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Concussion:
Current Evaluation and
Management Guidelines
David M. Harsha, M.D.
St. Vincent Sports Performance
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What is new?
• New State Law for concussion
management
• Much heightened awareness of long-term
effects
– NFL players and lawsuits
• Increased public awareness
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SENATE ENROLLED ACT No. 93
AN ACT to amend the Indiana Code concerning education
• Before July 1, 2012
– Requires the department of education disseminate
guidelines, information sheets, and forms to school
corporations for distribution to schools to inform and
educate coaches, student athletes, and parents of
student athletes of the nature and risk of concussions
and head injuries.
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SENATE ENROLLED ACT No. 93
AN ACT to amend the Indiana Code concerning education
• Before July 1, 2012
– Requires that a high school student athlete and the
student athlete's parent be given information
concerning head injuries and concussions and return
a form acknowledging receipt of the information to the
student athlete's coach each year before beginning
practice for a sport.
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Indiana Department of Education
• Provided “Heads Up-A Fact Sheet for Athletes” and
“Heads Up-A Fact Sheet for Parents” to meet this
requirement.
• Provided the “Concussion Acknowledgment and
Signature Form for Student Athletes and Parents” to
record receipt of this information.
• Schools can develop their own forms
• Forms should be provided and completed annually.
– Coaches are responsible for collection and storage of all forms.
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SENATE ENROLLED ACT No. 93
AN ACT to amend the Indiana Code concerning education
• Before July 1, 2012
– Requires that a high school student athlete who is
suspected of sustaining a head injury or concussion
be removed from play at the time of the injury.
Provides that the student athlete may not return to
play until the student athlete has been evaluated and
received written clearance from a licensed health care
provider trained in evaluating head injuries.
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IHSAA
• Clarifications:
– Game Officials may request player
assessment by a healthcare professional if
they suspect concussion.
– If healthcare professional confirms athlete did
not sustain a concussion, head coach may
advise officials and athlete may reenter
competiton.
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IHSAA
• Designated health care professional does
not clearly athlete for return:
– Only an M.D. or D.O. may clear the individual
to return to competition
– The clearance must be in writing
– The clearance may not be on the same date
on which athlete was removed from play
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IHSAA
• SEA 93 states that only a licensed healthcare
provider trained in the evaluation and
management of concussions and head injuries
may provide a release for return to play
– Hold a license to practice in their field
– He listed as a healthcare provider in Indiana code
– Be trained in the evaluation and management of
concussion and head injuries
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SENATE ENROLLED ACT No. 93
AN ACT to amend the Indiana Code concerning education
• Before July 1, 2012
– Provides that a health care provider who, as a
volunteer in good faith and gratuitously, provides
head injury evaluations to student athletes has
immunity from civil liability for acts or omissions
arising from the evaluations, except for gross
negligence or willful or wanton misconduct
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Traumatic Brain Injury (TBI)
► Silent epidemic
► Under reporting
► Under recognized
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Concussions in Sports and
Recreational activity (TBI)
3.8 million
new cases each year
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Traumatic Brain Injury (TBI)
50%
MVA
(adult and pediatric)
30%
Sports/Recreation
20%
Violence
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Concussion Epidemiology
• Highest incidence
rates by athlete
exposure
–
–
–
–
Football
Ice Hockey
Soccer
Lacrosse
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Concussion Epidemiology
• Competition
Concussion rates are
consistently higher
than practice rates
• In sports with same
rules (BB and
soccer), incidence
rates higher in
females
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Athletic Head Injury: Incidence
► Head injury 2X as common as neck injury
► 20% of athletes affected each year
► 43% head to head
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Athletic Head Injury: Incidence
► 33% head to ground
► Accounts for 3-5% of all HS sports
injuries
► Low reporting
► Player not aware of significance of
symptoms
► Wants to avoid disqualification
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Risk Factors
Increased body size
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Risk Factors
Increased Speed
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Risk Factors
Higher Skill Level
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Risk Factors
Helmet Used as Weapon
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Risk Factors
Poorly Fitting Equipment
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Risk Factors
May prolong or complicate recovery
– History of multiple concussions
• Number, proximity and severity
– Prolonged LOC- (>1 minute)
– Age
• Youth and Adolescent
– Susceptibility
• Concussions occurring with lower impact or
requiring longer to recover
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Risk Factors
May prolong or complicate recovery
– Preexisting Conditions
•
•
•
•
•
•
Migraine
ADD, ADHD
LD
Depression
Anxiety/panic attacks
APOE Promoter gene ?Tau genotypes
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What is a
concussion
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Concussion Defined
► Complex pathophysiological process affecting the
brain, induced by traumatic biomechanical forces.
► Direct blow to head, face, neck or elsewhere
on the body with “impulsive” force transmitted
to the head
► Rapid onset of short-lived impairment of
neurological function that resolves
spontaneously, in most cases in 7-10 days
► Acute clinical symptoms largely reflect a
functional disturbance rather than a structural
injury
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Concussion Defined
► May or may not involve loss of consciousness.
► Prolonged post-concussive symptoms in a
small percentage of cases
► No abnormality on standard structural
neuroimaging studies
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Pathophysiology
• Imparted linear and rotational accelerations to
the brain
• No currently known threshold for concussive
injury because of modifying factors
–
–
–
–
Concussion hx
Neck strength
Anticipatory reaction
Varying frequency and locations of impact
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Pathophysiology
• Alterations in intracellular/extracelluar glutamate,
potassium and calcium
• Relative decrease in cerebral blood flow in the
setting of an increased requirement for glucose
(hyperglycolysis)
• Mismatch in metabolic supply and demand may
potentially result in cell dysfunction and increase
vulnerability of cells to second insult
Figure Neurometaboli...
Ω-3 Polyunsaturated Fatty Acids and
Concussions: Treatment or Not?
Trojian, Thomas H.; Jackson, Eric
Current Sports Medicine Reports.
10(4):180-185, July 2011.
doi: 10.1249/JSR.0b013e31822458d5
Figure: Neurometabolic cascade after traumatic
injury. 1. Nonspecific depolarization and
initiation of action potentials. 2. Release of
excitatory neurotransmitters (EAA). 3. Massive
efflux of potassium. 4. Increased activity of
membrane ionic pumps to restore homeostasis.
5. Hyperglycolysis to generate more adenosine
triphosphate (ATP). 6. Lactate accumulation. 7.
Calcium influx and sequestration in
mitochondria leading to impaired oxidative
metabolism. 8. Decreased energy (ATP)
production. 9. Calpain activation and initiation
of apoptosis. A. Axolemmal disruption and
calcium influx. B. Neurofilament compaction via
phosphorylation or sidearm cleavage. C.
Microtubule disassembly and accumulation of
axonally transported organelles. D. Axonal
swelling and eventual axotomy. AMPA, αamino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; Ca2+, calcium; Glut, glutamate;
K+, potassium; Mg2+, magnesium; Na+, sodium
(Reprinted from Giza CC, Hovda DA. The
Neurometabolic Cascade of Concussion. J Athle
Train. 2001; 36(3):288-35. Copyright © 2001
National Athletic Trainers' Association. Used
with permission.)
Copyright © 2012 Current Sports Medicine Reports. Published by Lippincott Williams & Wilkins.
30
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Concussion Grading Systems
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Controversies in Guidelines
► Lack of scientific method in guidelines
► No data to support return to play guidelines
► Standard use for all groups and playing levels
► Does not account for individual variation in
symptoms and vulnerabilities to concussion at
different ages
► LOC grades concussions
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Summary Consensus Statements
► Concussion grading scales abandoned
► Combined measures of recovery to determine injury
severity and or prognosis
► Individually guide return to play decisions
► International Conference on Concussion in Sport
► Vienna 2000
► Prague 2004
► Zurich 2008
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Team Physician Consensus Statement
2011
• Published in MSSE and other publications
• Includes guideline, sideline assessment tool, and Postinjury care form
• 6 major organizations participated
–
–
–
–
–
–
AAFP
ACSM
AAOS
AMSSM
AOSSM
AOASM
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Zurich 2008 Consensus Statement
► Focus questions are Foundation of statement
► Acute simple concussion
► Return to play issues
► Complex concussion and long-term issues
► Pediatric concussion
► Future directions
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Concussion Evaluation
Assessment of range of domains
Clinical
Symptoms?
Behavior?
Physical
Signs?
Balance?
Sleep &
Cognition?
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Suspect Concussion if ANY
► Symptoms (headache)
► Physical Signs (loss of
consciousness)
► Behavioral changes
► Balance
► Cognitive impairment
► Sleep disturbance
or More!
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Concussion symptom scale
•
•
•
•
•
•
•
•
•
•
Headache
Nausea/vomiting
Drowsiness
Balance problems
Dizziness
Fatigue/low-energy
Confusion
Feeling foggy
Difficulty remembering
Difficulty concentrating
•
•
•
•
•
•
•
•
•
•
•
•
Feeling slowed down
Sensitivity to noise
Sensitivity to light
Blurred vision
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep
Sadness
Nervous or anxious
Feeling more emotional
Irritability
Numbness or tingling
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On-field or Sideline Evaluation
of Acute Concussion
► Player should be medically evaluated on site with
attention to C-spine injury
► Appropriate disposition of player must be
determined by treating healthcare provider
► If no healthcare provider available, player should
be safely removed from practice or play and
urgent referral to a physician arranged
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On-field or Sideline Evaluation
of Acute Concussion
► Assessment of concussive injury with SCAT2 or
similar tool
► Player should not be left alone following injury
► Serial monitoring for deterioration over several
hours
► Concussed player should not be allowed to
return to play on the day of injury
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Same-Day Return to Play
► Evidence that NFL football players RTP more
quickly without risk of recurrence or sequelae
► Evidence shows collegiate and high school
athletes allowed to RTP same day may
demonstrate NP deficits post injury that may
not be evident on sidelines
► Children should not be returned to practice or play
until completely symptom-free, which may
require a longer time frame than adults
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Sideline Cognitive Function
Maddock’s questions:
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Sideline Cognitive Function
Standard orientation questions
(time, place, person)
unreliable!
Concussive symptoms might be
delayed several hours!
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Office Medical Assessment
► History and neurological examination
►Focus on Mental status, cognitive function,
gait and balance assessment
► Determine need for emergent
neuroimaging
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Neuroimaging
► Brain CT or MRI contributes little to concussion
evaluation
► Obtain when suspicion of intracerebral structural
lesion exists
► Prolonged disturbance of conscious state
► Focal neurological deficit
► Worsening symptoms
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Balance Assessment
► Office assessment of gait and balance
► Modified BESS balance testing
► Double leg stance
► Single leg stance
► Tandem stance
►Number of errors in 3 20-sec tests
►Maximum of 10
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Computerized NP Testing
► Developed in response to time and cost
demands, as well as limitations in NP expertise
► Modified from standard pencil/paper tests to best
assess changes seen in concussion;
► Attention and concentration
► Cognitive processing (speed & efficiency)
► Learning and memory
► Working memory
► Executive functioning
► Verbal fluency
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Neuropsychological (NP) Assessment
► Cognitive recovery occasionally precedes or more
commonly follows symptom resolution
► Suggests that assessment of cognitive function an
important component in any return to play protocol
► NP testing usually done when symptom-free
► NP assessment should not be sole basis of
management decisions
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Neuropsychological (NP) Assessment
Multiple web-based tools available
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NP Assessment
► ImPACT
► Computerized neuropsychological battery
► Baseline and post-concussive testing
► Used by NFL, NHL
► Certification process
► Credentialed ImPACT
Consultant (CIC)
► Cogstate
►
Axon Sports
►Used by the NBA, WNBA
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NP Testing Recommendations
► Use NP testing when available
► Once you use it, you can’t imagine not
having it!
► Baseline test for high risk sports
► Computerized tests + additional P/P tests
ideal
► Establish relationship w/ Neuropsychology for
high risk or complicated patients
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NP Testing Recommendations
► Repeat tests every 6mo - 1yr for those <15 yr to
account for developmental changes in cognition
► Use some form of cognitive tests during initial
assessment and follow-up care of the injured
athlete
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NP Testing Recommendations
► Do not allow symptomatic athletes to RTP
► Follow up NP tests once athlete asymptomatic
► Repeat as necessary if not back to or above
baseline, understanding limitations of tests used
► Rely on clinical markers, burden & duration of
symptoms, and athletes individual history of prior
concussion to make RTP decisions.
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Acute Concussion Management
► Should not be left alone for 24-48 hrs
► Wake concussed athlete every 2-3
hours during the night to assess
arousability and gross cognitive function
► Avoid NSAIDs (Aleve, ibuprofen, Motrin,
Advil, aspirin) in the first 24-48 hrs due to
increased bleeding risk
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Acute Concussion Management
► Avoid narcotics in the first 24-48 hrs as
they impair ability to assess patient
► Tylenol for headache pain if needed
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Concussion Management
► Cornerstone of management is physical and
cognitive rest until symptoms resolve, followed
by a graded program of exertion prior to return to
play (RTP)
► Activities that require concentration and
attention may exacerbate symptoms and
possibly delay recovery
► Consider limiting children’s scholastic and
cognitive stressors such as text messaging
and video games
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Acute Concussion Management
• Fish oil
– Ω3 PUFA, especially DHA
• Animal model evidence is convincing that
especially DHA is beneficial after mild traumatic
brain injury
• Evidence is missing in humans. Potential benefit
seems to be greater than risk yet caution should
be used. Further research needed to determine
clinically measurable benefits
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Return to Play
Step-wise symptom limited program
Rest until
asymptomatic
(physical and
mental)
Non-contact
training drills
(resistance training)
Light aerobic
exercise
Sport specific
exercise
(stationary bicycle)
Full contact
training after
medical
clearance
Return to
competition
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Return to Play
Approximately 24 hrs (or longer) for each stage,
if symptoms recur, return to previous asymptomatic level and try to progress after 24 hrs
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Postconcussion syndrome
• Persistent postconcussion symptoms
lasting 3 months or longer
• Indicator of concussion severity
• Absolute contraindication to return to play
• Increased risk of depression
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Postconcussion syndrome
• Evaluation
– Neuropsychological evaluation
– Consider MRI
• Treat
– Headaches
– Depression
– Exercise recommendations
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Complications of Concussions
► Second impact syndrome
►Occurs within minutes of concussion in
athletes still symptomatic from prior brain injury
►Vascular engorgement leads to massive
increase in intracranial pressure and brain
herniation resulting in severe brain damage or
death
►May occur with associated small subdural
hematoma
►Except for boxing, most cases in literature in
adolescent athletes.
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Complications of Concussions
► Chronic traumatic encephalopathy
►Progressive neurodegenerative disease
(tauopathy) caused by total brain trauma
►Incidence and prevalence not known
►Diagnosed only after death
►NFL player Registry
►Decline of recent memory and executive function,
mood, and behavioral disturbance
►Initial signs and symptoms typically manifest
decades after trauma (40-50-yr).
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Complications of Concussions
• Depression
– Increased risk after
multiple concussions
– Athletes with
depression may
experience worsening
symptoms after
sustaining
concussions
• Mild cognitive
impairment
– Increased risk later in
life after multiple
concussions
– Multiple concussions
associated with earlier
onset of mild cognitive
impairment
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Prevention
• Helmets
– Do Not Prevent
Concussion!!!
– Incidence of skull
fracture and major head
trauma
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Prevention
• Personal Protective
Equipment
– Mouthguards
• Decrease risk of dental
or oral injury
– Headgear for soccer,
rugby, wrestling,
boxing
• Decrease risk of
lacerations and soft
tissue trauma
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Prevention
• Coaching
– Rules against
• Spearing
• Head-to-head contact
• Leading with the head
– Report symptoms of
head injury!!!!
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When to Consider Retiring an Athlete?
• Possible season ending
– Prolonged postconcussion
syndrome
– Diminished academic
performance
– CT or MRI brain scan
abnormality
– 3 or more concussions in
single season
– 2 or more major
concussions in single
season
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When to Consider Retiring an Athlete?
• Possible career ending
– Chiari malformation
– Intracranial hemorrhage
– Diminished academic
performance or cognitive
abilities
– Lowering of threshold for
concussion
– CT or MRI structural brain
injury
– CTE symptoms
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Future Directions
• Brain Imaging
–
–
–
–
–
fMRI
DTI
sMRI
MRS
Magnetoencephalogra
phy (MEG) / Magnetic
Source Imaging (MSI)
– Positron Emission
Tomography (PET)
• Rehabilitation
– Balance
– Sports Psychology
– Sport-specific exercise
RTP
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Future Directions
• Concussive, Subconcussive
impacts
– ?Effect on cognitive decline
and aging
– Current tests not designed to
detect long term effects
– Talavage. J Neurotrauma
• Cortical dysfunction not clinically
apparent
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Video
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References
• www.cdc.gov Heads up program. Great resources and
information
• www.acaindiana.com Athletes Concussion Alliance.
Resources for concussion care and ImPACT training
• MSSE Team Physician Statement-2011
– American College of Sports Medicine Web site. Clinicians,Team
Physician Consensus Statements. Available from:
http://www.acsm.org/AM/Template.cfm?Section=clinicians1
• Zurich Consensus Statement on Concussion in Sport. 3rd
International Conference held in Zurich, 2008.
– Clin J Sport Med. 2009; 19:185-200.
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Thank You!
The End