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ImPACT SPORTS CONCUSSION MANAGEMENT
Under Construction
Overview of Concussion
An excellent overview of concussion is provided on the ImPACT website. The following is taken from that website which in turn referred to:
National Center for Injury Prevention and Control, Division of Injury Response Heads Up! Concussion Information for Physicians Centers for Disease Control and Prevention
A concussion is a disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head, and in the United States, the annual incidence of sports-related concussion is estimated at 300,000. Estimates regarding the likelihood of an athlete in a contact sport experiencing a concussion may be as high as 19% per season.
Regarding Canada, it is reasonable to assume the incidence of injury is proportional to that found in the US. Thus, given that the population of Canada is approximately 1/10th that of the US, it is likely that the annual incidence of sport-related concussion is about 30,000.
Common Signs and Symptoms
Signs observed
•Appears to be dazed or stunned
•Is confused about assignment
•Forgets plays
•Is unsure of game, score, or opponent
•Moves clumsily
•Answers questions slowly
•Loses consciousness (even temporarily)
•Shows behavior or personality change
•Forgets events prior to hit (retrograde amnesia)
•Forgets events after hit (anterograde amnesia)
Signs reported by athlete
•Headache
•Nausea
•Balance problems or dizziness
•Double or fuzzy vision
•Sensitivity to light or noise
•Feeling sluggish
•Feeling "foggy"
•Change in sleep pattern
•Concentration or memory problems
In a University of Pittsburgh Medical Center (UPMC) study of high school and college athletes with concussion, on-the-field amnesia, not loss of consciousness, as long thought, was predictive of post-injury symptom severity and neurocognitive deficits.
Post-Concussion Syndrome
Although the majority of athletes who experience a concussion are likely to recover, an unknown number may experience chronic cognitive and neurobehavioral difficulties related to recurrent injury. Symptoms may include:
•Chronic headaches
•Fatigue
•Sleep difficulties
•Personality changes (e.g. increased irritability, emotionality)
•Sensitivity to light or noise
•Dizziness when standing quickly
•Deficits in short-term memory, problem solving and general academic functioning
In addition to Post-Concussion Syndrome, suffering a second blow to the head while recovering from an initial concussion can have catastrophic consequences as in the case of "Second Impact Syndrome," which has led to approximately 30-40 deaths over the past decade.
Concussion Assessment
Upon ruling out more severe injury, acute evaluation continues with assessment of the concussion. First, the clinician should establish the presence of any loss or other alteration of consciousness (LOC). LOC is relatively rare and occurs in less than 10% of concussions.
The identification of LOC can be very tricky, as the athlete may lose consciousness very briefly and this event may not be directly observed by others. By definition, LOC represents a state of brief coma in which the eyes are typically closed and the athlete is unresponsive to external stimuli. LOC is most obvious when an athlete makes no attempt to brace his or her fall following a blow to the head. Any athlete with documented LOC should be managed conservatively, and return to play is contraindicated.
Although helpful in identifying more serious concerns (e.g. skull fracture, hematoma, contusion), traditional neurological and radiologic procedures, such as CT, MRI, and EEG, are not useful in identifying the effects of concussion. Such tests are typically unremarkable or normal, even in athletes sustaining a severe concussion. The reason for this issue is that concussion is a metabolic rather than structural injury. Thus, structural neuroimaging techniques are insensitive to the effects of concussion.
Concussion Management Guidelines
At the forefront of proper concussion management is the implementation of baseline and/or post-injury neurocognitive testing. Such evaluation can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts.
Concussion Recommendations
According to the Vienna Concussion Conference Recommendations, athletes should complete the following step-wise process prior to return to play following concussion:
•Removal from contest following signs and symptoms of concussion
•No return to play in current game
•Medical evaluation following injury
•Rule out more serious intracranial pathology
•Step-wise return to play
- No activity - rest until asymptomatic
- Light aerobic exercise
- Sport-specific training
- Non-contact drills
- Full-contact drills
- Game play
Concussion Treatment
The goal of concussion treatment is to allow the brain injury to heal. Treatment of concussions differs depending on the level of severity. Treatment may include:
Concussion Recovery
Athletes who are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussion.
Such difficulties are prevented if the athlete is allowed time to recover from a concussion and return to play decisions are carefully made. No athlete should return to sport or other at-risk participation when symptoms of concussion are present and recovery is ongoing.
In summary, the best way to prevent difficulties with concussion is to manage the injury properly when it does occur.
Overview and Features of the ImPACT Test
ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most-widely used, and most scientifically validated computerized sports concussion evaluation system.
Developed in the early 1990's by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages. ImPACT Applications, Inc. was co-founded by Mark Lovell, PhD, Joseph Maroon, MD, and Michael (Micky) Collins, PhD.
Given the inherent difficulties in concussion management, it is important to manage concussions on an individualized basis and to implement baseline testing and/or post-injury neurocognitive testing. This type of concussion assessment can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts.
ImPACT can be administered by an athletic trainer, school nurse, athletic director, team doctor or psychologist, provided that they have completed training in the administration of the test. Post-concussion care and the management of concussion should only be administered by a trained professional such as a physician or neuropsychologist.
This may involve further more indepth neuropsychological testing (see Neuropsychological Assessment on this website). Thus, ImPACT assists the physician in making a final return-to-play decision and should never be used as a stand-alone tool.
ImPACT is the most widely used computer-based testing program in the world and is implemented effectively across high school, collegiate, and professional levels of sport participation.
Test Features
•Measures player symptoms
•Measures verbal and visual memory, processing speed and reaction time
•Reaction time measured to 1/100th of second(br>
•Assists clinicians and athletic trainers in making difficult return-to-play decisions
•Provides reliable baseline test information
•Produces comprehensive report of test results
•Results can be quickly assessed by a neuropsychologist
•Automatically stores data from repeat testing
•Testing is administered online for individuals or groups
The test battery consists of a near infinite number of alternate forms by randomly varying the stimulus array for each administration. This feature was built in to the program to minimize the "practice effects" that have limited the usefulness of more traditional neurocognitive tests.
ImPACT takes approximately 20 minutes to complete. The program measures multiple aspects of cognitive functioning in athletes, including:
•Attention span
•Working memory
•Sustained and selective attention time
•Response variability
•Non-verbal problem solving
•Reaction time
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