Concussion Assessment,
Recognition, & Return to Play
Leslie Duinink, MS, LAT
Today We Will
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Review Definition & Symptoms
Immediate Evaluation & Management
SCAT3 and Child SCAT3
Return to Play
New & Ongoing Research
Questions
Iowa’s Concussion Law – Senate File 367
• Iowa’s Law
• Summary
– Iowa High School Athletic Association (IHSAA) and the Iowa Girls High School Athletic Union
(IGHSAU) must work to distribute guidelines
– Provide parent/guardian information regarding concussion and obtain signature prior to
participation
– Immediate removal from participation if S&S observed by coach or official
– If removed, must be cleared by licensed healthcare professional (physician, physician
assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist,
licensed athletic trainer)
General Definition
“Concussion is a brain injury and is defined as a complex
pathophysiological process affecting the brain, induced by
biomechanical forces.”
Zurich 2012
Definitions
1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body
with an ‘‘impulsive’’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short- lived impairment of neurologic function that
resolves spontaneously. However in some cases symptoms and signs may evolve over a number of
minutes to hours.
3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a
functional disturbance rather than a structural injury and as such, no abnormality is seen on standard
structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of
consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.
However it is important to note that in some cases, post-concussive symptoms may be prolonged.
2012 Zurich Consensus Statement
Definitions
• Sub-concussion or sub-concussive –a blow to the head
that does not cause a concussion
– Over time these are thought to accumulate, potentially adding
up to problems in the future
– Unsure of what this may look like moving forward
Impact Data
from a Helmet
with an
Accelerometer
NatGeo
Summary of a Season of Hits
Four features of note
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Mechanism of Injury
Presentation
Functional disturbance
Graded set of symptoms (w/wo loss of
consciousness) resolution is typically
sequential course
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One or More Present
Suspect a Concussion
Symptoms – somatic, cognitive, and/or emotional
Physical signs
Behavior changes
Cognitive impairment (slowed reaction time)
Sleep disturbances (may not be immediate)
Mechanism of Injury (MOI)
• Direct blow to the head, face, neck or elsewhere on the
body with “impulsive” force transmitted to the head.
Examples can include
• Struck with an object – hit with a ball to the head
• Strike an object – head hits the floor or wall
• Take a body blow from
another person
• Fall hard on their bottom or from a height
• A sudden deceleration event
• Others?
http://journal.frontiersin.org/Journal/10.3389/fbioe.2013.00015/full
Signs You May Observe
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Vacant stare – appears dazed, stunned
Delayed verbal and motor response
Inability to focus attention
Disorientation
Slurred or incoherent speech
Gross incoordination – moves clumsily
Heightened emotions, irritability
Memory deficits (pre-event, post injury)
Symptoms They May Tell You
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Headache or “pressure” in the head
Nausea or vomiting
Balance problems or dizziness
Double, fuzzy or blurry vision
Sensitivity to light or noise
Feeling sluggish, hazy, foggy or groggy
Confusion
Don’t “feel right”
Concentration or memory problems
http://www.sportsclinic.ca/
On-field or Sideline Evaluation
• If ANY of the previous signs & symptoms are present:
– Evaluation by licensed healthcare provider (LHCP); if none
available, safely remove, urgent physician referral
– Address first aid issues, use a sideline assessment tool
(SCAT3 or other), neurological exam (motor & sensory), cranial
nerve assessment & balance test
– NO same day return to play (RTP)
Immediate Management
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Unconscious patient
Obviously concussed patient
Concussion suspected patient
Other – when in doubt…
Why Monitor?
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Bleeding in the brain
Serial monitoring for deterioration of symptoms
Do not leave alone
If not transporting, discuss home care with parent/guardian
What to Monitor for Changes
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Consciousness
Pupil reaction
Reflexes
Strength
• Breathing patterns
• Sensations
• Movements
Decision cannot be made in isolation with one “test”
Borrowed from Michael McCrea, PhD, ABPP-CN
Based on the Evidence
• Imaging contributes little to the evaluation unless
suspicion of an intracerebral or structural lesion (skull
fracture) exists
• 80-90% resolve in 7-10 days
• Role of balance testing (BESS test) is valid & reliable
• No same day RTP for anyone, at any level
Management: Zurich 2012
Recommendations
• Cornerstone – physical and cognitive rest
• Initial 24-48 hours of rest in acute symptomatic phase
• Gradual school and social activities should precede RTP (w/o
significant exacerbation of symptoms)
• Graduated RTP protocol
• Role of low level exercise
• Role of meds
Return to Learn
• Process of return students back to the classroom
• Recommendation is that normal classroom activity MUST
precede return to play decision
• Requires teams working together
• Individualized to the student
Return to Play (RTP)
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NO same day RTP
Each step 24 hours
Must be asymptomatic
Approximately 1 week to complete
What about the 10-20% that don’t recover in 7-10 days?
Neuropsychological (NP) assessments
• Cognitive function assessment is important PART of the overall
assessment and RTP protocol
• In absence of NP testing, a more conservative approach for RTP
is needed
• Perform when asymptomatic, but can also be done in early stages
of injury
• Baseline not required, but may provide useful information (for all
tests)
Mental Health Issues
• Depression
• Anxiety
• May require short term
medication
Pre-participation Physical Exam
&
Concussion History
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Recognize known history
Recognize likely UNKNOWN history
Include all head, face and cervical spine injuries
Knowledge and honesty of all parties, especially the
student athlete
Modifying Factors
• Gender - not unanimous but may be risk factor
• LOC >1 minute may modify management
• Amnesia - duration of post-concussive symptoms more important
than amnesia
• Motor & Convulsive phenomena – no special treatment required,
use standard protocols
• Depression
• Dizziness in initial symptom set
Why Can’t They Participate with a
Concussion?
• Second Impact Syndrome
Children
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Under 13
Child SCAT3 – 5-12
Home & school management
Must be clinically completely symptom free
NO RTP same day
PREVENTION
Protective Equipment & Rules
• “There is little evidence supporting the use of specific helmets or
mouth guards to prevent concussions outside of specific sports
such as cycling, skiing and snowboarding.” Daneshvar, et.al. Clin Sports Med 2011
• Risk compensation due to equipment
• Proper technique & coaching – no substitute for this!
• Rule changes
• Violence in sport
• Education
NEW & ONGOING RESEARCH
What is New?
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How many is too many?
Sub-concussive forces over time (HITS)
Concussion Threshold?
Future of computerized neurocognitive testing
Blood tests
Detection of Tau in living brain – PET scan
Rest vs light activity during recovery
King Devick Test
Changing the Culture
Sports Culture for Athletes
http://www.cdc.gov/headsup/pdfs/resources/concussion_at_play_playbook-a.pdf
Heads Up Concussion - CDC Program
• Concussion at Play: Opportunities to Reshape the Culture
Around Concussion
– The way coaches talk about concussion influences young
athletes’ decisions to report concussion symptoms
– Young athletes feel pressure to hide their concussion
symptoms
– More likely to play with a concussion during a BIG game
– Health care providers and school professionals can help young
athletes successfully return to learn and play
http://www.cdc.gov/headsup/pdfs/resources/concussion_at_play_playbook-a.pdf
References
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Courson R. Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for
Secondary Schools and Colleges. J Ath Train. 2014;49(1):128-137
http://www.nata.org/sites/default/files/SportsMedicineManagement.pdf (accessed 9/29/15)
Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. Helmets and Mouth Guards: The Role of
Personal Equipment in Preventing Sport-Related Concussions. Clin Sports Med. 2011; 30(1): 145-163.
Giza C, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports:
Report of the Guideline Development Subcommittee of the American Academy of Neurology.
Neurology,2013;90:2250-2257. http://www.neurology.org/content/80/24/2250.full.pdf+html (accessed 9/29/15)
McCrory P, et al. Consensus Statement on concussion in sport: the 4th International Conference on Concussion in
Sport held in Zurich, November 2012. BrJSportsMed 2013;47:250–258.
Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The Effect of Coach Education on
Reporting of Concussions Among High School Athletes After Passage of a Concussion Law. Am J Sports Med 2014;
42(5): 1197-203. doi: 10.1177/0363546514521774
SCAT3, SCAT3 child and Pocket Concussion Recognition Tool available for reproduction on
http://www.sportsconcussion.com/concussion-management
ttp://www.nata.org/sites/default/files/SportsMedicineManagement.pdf (accessed 9/29/15)
http://www.cdc.gov/headsup/pdfs/resources/concussion_at_play_playbook-a.pdf (accessed 9/29/15)