This document outlines topics to be covered in a session on concussions in children, including understanding the pathophysiology and symptoms of concussions, diagnostic tools, signs and symptoms, return to play requirements, and the role of assessment tools like ImPACT testing. It then provides details on concussion rates in various sports, symptoms, management guidelines, and interfacing with schools to support student recovery. The goal is for participants to gain knowledge on evaluating and managing concussions in youth athletes.

1. At the conclusion of the session, participants should be able to: 1. Understand the pathophysiology of concussions in children and the significance with regard to symptoms, management and recovery. 2. Understand the clinical and diagnostic tools available to assist in the evaluation and management of children with concussions. 3. Understand the signs and symptoms of concussive or minor traumatic brain injuries in children. 4. Be aware of the new MN Concussion Law for children and return to activity requirements. 5. Understand the role of adjunctive assessment tools in the management of children with concussions, including computerized neuropsychological testing.

2. Sports Concussions in the News

3. Concussions in Sports CDC estimates 3.8 million sports- and recreation-related concussions in U.S. every year Team sports with most ER visits Ice hockey Football Soccer Cheerleading Snow skiing, bicycling, playground

4. Concussions in Sports Youth hockey: 23.15 concussions/1000 player game-hours NHL: 29.59 concussions/1000 player game-hours Women’s hockey has highest rate of concussion of any NCAA sport, even though checking is not allowed

5. VALID | RELIABLE | SAFE Mark R. Lovell, Ph.D., FACPN Professor and Director UPMC Sports Medicine Concussion Program Chairman and Developer ImPACT Applications, InC. WHAT IS A CONCUSSION? A Mild Traumatic Brain Injury A Change in brain function that occurs when there is a blow to the head and the brain is shaken violently This results in chemical changes in the brain The brain is more vulnerable to injury while it is recovering Additional injury during the recovery period is very dangerous

11. Neurometabolic Cascade Following Injury

12. Neurometabolic Cascade Following Injury

13. Evolving Definition of Concussion CDC Physicians Toolkit 2007 REGARDING CEREBRAL CONCUSSION…… A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.”

14. Commonly Reported Symptoms High School and College Athletes-within 3 days of injury SYMPTOM PERCENT # 1 Headache 71 % # 2 Feeling slowed down 58 % # 3 Difficulty concentrating 57 % # 4 Dizziness 55 % # 5 Fogginess 53 % # 6 Fatigue 50 % # 7 Visual Blurring/double vision 49 % # 8 Light sensitivity 47 % # 9 Memory dysfunction 43 % # 10 Balance problems 43 % Lovell, Collins et al., 2004; N = 215

15. Symptom Evaluation/Clinical Interview: What is Asymptomatic? IS NOT “How are you feeling?” or “Do You Have a Headache?” IS a series of questions inquiring about subtleties of injury “Do you have a pressure in your head that increases as day progresses?” “Are you more sensitive to lights and noises than normal?” “Do you become dizzy when looking up/down, turning head, standing quickly?” “Do you feel more fatigued than normal at the end of the day?” “Do you have blurred or fuzzy vision while reading or difficulty reading?” “Do you feel more distractible in school than normal?” “Do you feel a sense of fogginess during the day?” “Do you have difficulty falling/staying asleep?” “Have you or your parents noticed that you are more irritable than normal?” “Asymptomatic” is not an easily defined term, although it is at the core of concussion management

16. COMMON SIGNS/SYMPTOMS? Headache Dizziness Confusion Memory Loss (amnesia) Blurred or double vision, seeing stars Nausea Light or noise sensitivity Balance problems Loss of consciousness is rare (<10 percent)

17. Risk Factors for Poor Recovery Effects of Multiple injuries (more is not better) Younger Age? (being young is not always better) Gender? (its just not a boys injury)

19. Athletes with 3 or more prior mTBI’s were more likely to demonstrate markers of concussion during the period of our study (Collins, Lovell et al., Neurosurgery,

21. High school athletes demonstrated longer lasting memory deficits compared to college athletes (Sim et al., J. Neurosurgery, 2008)

23. Neuropsychological Test PerformanceMale vs. Female AthletesT Scores with Mean of 50 and S.D. of 10(Colvin, Lovell et al., AJSM, 2009) p.<.004 NS NS p.<.00001 Reaction Time Symptoms Verbal Memory Proc. Speed N=238 (143 Females, 95 Males) Groups were not different at baseline and were matched for age and BMI

25. Post-Concussion Syndrome Chronic Headache (Migraine type) Photo/Phonosensitivity Nausea Chronic Fatigue Vestibular Deficits Mood Issues-Depression/Anxiety Sleep Deficits Cognitive Deficits (potentially severe) Academic Difficulties Chronic traumatic encephalopathy?

28. CT and MRI insensitive to subtleties of injury.

29. Self-report predicates management directives.

30. Variability in clinician recommendations.

31. Lack of education and awareness of injury.

33. CONCUSION EVALUATION TIMELINE Pre-Season 1-3 Days Follow-ups As needed First Follow-up Baseline Testing CONCUSSION REMOVE FROM PLAY Re-Evaluation Rest Gradual Exertion At school or clinic Return to Play

34. Concussion: The Diagnostic, Management and Return to Play Dilemma How to recognize the moods of an Irish setter

35. History and Development of ImPACT

36. The Pittsburgh Steelers Program First program to monitor professional athletes Resulted in League Wide Program in NFL Resulted in adoption by other sports/leagues Resulted in the development of ImPACT

37. Computer-Based Neurocognitive Testing Currently Available Programs Cogsport Headminders (CRI) ANAM ImPACT Explosion of research since 2001

38. Immediate Post-Concussion Assessment and Cognitive Testing Mark R. Lovell, Ph.D., FACPN, CEO, Chairman and Developer Joseph C. Maroon, M.D., Co-Founder Michael W. Collins, Ph.D., Co-Founder ImPACT was developed to provide a scientific way of evaluating readiness to return-to-play following concussion

39. Development of ImPACT:A Tradition of Research 1988- 1994 Steelers Project (pre-ImPACT) 1994 - 1996 Test Development 1996 - 1997 Field Testing (Multiple Sites) 1998 - 2000 NCAA/NAN Studies 2000 UPMC Program Established 2001 - 2006 NIH fMRI Study ($2.8 Million) 2003 - 2007 CDC Child Study ($2.0 Million) 2000 - 2010 Reliability/Validity Data Published 1999 - 2010  Over 80 Peer Reviewed Manuscripts 3 Textbooks / 55 Chapters

41. Ontario Ice Hockey League

42. Western Ice Hockey League

43. Australian Rugby

44. New Zealand Rugby

45. South African Rugby

46. Irish Rugby

47. Swedish World Cup Soccer

48. 600 + Universities in US

49. Many Neuropsychology Clinics

50. Major League Baseball Umpires

51. Army, Navy, Air Force Academies

52. US Military Special Ops (Army)

53. US Military Navy Seals

54. US Olympic Team (sliding sports)

55. All NFL Teams

56. All NHL Teams

57. All Major League Baseball

58. IRL, CHAMP Car (Racing)

59. Formula 1 Racing

60. USA Olympic Ice Hockey

61. USA Ice Hockey

62. 4,000+ High Schools

63. 200+ Clinics

64. USA Ski/Snow Board Team

65. USA Soccer Juniors

66. Major League Soccer

67. Six NBA Teams (Basketball)

68. Cirque Du Soleil

69. WWE (Pro wrestling)*Mandated by league or team

70. Why Bother with ImPACT? Dispelling Common Myths of Concussion “The athlete’s know when they are better” “Just wait two weeks and return them to play” “Don’t test the athlete until they are symptoms free”

72. Cognitive Speed

75. Myths and Misperceptions about ImPACT “ImPACT is unreliable” (multiple studies have showed that it is) “ImPACT has not been validated” (it has) “ImPACT is Too Expensive” (it is not)

76. Pressure to Play in Sports: Can We Trust What the Athlete Tells Us? We can’t trust a concussed athlete to diagnose their own injury Athletes are notorious for hiding symptoms Studies suggest that up to50% of athletes experience concussion symptoms per yearbut only 10 percent report Most SIS cases are known to have played with symptoms

77. “When it comes to concussion, don’t believe me when I tell you that I’m OK ” NFL Athlete, 2010

78. Never Believe a Cheerleader (Or any other athlete)

79. Pros/Cons of ImPACT Testing When Symptomatic PROS Helps todetermine severityof injury Helps to determines prognosis for outcome (Iverson, Collins Lovell et al, CJSM 2007) Guides management for levels of physical/cognitive exertion Helps to determine specific academic needs/accommodations Objectifies injury (it becomes real when they Legitimizes injury to athletes, parents, coaches, physicians Helps to establish therapeutic bond amongst all parties CONS Potential for exacerbation of symptoms Requires time commitment from ATC/Physician, etc

80. Unique Contribution of Neurocognitive Testing to Concussion Management Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion N=215, MANOVA p<.000000 (Fazio, Lovell, Collins et al., Neurorehabilitaiton, 2007

82. Current Status of Concussion Management

84. Second injury produced malignant brain swelling and permanent brain damage.

85. State of Washington passed law requiring evaluation prior to return to play.

86. 20 states have passed some type of concussion legislation.

88. What’s happening in Minnesota? 15-year-old Kayla Meyer of New Prague: "just need to realize that their health is more important than the game sometimes. They need to really take care of themselves for the future."

89. Minnesota Concussion Law Signed Gov Dayton on May 11 2001 –effective Sept 1st 2011 Applies to any organization that organizes a youth athletic activity for which an activity fee is charged Coaches must have training on concussions Information must be made available to the parent regarding the risks of concussions. Must remove player (18 and under) from all activity if they have symptoms or suspected of having a concussion Must have evaluation by a provider trained and experienced in evaluating and managing concussions and permission to again participate in the activity.

90. MANAGING CONCUSSION Promoting a Safe Return-to-Play

92. CURRENT MANAGEMENT GUIDELINES “When in doubt, sit them out” No athlete should play with symptoms (both at rest and following exertion) Athlete should be back to baseline level on neurocognitive testing (e.g. ImPACT) 1st-3rd International Symposia On Concussion in Sport

94. Any positive findings should result in removal WHEN IN DOUBT SIT THEM OUT!

96. Progress to Moderate exercise (running, lifting)

97. Progress to heavy non-contact (sprinting)

98. Return to practice/playIf symptoms occur at a level, go back one level

127. The ImPACT Applications, Inc. software is a diagnostic tool that provides basic data related to neurocognitive functioning. The software does not provide treatment recommendations or a specific medical diagnosis with respect to any particular end user. Training provided or facilitated by ImPACT Applications, Inc. on the use of its software is intended to provide users with the ability to properly administer the tests embedded in the software and to become familiar with the types of data generated by the software. Treatment decisions that you and/or your organization make based on the data generated by the software is in you and/or your organization’s sole and absolute discretion. By participating in the training, you and your organization acknowledge and agree that ImPACT Applications, Inc., its officers, directors, employees, or agents and affiliates and their respective successors and assigns will not be held liable for claims of medical malpractice, practicing medicine without a license or similar claims made by you, your organization or any third party. To the fullest extent permitted by applicable law, you and your organization agree to hold ImPACT Applications, Inc., its officers, directors, employees, agents, and affiliates and their respective successors and assigns harmless and to indemnify ImPACT Applications Inc. and its officers, directors, employees, agents, and affiliates and their respective successors and assigns against any and all such claims.

128. Copyright © 2011 by ImPACT Applications, Inc. All rights reserved. No part of this publication maybe reproduced in whole or in part or transmitted in any form or by any means without the prior written permission of ImPACT Applications, Inc. For information regarding permission, please write to ImPACT Applications, Inc., LRUSSO@impacttest.com ImPACT™ and associated logos are trademarks of ImPACT Applications, Inc.

129. ImPACT™ and the ImPACT Logo are trademarks of ImPACT Applications, Inc. and are used herein with the express written permission of ImPACT Applications, Inc. and may not be duplicated, removed or altered without ImPACT Applications, Inc.’s written consent.

130. Thank you! Questions? Joseph Petronio, MD Director of Pediatric Neurosurgery Children’s Hospitals and Clinics of MN joseph.petronio@childrensmn.org (612) 343-2121

131. Sports Concussions in the News

133. Fundamentals of Concussion Management