Current Concepts in
Concussion and
Concussion Management
Matt Leiszler, MD
Office-Based Sports Medicine Symposium
May 17, 2014
 I have no relevant financial disclosures.
OUTLINE
 Key Points
 Background
 Definitions
 Presentation
 Investigations/Studies
 Management
 Key Points
Key Points
 These are the CURRENT concepts—very likely to evolve
 80-90% of concussions resolve in 7-10 days
 Majority of concussions do not involve loss of consciousness
 No same day return to play
 Sports Concussion Assessment Tool (SCAT-3)
 New Imaging and Treatment options are on the horizon
 State of the Art treatment currently: Rest
Background
 Concussion
Background
 CDC estimates 1.6 – 3.8 million
concussions occur annually in
sports/rec activities in the US each
year
 33% of all concussions are sportsrelated (ages 5-19)
Background
Definition: Concussion (Zurich 2012)
“Concussion is a brain injury and is defined as a complex pathophysiological process
affecting 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 head
injury include:
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.
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.
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.
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.”
Definition:
 Concussion (AMSSM):
“A traumatically induced transient disturbance of
brain function and involves a complex
pathyphysiological process. Concussion is a
subset of mild traumatic brain injury which is
generally self-limited and at the less-severe end
of the brain injury spectrum”
Definitions
 Concussion and Traumatic Brain Injury
Definitions
 Post-Concussion Syndrome
 AMSSM Position Statement 2013:
 “Difficult to determine where concussion ends and
post-concussion syndrome begins”
 “Symptoms and signs that persist for weeks to
months”
 Zurich 2012: “Prolonged Symptoms”:
 Symptoms > 10 days
 10-20% of concussions
Definitions
 Second Impact Syndrome
 Numerous case reports, essentially
all under 22 years old
 Rare, but devastating event
 Unclear whether this has occurred
in an asymptomatic person
 Head trauma on already injured
brain  worsening metabolic
changes in the cells
 Coherent for 15-60 seconds  rapid
coma and respiratory failure
Concussion Legislation
Colorado’s
Senate Bill 40
“The Jake Snakenberg
Youth Concussion Act”
Signed March 29, 2011
Colorado Senate Bill 40
Senate Bill 40 Requirements
1. Training of coaches
2. Removal from play
3. Notification of a parent
4. Sign-off on return to play be medical
provider
Concussion Presentation
 Multiple manifestations
 No two concussions are exactly the same
 Headache most common symptom; dizziness second
 90% do not include loss of consciousness
Signs and Symptoms
Symptoms
 Randolph, et al (2009):
 12 Validated Symptoms: Concussion Symptom Inventory
• Headache
• Nausea
• Balance
problem/dizziness
• Fatigue
• Drowsiness
• “In a fog”
•
•
•
•
•
•
Difficulty concentrating
Difficulty remembering
Sensitivity to light
Sensitivity to noise
Blurred vision
Feeling slowed down
On-field/Sideline Evaluation
of Acute Concussion
 Should occur if concussion even suspected
 Player evaluated by physician or other licensed healthcare
provider
 If no healthcare provider available  remove from practice/play,
refer
 ABC’s, Exclude cervical spine injury
 After first aid issues addressed  Sideline assessment tool
 Do not leave player alone  monitor over a few hours
 A player with a diagnosed concussion should NOT be allowed
to return to play on the day of injury
 When in doubt—sit them out!
Sport Concussion Assessment Tool
SCAT 3
Symptoms
SCAT 3
SCAT 3
SCAT 3
Referral to Emergency Department?
 Worsening/Severe headache
 Deteriorating mental status
 Active vomiting
 Focal neurologic findings
 Numbness, tingling, weakness,
seizure, unequal pupils
Office or Emergency Department Evaluation
 Full history, detailed neurological exam
 Essentially perform a SCAT3
 Determine clinical status—improving or
deteriorating?
 Determine need for emergent neuroimaging in
order to exclude a more severe brain injury
involving a structural abnormality
Investigations/Studies
Investigations/Studies
 Postural stability testing
 Often returns to normal after 72 hours post-conc
 Force plate technology
 Balanced Error Scoring System
Investigations/Studies
 Imaging of the Brain
 CT, MRI—typically normal
 If suspicion of intracerebral or structural lesion
exists  Imaging
 Prolonged disturbance of conscious state
 Focal neurological deficits
 Worsening symptoms
Investigations/Studies
 Imaging of the Brain
 Alternative imaging
 Several methods being investigated
 Exciting area of research
Investigations/Studies
 Electrophysiological Recording Techniques
 Electroencephalogram (EEG)
 Evoked response potential (ERP)
 Cortical magnetic stimulation
 Reproducible abnormalities in postconcussive state
 Not all studies differentiate concussed
athletes from controls
Investigations/Studies
 Neuropsychological Assessment—Computer Testing
 Evaluating cognitive recovery
 Important component in overall assessment and
return to play
 Baseline testing useful
 Aids in clinical decision making—but not the sole
basis of management decisions
Investigations/Studies
 Neuropsychological Assessment
 Formal Neuropsych testing
 Trained Neuropsychologist
 Not required for all
 May be beneficial in prolonged symptoms
 Help identify other conditions
Investigations/Studies
 Genetic testing and Biomarkers
 Insufficient evidence for routine clinical use
 Apo E4, ApoE promotor gene, Tau polymerase
 IGF-1, IGF binding protein 2, Fibroblast
growth factor, Cu-Zn superoxide dismutase,
nerve growth factor, S-100
 Serum and Cerebral Spinal Fluid biomarkers
being evaluated
Management
 Cornerstone
REST
Management
 Rest
 Physical Rest
 No training, playing, exercise, weight lifting
 Exertion with ADLs
 Cognitive rest
 Minimize TV, extensive reading, video games
 Limit to exacerbation of symptoms
Management
 Return to school and social activities
 Encouraged
 School Accommodations
 Extra time or delay tests and quizzes
until student is asymptomatic
 Partial days
 CDC: educational materials for
teachers/administrators
Management
 Gradual resolution
 80-90% of concussions resolve in a short
period (7-10 days)
 Recovery may be longer in children and
adolescents
 May require multiple office visits
Recovered?
 Everyone says they “feel fine”
 Ask:
1. “On a scale of 0–100%, how do you feel?”
2. “What makes you not 100%?”
3. Symptom Checklist—SCAT 3
Graduated Return to Play Protocol
Rehabilitation stage
1. No activity
2.Light aerobic
exercise
3.Sport-specific
exercise
4.Non-contact training
drills
5.Full contact practice
6.Return to play
Functional exercise at each stage of
rehabilitation
Objective of each stage
Symptom limited physical and cognitive Recovery
rest.
Walking, swimming or stationary
Increase HR
cycling keeping intensity < 70% MPHR
No resistance training.
Skating drills in ice hockey, running
drills in soccer. No head impact
activities.
Progression to more complex training
drills e.g. passing drills in football and
ice hockey.
May start progressive resistance
training
Following medical clearance participate
in normal training activities
Add movement
Exercise, coordination,
and cognitive load
Restore confidence and
assess functional skills by
coaching staff
Normal game play
 24 Hours per step (so almost a week for full protocol)
 If symptoms recur return to previous level
 Evaluation by health care provider required for school age athletes
Difficult cases—persistent symptoms
 Symptoms >10 days
 Sports-related concussions less likely to
result in PCS
 Consider other issues:Depression? Chronic
headaches? Learning disorders?
 Multidisciplinary clinic
 Children’s Hospital Complex Concussion Clinic
 Sub-symptomatic exercise may be beneficial
Management
 Pharmacotherapy
 Useful for prolonged symptoms
 Sleep disturbance
 Anxiety
 Anti-depressants
 Upon return to play should not be on medications that
could mask symptoms
 Avoid NSAIDs in first 48-72 hours
 TCAs, Amantadine, Methylphenidate commonly reported as
being used for management
 Antioxidants?
Other Treatment
 Vestibular Therapy
 Balance Therapy
 Transcranial LED—Chronic TBI
 Red and Near-Infrared LED
applied transcranially
Chronic Sequelae?
 Chronic cognitive dysfunction
 Chronic Traumatic Encephalopathy
 Chronic Neurocognitive Impairment
 CTE unknown incidence in athletic populations, cause/effect not
yet demonstrated between CTE and concussions or exposure to
contact sport
 Acknowledge potential for long-term problems in all athletes
To Be Determined
Prevention
 Protective equipment
 Mouth guards
 Prevent oral injuries
 Head gear and helmets
 Reduce impact forces, not concussions
 Reduce head and facial injury
 Cervical muscle strengthening?
Other Issues
 Rule Changes
 Checking
 Limiting contact practices
 Heading in soccer (50% of concussions are
due to arm to head contact)
 Education of athletes, parents, coaches
 Awareness of concussion symptoms and signs
 Web-based resources, social media
Questions
 How many concussions is “too many”?
 Who will develop CTE? Number of hits? More “significant”
concussions?
 Evolving role of advanced imaging?
 What treatments may prove beneficial in concussion?
 Validation of tools?
 Prevention?
Key Points
 These are the CURRENT concepts—very likely to evolve
 80-90% of concussions resolve in 7-10 days
 Majority of concussions do not involve loss of consciousness
 No same day return to play
 Sports Concussion Assessment Tool (SCAT-3)
 Imaging and Treatment options are on the horizon
 State of the Art treatment: Rest
References

Consensus statement on concussion in sport: the 4th International Conference on Concussion in
Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.

McCrory P, Johnston K, Meeuwisse Wet al. Summary and agreement statement of the 2nd International
Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196–204.

Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents
following sports-related concussion. Reddy CC, Collins M, Lovell M, Kontos AP. J Head Trauma Rehabil.
2013 Jul-Aug;28(4):260-5.

Management strategies and medication use for treating paediatric patients with concussions. Kinnaman
KA, Mannix RC, Comstock RD, Meehan WP 3rd. Acta Paediatr. 2013 Sep;102(9):e424-8.

Vestibular and balance treatment of the concussed athlete.Aligene K, Lin E. NeuroRehabilitation.
2013;32(3):543-53.

Should we treat concussion pharmacologically? The need for evidence based pharmacological
treatment for the concussed athlete. McCrory P. Br J Sports Med. 2002 Feb;36(1):3-5.

American Medical Society for Sports Medicine position statement: concussion in sport. Harmon KG,
Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A, Putukian M, Roberts W;
American Medical Society for Sports Medicine. Clin J Sport Med. 2013 Jan;23(1):1-18.
Thank You!