who Needs To Go To The ER? Loss of consciousness or posttraumatic amnesia and one of the following: O Headache O Vomiting O Deficits in short-term memory O Physical evidence of trauma above the clavicle O Posttraumatic seizure GCS score < 15 O Focal neurologic deficit O Cervical spine injury.

Who Needs To Go To The ER? Head trauma patients with no loss of consciousness or posttraumatic amnesia and one of the following: O Focal neurologic deficit O Vomiting O Severe headache O Physical signs of a basilar skull fracture O GCS score < 15 O cervical spine injury.

Sideline Tools: An Overview O Subtle changes O No treatment or rehab O Numerous assessment tools O Combination of tools O Baseline measurements

Symptom Checklists O Most commonly used O Cost effective O Self-reporting O Symptom reporting can become complicated.

Neuropsychological Tests O Subtle Cognitive Deficits O Written vs Computer Based O Tests are not yet validated; data O Under age 12 – Still being developed O Balance Error Scoring System (BESS) O ImPACT – Sway test with Iphone application.

BESS Score Card O FIRM Surface O FOAM Surface O Balance Error Scoring System – Types of Errors – Out of Position O 1. Hands lifted off iliac crest O 2. Opening eyes O 3. Step, stumble, or fall O 4. Moving hip into > 30 degrees abduction O 5. Lifting forefoot or heel O 6. Remaining out of test position >5 sec O The BESS is calculated by adding one error point for each error during the 6 20-second tests.

Sideline Assessment Tools O Maddocks Questions O Standardized Assessment of Concussion (SAC) O Sport Concussion Assessment Tool (SCAT) O (SCAT2) O (SCAT3), (Child-SCAT3)

CDC Guidelines For Return To Play O Athletes should not return to play the same day of injury. O Under the supervision of a healthcare provider O Stepwise symptom-limited program with stages of progression: 1. Rest until asymptomatic (physical and mental rest) 2. Light aerobic exercise (e.g., stationary cycle) 3. Sport-specific exercise 4. Non-contact training drills (light resistance) 5. Full contract training after medical clearance 6. Return to competition

Bibliography O Sports Health May; 3(3): 287–295. doi: / PMCID: PMC / O Systematic Review of the Balance Error Scoring System O David R. Bell, PhD, ATC, * Kevin M. Guskiewicz, PhD, ATC, † Micheal A. Clark, DPT, MS, PES, CES, § and Darin A. Padua, PhD, ATC †‡ David R. BellKevin M. GuskiewiczMicheal A. Clark Darin A. Padua O evaluation/maddocks-questions-test-concussion#ixzz2j8huVXDK evaluation/maddocks-questions-test-concussion#ixzz2j8huVXDK O Scorza, Keith, MD, MBA, Raleigh, Meghan F., MD, O’Connor, Francis G., MD, MPH, Current Concepts in Concussion: Evaluation and Management, Am Fam Physician, 2012 Jan 15;85(2): O McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J, Aubry, M., Molloy, M., Cantu, R, Consensu Statement on Concussion in Sport: the 3 rd International Conference on Concussion in Sport held in Zurich, November 2008, Br J Sports Med 2009;43 (Suppl 1): i76-i84 O O accessed 10/30/13 O accessed 10/30/13