Sports Concussion: Research Findings and Practical Implications Amy D. Seay, Martin L. Rohling University of South Alabama, Mobile David Erlanger, & Tanya Kaushik Headminder, Inc., New York

Introduction 1. In the US, approximately 175,000 athletes sustain a concussion each season (Collins et al., 2003). 2. Currently, most concussion scales use LOC or PTA to determine severity. 3. Research has been inconclusive regarding these two variables in assessing concussion severity (Erlanger et al, 2003). 4. Some believe both variables are predictive, neither should be ignored (Randolph, 2004; personal communication).

Definitions of Concussions Problems with Assessment: No agreed upon definition or grading system for severity (Broshek & Barth, 2000). More than 15 systems are currently utilized. Most Commonly used systems: 1. American Academy of Neurology (AAN, 1997) 2. R. C. Cantu (1991), who summarized the Comm. of Head Injury Nomenclature of the Congress of Neurological Surgeons recommendations.

Incidence of Concussion: A Tale of Two Systems Cantu System Grade I: LOC = 0 and PTA < 30 min (47%) Grade II: LOC < 5 min, PTA = 30 min – 24 hrs (24%) Grade III: LOC > 5 min, PTA > 24 hrs (29%) AAN System Grade 1: Transient confusion, LOC = 0, Symptoms < 15 min (9%) Grade 2: Transient confusion, LOC = 0, Symptoms > 15 min (75%) Grade 3: LOC > 0 (16%)

Incidence of Concussion Broshek et al. (2003) incidence of concussion in 3,000 collegiate and high school athletes = 5.6% annually. Approximately 18% of sports related concussions result in a loss of consciousness and or post traumatic amnesia (Guskiewicz et al., 1997). 1.25 million athletes compete in contact sports (Lovell et al., 2003). The chances of incurring mild head trauma ranges between 2-10% (Broshek & Barth, 2000).

Signs & Symptoms of Concussion Sideline Evaluation of Concussion (Erlanger et al, 2003) Headaches 94% Dizziness 85% Confusion/disorientation 83% Nausea 53% Loss of consciousness (LOC) 26% Retrograde amnesia (RA) 13% Vomiting 4%

Signs & Symptoms Cont…… Follow-up Evaluation 24 hrs Post Concussion (Erlanger et al, 2003) Headache 57% Cognitive Impairment 55% Fatigue 44% Memory problems 37% Nausea 32% Concentration problems 23% Dizziness 17% Weak, irritable, poor vision (each) 15% Vomiting 0%

Sports Concussion: Risk Factors I Type of Sport: Head injuries can occur in a variety of sports with the top six estimated ranges of rates of concussion as follows (Broshek & Barth, 2000): -equestrian 47% -boxing 35% -rugby 26% -soccer 13% -football 11% -hockey 9%

Sports Concussion: Risk Factors I Level of Play: The younger a player is, the more likely they are to be at risk for concussion. Examples of sports from greatest amount of risk to least amount of risk are: Recreational Teams (e.g. Tee-Ball, Little league) High School Teams Collegiate Teams Amateur Professional

Sports Concussion: Risk Factors II Demographic Factors (Broshek et al., 2003) 1. Gender: Women greater risk w/ equal severity. 2. Age: Younger greater the risk w/ equal severity. 3. LD/ADHD: Disabled greater risk w/ equal severity. Behavioral Factors 4. Substance Abuse: Increases risk concussion & causes prolonged recovery. 5. Player Position: Clear effects of position by sport QB & RB but not linemen in football Defensemen but not goalies in hockey

Methods of Assessment Sports Trainers and/or Team Physicians Symptom self-report and brief objective screening (no formalized system). Consulting Neuropsychologists Standardized test batteries for objective and subjective assessments used at baseline and following injury. CRI (Erlanger et al.) ImPACT (Echemendia et al.) SAC (Cantu et al.) SLAM (Barth et al.)

Meta-Analytic Results: Sports Concussion We are currently analyzing results from 15 studies that reported codeable data. Results to be submitted for publication in an invited paper soon (deadline – 12/2004). Preliminary findings suggest: Concussion typically resolves 7 days (range: 3-14) Symptom complaint parallels cognitive scores. Age, gender, & level of play are moderators. Cost likely to be a factor in deciding best method.

Assessment Effect Sizes: Reaction Time vs. Symptom Complaint CRI Test Battery Erlanger et al. (2003). Symptom-based assessment of the severity of a concussion. J Neurosurg, 98, 477-484.

Assessment Effect Sizes: Memory vs. Symptom Complaint ImPACT Battery Data Lovell et al. (2003). Recovery from mild concussion in high school athletes. J Neurosurg, 98, 296-301.

Assessment Effect Sizes: Cognition vs. Symptom Complaint SAC Battery Data McCrea et al. (2002). Immediate neurological effects of concussion. Neurosurgery, 50, 1032-1042.

Decisions to Return to Play: Immediate Dilemmas Severity best indicator of when to return to play. Unclear if LOC or PTA are related or independent var. Unclear if one needs a cognitive test battery. Maybe just as effective to ask athlete about symptoms. (Randolph, 2004 personal communication) The athletes’ age, gender, and position should be factored into return to play decisions. Safest decision may be fixed time (e.g., 7-14 days), regardless of other factors before returning to play.

Decisions to Return to Play: Career Implications Cognitive assessments may prove more valuable in deciding return to play after multiple concussion. as an athlete ages. More frequent concussions increase risks of neurological disease of aging (e.g., Alzheimer’s). Pre-existing factors such as substance abuse or LD/ADHD should lead to earlier termination decision to reduce the risk of developing age-related cognitive problems prematurely. (e.g., 4 rather than 8 injuries or 5 rather than 10 yrs)

Preventing Sports Concussion Protecting Athletes (Broshek & Barth, 2000): Proper strengthening of certain muscles (head and neck) to minimize the impact Important to educate athletes concerning the proper techniques used to head and block to reduce risk. Use of certain equipment (e.g., head gear in soccer) should be mandatory. Have certified athletic trainers or physicians present at games and practices.

We’re not telling you how many concussions we’ve each had. Any Questions? We’re not telling you how many concussions we’ve each had.