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ImPACT Testing

Protocol for concussion management and return to play

CONCUSSION MANAGEMENT AND “RETURN TO PLAY” CRITERIA

By Rob Nolfo M.D. and Mike Eldridge A.T.C.

At the forefront of proper concussion management is the use of proper baseline and post-concussion 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.  Neurocognitive testing has recently been referred to as the “cornerstone” of proper concussion management be an international panel of sports medicine experts.

The following are the Vienna Concussion Conference Recommendations:

Athletes should complete the following step-wise process prior to returning to play after concussion.

  • Removal from contest following any signs/symptoms of concussion.

  • No return to play in current game.

  • Medical evaluation following injury to rule out more serious intracranial pathology.

  • Step-wise return to play.  Before returning to play the athlete must:

  1. Return to baseline on neurocognitive testing.

  2. Be symptom free.

  3. Complete the following step-wise rehabilitation program

 

DAYS 1 and 2: Exercise bicycle for 10-15 minutes and get heart rate up to 150 bpm.  If athlete remains symptom-free after DAYS 1 and 2, they may advance to next step.

DAY 3: Sport-specific non-contact drills.  If athlete remains symptom-free after this step, they may advance to the next step.

DAY 4: Full contact drills.  If completed without symptoms, athlete may return to play on DAY 5, as directed by Rob Nolfo M.D., Guilford Public Schools Medical Advisor and executed by Mike Eldridge, Athletic Trainer.

Parent information letter about the ImPACT Program

Dear Parent/Guardian,

The purpose of this letter is to inform you about a special program now required for all student athletes at GHS.  This program is called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing).  It is a computerized, 20 to 30 minute test, similar to the six to eight hour neuropsychological tests used by clinicians to determine when an athlete may return to play after suffering a concussion. 

Traditionally, it has been difficult for physicians and trainers to determine the extent of brain injury from a concussive episode.  Often the young athlete is so eager to return to play, or is under such considerable peer pressure, that they are less than truthful about their symptoms.  This puts the athlete at significant risk for Second Impact Syndrome.  This is a second concussive episode before complete recovery from the first.  Second Impact Syndrome is a well-documented phenomenon, which can result in permanent brain injury, and, in rare cases, death.  It has gained considerable press concerning its use in professional and collegiate sports, in the past five years.

The benefit of ImPACT is that any athlete can complete the test modules in 20-30 minutes, at specific computer terminals at the high school.  This can be used later for comparison, in the event of a head injury.  Although age-appropriate norms are available for comparison, the best reference is ones own baseline scores. Generally only one baseline test is required during a high school career, however some sports may require another baseline during the students junior year.

ImPACT is not an IQ test.  The test looks at abilities such as reaction time, speed of information processing, and memory, which neuropsychologists and neurologists find correlate well with functional MRIs performed on athletes who have suffered concussions.  Early studies indicate that ImPACT is a highly useful tool, whose results are intended for use by your pediatrician or family doctor.  This information will help parents and students know if the athlete is at risk for Second Impact Syndrome. All test information is confidential and will be stored in a secured computer file.

There is no cost to families for the athlete’s baseline study.  In the event that an athlete suffers a concussion as determined by a change in mental status as a result of a blow, ImPACT testing will be performed by the GHS trainer within 24-72 hours. The results of the post concussion test need to be evaluated by a physician or neurophyschologist who is trained in interpreting Impact results.

Dr. Rob Nolfo, Medical Advisor for the Guilford Public Schools and pediatrician in Guilford, enthusiastically endorses the ImPACT program

All athletes must make appointments with a secretary in the main office once testing dates are determined. They must have their computer authorization number to take the test.  If they have not gotten a number they must get the appropriate forms from the Student Affairs Center.

If you have any questions about this program please contact me at 453-2741 ext. 222

 

Sincerely,  

Chip Dorwin

Athletic Director

 

MANAGING CONCUSSIONS IN SPORTS

      Recent research shows that there are up to 300,000 concussions per year in high school and college athletics. Unfortunately, most players, coaches and parents do not understand what a concussion is.

      A concussion is defined as “an alteration in mental status induced by mechanical forces affecting the brain”. Although concussions sometimes result in a loss of consciousness, an athlete does not have to lose consciousness to have sustained a concussion. Problems with memory, feeling “stunned” or “dazed” or becoming confused or disoriented, even temporarily, are indicative of a concussion. Athletes who report having had their “bell rung” have usually sustained a concussion. It is very important to understand that most concussions in sports DO NOT result in a loss of consciousness and to properly define head injuries as concussions:

      Early symptoms include: headache, dizziness, nausea, vomiting, drowsiness, blurred vision, disorientation, mental confusion and memory impairment. Most of these symptoms are short lived, although headache and dizziness may persist for weeks.

      Late symptoms include: irritability, anxiety, impaired memory and concentration, problems with sleep, fatigue and visual complaints.

      If, after contact, an athlete in any sport experiences any of these symptoms, they must be reported to the athletic trainer, coach, and parent. An athlete who is experiencing any of these symptoms should not be permitted to return to activity. If symptoms persist for more than 15 minutes, or if the athlete had lost consciousness, the athlete should have further medical evaluation to rule out more serious problems.

     In the past, it has been extremely difficult to easily and accurately evaluate an athlete’s ability to return to play after a concussion. Diagnostic testing such as CT scans are valuable in identifying structural brain damage and blood clots, but do not pick up the microscopic tearing and shearing of axons that occur in the overwhelming majority of concussions. There have been numerous “concussion guidelines” published for physicians to follow in determining when to allow return to activity, but these have not been reliable. There has also been a dependence on how the athlete “feels”, which often leads to minimizing of symptoms or lying by the athlete, and is often not accurate in indicating actual recovery even when the athlete is completely honest about symptoms.

     An athlete who returns to activity prior to his or her brain having healed from a concussion is at risk for “Second Impact Syndrome”. This occurs when there is a second head injury while the brain is still damaged from the initial injury. Even a minor blow to the head, or a collision that results in a whiplash type injury (without any direct head trauma), can cause significant damage. Second Impact Syndrome can lead to rapid swelling of the brain, permanent brain damage, and in some cases, death.

     Recently, neuropsychologists have developed testing methods to accurately and quickly evaluate whether the brain has healed sufficiently after concussion. This allows for a more accurate determination of when it is safe to allow the athlete to return to activity. Experts involved in managing concussions strongly recommend that athletes, particularly those involved in contact or collision sports, have a baseline neuropsychological test prior to participation, in order to establish “normal” for the athlete. If the athlete sustains a concussion during his or her career, the athlete should then be re-tested, with post injury results compared to the athlete’s baseline.

     ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is a computerized neuropsychological test battery that was designed to assess recovery from sports-related concussion. The test measures different aspects of memory, reaction time, and information processing speed. The results have so far been correlated highly with results of functional MRI testing, which measures microscopic tearing of brain axons. ImPACT is being used by numerous professional sports teams and leagues, including the NFL, NHL, CART, and Olympic ice hockey, as well as hundreds of university and high school athletic programs.

Prepared by:

Kenneth W. Gilstein, Ph.D.

Vicky Graham, ATC, Wesleyan University