Concussion in Sports
Kevin deWeber, MD, FAAFP
Primary Care Sports Medicine Fellowship Director
USUHS/Dewitt Army Hospital
August 2010
Zurich Guidelines


Consensus Statement on Concussion in
Sport. 3rd International Conference on
Concussion in Sport Held in Zurich,
November 2008.
Clin J Sports Med May 2009; 19(3):185.
Concussion - Definition


Complex pathophysiological process
affecting the brain
Induced by traumatic forces


Direct or Indirect
Functional Disturbance rather than
Structural Injury

No abnormality on standard structural
neuroimaging
Pathophysiology

Neuronal dysfunction




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Ionic shifts
Altered metabolism
Impaired connectivity
Changes in neurotransmission
Neuropathological Changes

No evident structural changes
Classification
Simple
vs
Complex
Signs and Symptoms
One or more of the following:

Symptoms




Physical Signs


Irritable, nervous
Cognitive Impairment


Loss of Consciousness, Amnesia, motor/sensory deficits
Behavioral Changes


Somatic: Headache, pressure, neck pain, n/v, vision changes, balance
problems, light or noise sensitivity, “don’t feel right”
Cognitive: Feeling “In a Fog”, difficulty concentrating or remembering,
confusion
Emotional: more emotional, sadness,
Slowed reaction times, memory or concentration deficits
Sleep Disturbance

Drowsiness, difficulty falling asleep
What proportion of athletes recognize
symptoms as being due to a concussion?
1.
2.
3.
4.
5.
1 of 10
1 of 5
1 of 3
1 of 2
Practically all


1 of 3
Implication: YOU
as the physician
need to be
LOOKING for
athletes w/
concussion
On the Field Management

If unconscious, assume cervical spine
injury


Stabilize c-spine
Don’t rush to get the athlete off the field,
but also don’t do your entire neuro/mental
status exam on the field either
Sideline Management

Place the athlete in a area where he/she
can sit, not be bothered by other athletes
and coaches, and can hear questions
Sideline Management



Notify coach that the athlete is out until
further notice
Consider giving the athlete a few minutes
to regain his composure
Observe the athlete


blank stare, shaking head, abnormal body
language
Assess with brief concussion tool



Maddocks questions
SAC
Pocket SCAT2





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Brief neuro exam
Symptom score
Glascow Coma scale
Maddocks game
questions
Short Assmt of
Concussion (SAC)
Balance
Coordination
Concussion or not?

YES – if ANY of the following:

Symptoms


OR
Signs (LOC, neuro deficits, cognitive deficits)
Pearl

Once a concussion has been diagnosed,
take and hide the athlete’s
helmet/headgear to prevent him from
returning to the game
1.
2.
3.
4.
5.
Q: For a concussion with no loss of
consciousness and resolution of symptoms in
less than an hour, when is return to play
safe?
Immediately
Second game of double-header
In 24 hours
In 10 days
Determined on case-by-case
basis
Return to Play Rules

Individualized RTP decisions




no cookie-cutter RTP guides
NO ONE returns while still symptomatic
Athletes must be asymptomatic both at
rest, w/ cognition, and w/ exertion
Must have normal cognitive function

“There is data...that, at the collegiate and
HS level, athletes allowed to RTP on the
same day may demonstrate NP deficits
post-injury that may not be evident on the
sidelines and are more likely to have
delayed onset of symptoms.”

…Zurich guidelines 2009
Symptoms may be delayed
or recurrent

Many athletes may seemingly “normalize” within
minutes of an injury, but then have a recurrence
and potential worsening minutes to hours later
 IMPLICATION:
very rare
same-day RTP
Explain Risks of Premature RTP
before full recovery

2nd impact syndrome




Death
Higher risk in young athletes
2nd concussion, more severe
Prolonged symptoms
Staged Return To Play:
24 hours for each stage
1.
2.
3.
4.
5.
6.
Cognitive and Physical Rest until
asymptomatic
Light aerobic exercise
Sport-specific aerobic exercise
Noncontact drills; light resistance training
Full-contact training if medically cleared
Game play
Staged Return to Play



24 hours for each stage
Progress to next stage ONLY if
asymptomatic
If sxs recur w/ exertion:



Return to the previous stage
Rest for an additional 1-3 days
Return to stage 1
OR
OR
f/u Management Issues



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Comprehensive evaluation
Imaging?
Serial assessments until normalized
Neuropsych testing
Symptom treatment
Activity progression
Return to play determination
In-Office (or ED)
Comprehensive Evaluation

Comprehensive H&P and detailed
neuro exam by HCP




Clinical status determination


Mental status
Cognitive function
Gait and balance
Improvement vs deterioration
Determine if emergent neuroimaging
is needed
Immediate Imaging?

Consider an immediate CT scan under the
following conditions:





Prolonged loss of consciousness (>60 seconds)
Post-concussive prolonged seizures
Major neurological deficits, especially motor
deficits
Significant lethargy or rapid/progressive
worsening of symptoms
Computed tomography and MRI rarely
have a role in the diagnosis of
uncomplicated concussions
“Concussion Modifiers”
Things that may influence eval, mgmt, and may
predict prolonged recovery






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Severe symptoms, or duration >10d
LOC > 1 minute, or amnesia
Concussive convulsions (other than immediate)
Repeated concussions, esp close together or
progressively requiring less force
< 18 years age
Co-morbidities: migraine, depression, ADHD, LD, sleep
disorders
Psychoactive drugs, anticoagulants
Dangerous style of play
Contact/collision sport, high sporting level
?? Female gender
Implications for + “Modifiers”



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Neuropsych testing more important
Balance assessment more important
Neuroimaging more important
Multi-disciplinary management
Post-Game Management

Find out the plans of the athlete for the evening




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Who can monitor him?
Suggest strict rest
Supply the athlete and/or roommate/parents with
phone numbers for the physician or ATC
Give copy of SCAT2 insgtructions
Schedule follow-up with ATC or MD


Next day for moderate-severe concussions
1-3 days for mild concussions
Monitor for cognitive recovery with
Neuropsych Testing


One of the cornerstones of concussion
evaluation
Tools available

Sport Concussion Assessment Tool (SCAT2)


Poor-man’s method
Computerized testing--$$ but GOOD
ImPACT (Immediate Postconcussion Assessment
and Cognitive Testing)
 Headminder
 CogSport
 ANAM (Automated Neuropsych Assmt Metrics)

Neuropsychological Testing


OBJECTIVE evaluation of function
Baseline testing is VERY helpful


Allows comparison of baseline to post-injury
tests
If baseline testing not available, compare to
age-matched controls and a percentile
generated
Neuropsychological Testing

When to test and how often?

most useful when athlete becomes asymptomatic

may be useful for the symptomatic STUDENT athlete
to help plan school & home mgmt
 Neuropsychological
tests should
neither be the primary
determinant regarding return-toplay, nor should they take the
place of good clinical judgment
Concussion Treatment
Symptom Treatment
REST!...
the
only known effective
treatment for a
concussion


Encourage frequent
breaks from studying
Encourage good
hydration and regular
meals to avoid
dehydration and
hypoglycemic-related
headaches
Medications

Tylenol may be used to
treat headache symptoms
if there is no immediate
intent to return-to-play

NSAIDs safety?

No sedating meds
Managing Exercise


1. Rest completely until asymptomatic and NP
test suggests resolution
2. light aerobic exercise


Preferably indoors, e.g. stationary bike
3. sport-specific exercise

E.g. running, skating, swimming
Managing Exercise
(continued)

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4. non-contact sport drills
5. Full-contact practice


(if medically cleared)
6. Competition
Managing Exercise: Principles


To advance to the next stage, the athlete has to
remain asymptomatic
If symptoms develop, then consider:




Rest for an additional 1-3 days
Return to the previous stage
Return to stage 1
OR
OR
Consider making each stage 2-3 days if
returning from a more severe concussion or if
multiple concussions during that season
Special Populations
Q: Compared to adults, children’s and adolescents’
recovery from concussion can be described as…
1.
2.
3.
Slower recovery
 Slower recovery
Same rate of recovery
Faster recovery
High school athletes’ recovery
from concussion
90
80
70
60
50
% returned
40
30
20
10
0
1 week
2 weeks
3 weeks
Collins M, et al. Neurosurg 2006
Pediatric Athletes (<18)
 AAP
recommends
“conservative” management
 NO
return to play on same
day
 Seriously, NO return to play
on same day
Student Athlete Management



COGNITIVE REST
If sxs recur with
cognitive activity,
time off school may
be needed
Involve teacher,
school nurse,
principal, coact
Student Athlete Management


Trial and error; no students alike
Tailor activities to minimize sxs

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Drive to school
Reduce length of school day
Rest periods as needed
Reduce homework
Longer time for tests; delayed tests
Minimize background noise & excessive
light
Elite vs.


Non-Elite Athletes
Manage using SAME tx and RTP
paradigm
Recommend formal baseline NP
screening in high-risk sports
In-Game Return-to-Play
is CONTROVERSIAL

Only clear an ADULT, PROFESSIONAL athlete for
return to same game under the following
conditions:





Initial presentation was mild (no LOC)
Symptoms completely resolve within only a few
minutes (less than 5-10)
All neurological testing is normal
Sport-specific drills (running, cutting, kicking,
catching) reveal normal speed and coordination and
do not cause any symptoms
You truly believe the athlete is being honest with
regards to the reporting of his symptoms
Return to Play Decisions:
The tough cases

Three or more concussions: end the
season


At least 3 months before resuming any
contact sports
Decreasing levels of trauma producing
concussion

End the career
Robert Cantu, expert opinion, Curr Sports Med Rep 2009
Persistent Cases
(>2-3 weeks)


Multidisciplinary approach needed
Physician



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Control HA’s with meds
Referrals
Full neuropsych testing
Refer for specific treatment of identified
problems
The Role of Imaging

PET scans, SPECT scans and
functional MRI may be on the horizon to
assist with concussion diagnosis, severity
grading and return-to-play
NCAA Concussion Management
Memo to Head ATCs April 2010


Must have concussion mgmt plan on file
Athletes w/ suspected concussion WILL BE
removed from practice/competition and be
evaluated



Unchallengeable mgmt authority by
healthcare providers
Baseline assessments required


No RTP that day
MIN: Symptoms, cognitive fxn, balance fxn
Final RTP authority: Tm Physician/ designee
Conclusion

Individualize your approach with each athlete



Concussion management is not “cookie-cutter” medicine
Disqualifying an athlete from competing for the
remainder of the season is difficult, and must be
individualized and based on multiple factors
Determine who your concussion experts are


Who manages the most?
Many neurologists and neurosurgeons rarely see or
manage athletes with concussions
Questions?