Concussion in Sports:
A review of the AMSSM Position Statement
and AAN Guidelines
James W. Bryan IV, MD
Little Rock, AR
Concussion defined
 Concussion is a brain injury and is defined a a complex
pathophysiological process affection the brain,
induced by biomechanical forces.
 Several common features that incorporate clinical,
pathologic and biomechanical injury constructs that
may be utilized in defining the nature of a concussive
injury include:
Consensus Statement on Concussion in Sport: The 4th International
Conference, Nov 2012, Zurich
Concussion defined:
common features
 Caused by either a direct blow to the head, face, neck
or elsewhere on the body with an impulsive force
transmitted to the head
 Typically results in the rapid onset of short-lived
neurological function that resolves spontaneously
 Symptoms and signs may evolve over minutes to hours
 May result in neuropathological changes
 Reflect a functional disturbance rather than a structural
injury
 No abnormalities are typically seen on standard
neuroimaging studies
Consensus Statement on Concussion in Sport: The 4th International
Conference, Nov 2012, Zurich
Concussion defined:
Neurometabolic cascade
Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC,
Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co;
2000:80–100
Concussion defined:
Neurometabolic cascade
Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic
Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100
Concussion defined:
common features
 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
 In some cases the symptoms may be prolonged
 The majority of cases resolve in a 7-10 day period
 The recovery time frame may be longer in children and
adolescents
Consensus Statement on Concussion in Sport: The 4th International
Conference, Nov 2012, Zurich
Background
*First concussion symposium: Vienna, 2001
-International Ice Hockey Association, FIFA
(soccer), and the International Olympic
Committee
*Second symposium: Prague, 2004
-Sideline assessment tool (SCAT)
*Third symposium: Zurich, 2008
-SCAT revised (SCAT 2)
-Designed to follow US NIH consensus criteria
*Each produced a summary-and-agreement statement on
concussion in sport.
Background
 The Fourth Conference: Zurich 2012
 Used the same format as previously:






32 international experts
2 full days of new research presentations
Extensive structured discussion
Drafted a consensus paper, edited until all were in agreement
Updated version of SCAT (SCAT 3)-with 3 distinct tools
Final drafting of 12 critical review papers, co-published in
multiple journals
British Journal of Sports
Medicine April 2013; 47:
250-258
Panel included Stanley Herring and
Margot Patukian from AMSSM
American Medical Society for Sports Medicine
position statement: concussion in sport
 Kimberly G Harmon, Jonathan A Drezner, Matthew
Gammons, Kevin M Guskiewicz*, Mark Halstead, Stanley
A Herring, Jeffrey S Kutcher*, Andrea Pana, Margot
Putukian*, William O Roberts
 Endorsed by the National Trainers’ Athletic Association
and the American College of Sports Medicine
 Press release December 13, 2012
 British Journal of Sports Medicine April 2013, 47, 15-26
 Clinical Journal of Sport Medicine Jan 2013, 23 issue 1, 1-18
 [Asterisk indicates Zurich 2012 participants]
AMSSM Position Statement:
concussion in sport
--Purpose- To provide an evidence-based, best practices
summary to assist physicians with the evaluation and
management of sports concussion
 To establish the level of evidence, knowledge gaps
and areas requiring additional research
AMSSM Position Statement:
concussion in sport
--Importance- While directed toward sports physicians, it may help
other health care providers in the care of concussed
patients
 Care is ideally performed those with specific training
and experience—not dictated by specialty
 Sports physicians are trained to provide care from the
time of injury to return-to-play
Pathophysiology
 Both human and animal studies support the concept
of postconcussion vulnerability
 A second blow sustained before recovery results in
worsening metabolic changes within the neuron
 This concept is distinct from “second impact syndrome”
 The concussed brain is less responsive to usual
neuron activation
 Prolonged dysfunction may result from premature
cognitive activity or vigorous physical activity
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Incidence
 3.8 million sports related concussions annually in the
USA
 Estimated that up to 50% are unreported or
unrecognized
 Concussions occur in all sports
 Football, hockey, rugby , soccer, and basketball
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Risk factors for sports-related
concussion
 History of previous concussion
 The greater the number, severity, and duration of
symptoms predict a prolonged recovery
 In sports with similar rules, female athletes
experience a higher incidence of concussion
 Certain positions within a sport present a greater
exposure risk
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Risk factors for sports-related
concussion
 Pre-injury mental health conditions complicate the
diagnosis and management of concussion
 Youth athletes have additional considerations
 More prolonged recovery
 Greater susceptibility to concussion accompanied by
catastrophic injury
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Diagnosis of concussion
 Concussion is a clinical diagnosis
 Diagnosis is ideally made by a healthcare provider who is
 familiar with the athlete
 knowledgeable in the recognition and evaluation of
concussion
 Graded symptoms checklists [e.g. SCAT3]
 Objective tool for assessing a variety of symptoms
 Useful in tracking the severity of symptoms over serial
exams
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Diagnosis of concussion
 Standardized assessment tools
 Can provide a helpful structure in evaluation
 Limited valuation of the assessment tools is available
 Examples include






The Maddocks Questions
Standardized Assessment of Concussion (SAC)
Balance Error Scoring System (BESS, modified BESS)
SCAT2, SCAT3, SCAT3 Child, CRT (lay person)
NFL Sideline Concussion Assessment Tool
Glasgow Coma Score
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Diagnosis of concussion
 SCAT3
 http://bjsm.bmj.com/content/47/5/259.full.pdf+html
 SCAT3-CHILD
 http://bjsm.bmj.com/content/47/5/263.full.pdf+html
 Pocket Concussion Recognition Tool
 http://bjsm.bmj.com/content/47/5/267.full.pdf+html
Neuropsychological testing
 NP testing is an objective measure of brain-behavior
relationships
 More sensitive for subtle cognitive impairment than clinical
exam
 Should be used as part of a comprehensive management
strategy and not relied upon alone
 Ideal timing, frequency and type of NP testing is not
established
 Unknown if NP testing helps prevent recurrent concussion,
catastrophic injury, or long-term complications
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Neuropsychological testing
 Paper and pencil NP tests
 Can be more comprehensive
 Can test different domains and assess for other
conditions which may mask or complicate the
assessment of concussion
 May provide added value to assess cognitive function
and recovery
 Helpful in the management of patients with
prolonged symptoms and complicated courses
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Neuropsychological testing
 Computerized NP testing should be interpreted by
providers trained and familiar with





The type of the test
The individual test limitations
The reliable change index
The baseline variability
False-positive and false-negative rates
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Neuropsychological testing
CPT ® codes
 96118 Neuropsychological testing, interpretation and
reporting per hour by a psychologist ($92/unit)
 96119 Neuropsychological testing per hour by a
technician ($74/unit)
 96120 Neuropsychological testing by a computer,
including time for the psychologist’s interpretation
and reporting ($103)
 Formal NP testing, scoring, interpretation and
conference may require up to 4-8 hours
http://www.apapracticecentral.org/update/2012/11-29/medicare-payment.aspx, accessed 5/14/13
Return to class
 Students will require a period of cognitive rest
 May require academic accommodations
 Reduced workload
 Extended time to complete tests
 Protections afforded under Section 504 / ADA
AMSSM Position Statement: concussion in sport. Harmon KG,
Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26
Education
 Arkansas ACT 1435
 Sen. David Sanders/SB1158
 Rep. Gary Deffenbaugh
 Signed April 23, 2013
 Requires the State
Department of Health to
develop concussion protocols
to all youth athletes involved
in youth athletic activities
 Based on existing AAA
guidelines for sanctioned
sports in grades 7-12 enacted in
2012
As of April 2013, 47 states have
enacted legislation
Education
 “Heads Up” Tool Kit for
Youth Sports
 CDC
 Coaches, athletes and
parents
 Online videos
 Fact sheets, wallet cards
 NFLEvolution.com
 Promotion of the Lystedt Law’s three
tenets
 Inform and educate youth athletes,
their parents and guardians and
require them to sign a concussion
information form
 Removal of a youth athlete who
appears to have suffered a
concussion from play or practice at
the time of the suspected concussion
 Requiring a youth athlete to be
cleared by a licensed health care
professional trained the evaluation
and management of concussions
before returning to play or practice.
Education
 AMSSM
 2014 AMSSM 23rd Annual
Meeting
 April 5-9, 2014
 Hyatt Regency New Orleans
 New Orleans, LA
 Advance Team Physicians
Course
 Cosmopolitan Hotel Las Vegas,
NV December 5-8, 2013
• 2013 AAFP Scientific
Assembly: Concussion and
Minimal Brain Injury
• Thursday, September 26, 2013,
San Diego Convention Center
Summary of evidence-based guideline update:
Evaluation and management of concussion in
sports
Neurology; Published online before print
March 18, 2013
Christopher C. Giza, MD, Jeffrey S. Kutcher, MD,
Stephen Ashwal, MD, FAAN, Jeffrey Barth, PhD, Thomas S.D.
Getchius, Gerard A. Gioia, PhD, Gary S. Gronseth, MD, FAAN, Kevin
Guskiewicz, PhD, ATC, Steven Mandel, MD, FAAN, Geoffrey Manley,
MD, PhD, Douglas B. McKeag, MD, MS, David J. Thurman, MD,
FAAN and Ross Zafonte, DO
 Objective: To update the 1997 AAN practice parameter
regarding sports concussion focusing on 4 questions
AAN Guideline Update:
4 questions
 1. What factors affect
risk?
 2a.What diagnostic tools
identify those with
concussion and (2b)those
at increased risk?
 3.What clinical factors identify
those at increased risk for
severe/ prolonged early
impairments, neurological
catastrophe, recurrent
concussion, or chronic
impairment?
 4.What interventions enhance
recovery, reduce recurrent
concussion risk, or diminish
long-term sequelae?
Neurology, Mar 18, 2013
AAN Concussion Guidelines
 Preparticipation
Counseling
 Number and type of
previous concussions
 Symptoms and duration
 Other neurologic
conditions (e.g. seizures)
 Assessment
 Post-Concussion Symptom
Scale or Graded Symptom
Checklist
 Standardized Assessment of
Concussion
 Neuropsychological testing
 Balance Error Scoring System
 Sensory Organization Test
 Combination of measures
Neurology, Mar 18, 2013
AAN Concussion Guidelines
Management of suspected concussion
 Train inexperienced
licensed HCPs to use a
standardized assessment
tool
 Use standardized
assessment tools
 Warm handoff from
sideline HCP and clinical
HCP
 Obtain baseline scores
 Remove athlete from play
 No RTP without clearance
by licensed HCP
 Don’t perform imaging to
make concussion
diagnosis
 Do perform imaging to
rule out suspected TBI
Neurology, Mar 18, 2013
AAN Concussion Guidelines:
DIAGNOSED CONCUSSION
 No RTP until resolved &
asymptomatic
 Conservative approach for
youth and high school
 Assessment tools specific
for preteens
 Consider NP testing
 Individualize management
plan
 No indication for “absolute
rest”
Neurology, Mar 18, 2013
AAN Concussion Guidelines:
Multiple concussions
 Professional athletes:
 Refer for neurologic and
neuropsychological
evaluation
 Contact-sports with
chronic impairment:
RETIREMENT
 Amateur athletes:
 Formal neurologic/cognitive
assessment
 Offer risk factor counseling
Neurology, Mar 18, 2013
Conclusions
 Numerous organizations have published guidelines
regarding the management of sports-related
concussions
 Emerging consensus that education is a key factor
 Treatment considerations differ slightly between
youth, adolescent, and adult/professional athletes
 Inconclusive data regarding long-term risk