Sports related concussion:
Assessment and management
P. Jeffrey Ewert, Ph.D., ABPP
 Carolina Neuroservices/The Head Injury
Center
 Neuropsychologist – Charlotte Checkers
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Definition of Concussion adopted
by the NHL
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Caused by direct blow to the head, face, neck
of shoulders with impulsive force transmitted
to the head
Results in rapid onset of short-lived
impairment that usually resolves rapidly
Neuropathological changes may result, but
results are usually functional, not structural
Results in a graded set of clinical symptoms
that doesn’t definitely cause uncsness.
Resolution of symptoms typically take
sequential course, but some cases are
prolonged
No structural changes seen on neuroimaging
Observable Concussion Signs
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Loss of consciousness
Slow to get up following hit
Motor incoordination/balance problems
Blank or vacant look
Disorientation
Clutching of head after hit
Visible facial injury in combo with any of above
Concussion symptoms
(player reported)
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Headache
Dizziness
Balance or coordination problems
Nausea
Amnesia for events around injury
Cognitive slowness
Photo/phonosensitivity
Disorientation
Visual disturbance
Tinnitus
Incidence
1990s - 300,000 in United States
 2000s - 1.6-2.3 million
 One-half of sports concussions go
unrecognized
 90% of sports concussions have no loss of
consciousness
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Assessment
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SCAT2
-Used for serial testing
-Contains both symptom checklist and
cognitive evaluation
Computerized neurocognitive testing
-ImPact
-Headminder
Neuropsychological testing
-Specific tests vary, but have better reliability
NHL postconcussion battery
Baseline ImPact testing
 Postinjury ImPact testing and
neuropsychological testing
 Testing repeated once a week, until player
returns to baseline and is asymptomatic
upon rest and exertion (both cognitive and
physical)
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Post Injury Management
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No return to play if symptomatic
Limited cognitive/physical exertion when
symptomatic
Graded increase in exertion over time
Adolescents take longer to recover (13-15) and
should be monitored more closely
Neuropsychological testing recommended in 3
weeks if not returned to normal
Balance testing recommended if not returned to
normal
Academic Accommodations
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Homebound instruction if student cannot
manage school
Limit homework, reading assignments
Make tests multiple choice due to memory
impairment
Only one test per day
Provide teacher notes
Return to school first part-time, then increase
to full-time, dependent upon mental stamina,
memory and concentration
Untimed tests
Separate testing environment
Preferential seating
Gfeller-Waller Concussion
Awareness Act
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All coaches, school, nurses, athletic directors,
students and parents receive concussion and
head injury information each year
Athletes exhibiting signs or symptoms
consistent with a concussion injury shall by
removed from play or practice and not return
to participation until cleared by a medical
professional
Each school must develop an emergency
action plan to deal with serious injuries. Plan
must be in writing and reviewed by an athletic
trainer certified in NC and approved by the
principal
Schools must maintain complete and accurate
records of compliance
Controversies (of course)
Randolph and Kirkwood (2009)
PERMANENT BRAIN INJURY OR DEATH
 Over last 10 seasons in American football,
 50 cases of permanent disability and 38
deaths
 Majority of deaths from subdural
hematomas
 Risk of permanent injury is 1 per 20,500
player seasons (per year)
 Squad of 100 football players, 1 injury
every 205 seasons
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Controversies cont.
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SECONDARY IMPACT SYNDROME
Only 17 reported cases, 5 involved repeat
injury. All repeat injuries within 7 days
Recent study of 18 cases found thin layer of
subdural hematomas in all cases
Underlying vulnerability causes this outcome,
possibly calcium channel subunity gene
mutation (familial hemiplegic migraine)
Delayed swelling found in children after 1
injury in 16% of cases, that were not sports
related
Only 1 case of delayed swelling in American
football in last 10 years
Controversies (cont)
SAME SEASON REPEAT CONCUSSIONS
 2 studies indicate risk of same season
concussions is the same for repeat
concussions as it is for single concussions
(3-6%)
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LATE LIFE CONSEQUENCES OF
REPEAT CONCUSSIONS
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Cognitive reserve ( more education, higher
cognitive demands of employment and increased
physical and mental activity during aging) delays
neurodegenerative disorders
Cognitive reserve decreased by multiple
concussions and subconcussive blows
Possible increase in DAT in retired NFL players
related to concussion
Conclusions
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CT/MRI imaging important to rule out
hematomas
Prolonged recovery requires a NP eval to rule out
coexisting conditions, including malingering
Computerized testing is not enough, due to
limited reliability. ImPact is only a tool, and does
not replace an experienced clinician, and
treatment team.