1. Player Safety: Concussion & Baseline Impact Testing David Bernhardt, M.D. University of Wisconsin Sports Medicine

2. Concussion Mild traumatic brain injury Vienna Consensus Statement 2001

3. Symptoms Dazed appearance Confusion Memory Loss Headache Dizziness Balance problems Irritable Personality change Slowed response Poor focus/attention +/- LOC

5. Memory

6. What if the athlete suffers brief LOC? Should this athlete be DQ’d for the remainder of the game? Does LOC predict long term prognosis?

7. What if the athlete suffers brief LOC? 383 MTBI patients (GCS 14-15) Confusion, agitation, retrograde amnesia, LOC Poorer performance for all groups on neuropsychological tests sensitive to MTBI No differences between groups based on LOC, uncertain LOC and no LOC Lovell MR, et al. Clin J Sports Med 1999

8. Simple Concussion Resolves without complication in 7-10 days Rest until all symptoms have resolved Graded return to play

9. Complex Concussion Persistent symptoms Specific sequelae (seizures) Prolonged LOC (> 1 minute) Prolonged cognitive impairment Repeated concussions with less force Consider neuropsychological testing Multidisciplinary approach

10. Sideline evaluation Orientation Concentration Month: ___________________ 0 1 Digits backward (If correct, go to Date: _____________________ 0 1 next string length. If incorrect, read Day of week: ______________ 0 1 trial 2. Stop if both incorrect. Year: ____________________ 0 1 4-9-3 6-2-9 ______0 1 Time (within 1 hour): _______ 0 1 3-8-1-4 3-2-7-9 _____0 1 6-2-9-7-1 1-5-2-8-6 ______0 1 Orientation Total Score _________ / 5 7-1-8-4-6-2 5-9-1-4-8 _____0 1 Months in reverse order: (entire sequence correct for 1 pt) Dec  Jan 0 1 Concentration Total Score ____ / 5

11. Sideline evaluation Immediate Memory: (all 3 trials are complete regardless of score on trial 1 & 2; total score equals sum across all 3 trials) ListTrial 1Trial 2Trial 3 Word 10 10 10 1Exertional maneuvers Word 20 10 10 1Coordination Word 30 10 10 1Strength Word 40 10 10 1Sensation Word 50 10 10 1Recall of injury Total Immediate Memory Total Score _____ / 15 Delayed recall Word 1 0 1 Word 2 0 1 Word 3 0 1 Word 4 0 1 Word 5 0 1 Delayed Recall Total Score _____/5McCrea M et al. Summary of Total Scores _____ / 30Neurology 1997

12. Serial 7’s 522 high school athletes, PPPE Serial 7, serial 3, months in reverse Seven consecutive or 11 with one mistake 51% serial 7’s, 79% serial 3’s 89% months in reverse Young CC, Jacobs BA et al. Clinical Journal of Sports Medicine 1997

13. DO NOT ALLOW RETURN TO PLAY UNTIL COMPLETELY ASYMPTOMATIC

14. If You Do Not Know Athlete’s Baseline Neuropsychological Status, It Is Difficult To Judge Normal

15. High school athletes often require a significantly longer period of time to become asymptomatic and for their cognitive function to return to normal than both collegiate and professional athletes

16. Catastrophic complications Epidural Subdural Second impact syndrome

17. Not fully recovered from previous head injury when sustain a second head injury Loss of vascular autoregulation Cerebral vascular congestion Malignant brain edema, brainstem herniation, death

18. POST CONCUSSIVE SYNDROME Recurrent headachesDizziness Memory impairmentDepression Loss of libidoTinnitus AtaxiaAnxiety Alcohol intolerance Photophobia HyperacousisConcentration

19. Post concussive syndrome Not necessarily related to severity of concussion Attention and learning difficulty may be subtle Cumulative effects of multiple concussions

20. Neuropsychological testing Nature and degree of deficit acutely Relationship to standard sideline evaluation Recovery curves

21. Computerized Neurocognitive Testing IMPACT Headminders Cogsport http://www.wiyouthsoccer.com/impact.html