Recognizing and Managing
Sports Concussion
June 2014
Brian P Rieger, PhD
Chief Psychologist & Clinical Assistant Professor
Department of Physical Medicine & Rehabilitation
SUNY Upstate Medical University
Director, UPSTATE Concussion Center
NYSPHSAA Concussion Team & Safety Committee
NYS TBI Coordinating Council  Public Education Committee
Concussion – A Hot Topic
 Growing concern about the effects of
concussions and of repeated head trauma
 Recognition of the need for more
education, and to treat concussion more
seriously
 Proper management of concussion can
make a difference
 All 50 states have passed sports
concussion laws
Concussion—What are the risks?

Athletes who return to play while still
symptomatic from a concussion are at
increased risk of . . .

Another concussion

More severe symptoms

Prolonged recovery, with
associated medical,
psychological, and
academic difficulties
Concussion—What are the risks?

Athletes who suffer multiple concussions
are at increased risk of . . .



Another concussion (increasing
concussability)
More severe symptoms or
prolonged recovery
Permanent problems

Headache

Cognitive problems

Depression
What’s the big deal?
“The hidden nature of the signs and symptoms of
concussion often make detecting this injury
challenging. Moreover, at younger competitive
levels there is often limited medical coverage,
which often places increased responsibility on
coaches for addressing any medical issues that
may arise. Therefore, it is important that
individuals involved in youth sports, coaches in
particular, be aware of the signs and symptoms of
concussion and know how to respond if a
concussion is suspected.”
Covassin et al. 2012
Epidemiology




1.6 to 3.8 million sports concussions
each year in the United States
Football, hockey, and lacrosse are the
riskiest male team sports
Soccer and lacrosse are the
riskiest female team sports
In H.S. sports played by both sexes with
the same rules, girls have a higher rate
of concussion
Concussion in
H.S. Sports
Lincoln et al. 2011
Guerriero et al. 2012
Boys High School Lacrosse
Concussion Video Analysis



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518 games ● 86 concussions ● 34 analyzed
Player-to-player contact was the mechanism for
all concussions
Most often, injured players were unaware of the
pending contact, and the striking player used his
head to initiate contact
Education of coaches and officials and
enforcement of rules designed to prevent
intentional head-to-head contact is warranted
Lincoln et al. 2013
Concussion in
Men’s Lacrosse

NCAA data 1988 - 2004

8.6% of game injuries

3.6% of practice injuries

3% of severe injuries (10+ days out)

80% due to contact or collision with
another player
Dick et al. 2007
Concussion in
Women’s Lacrosse

NCAA data 1988 - 2004

9.8 % of game injuries

4.6 % of practice injuries

5 times more likely in game vs. practice

56% of head and neck injuries due to
stick, and 20% due to ball
Dick et al. 2007
Pediatric ER Data



Pediatric ER data 1990 - 2003
Young children (ages 2-9) were twice as
likely to sustain an injury to the head
and face than older children (10-18)
Most facial injuries in female lacrosse
occur away from the eye and mouth
Yard & Comstock 2006
What is a concussion?




Mild traumatic brain injury
A disruption in normal brain function
due to a blow or jolt to the head
CT or MRI is almost
always normal
Invisible injury
Mechanisms of Injury

Complex physiological
process
 sudden chemical
changes
 traumatic axonal
injury
 altered cerebral
blood flow
Common Physical Symptoms
 Headache
 Nausea and vomiting
 Fatigue and lack of energy
 Clumsiness and poor balance
 Dizziness and lightheadedness
 Blurred vision and light sensitivity
 Sleep problems
Common Emotional Symptoms
 Irritability
 Anxiety or depression





Extreme moods
Easily overwhelmed
Personality change
Lack of motivation
Emotional outbursts
Common Cognitive Symptoms
 Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’
 Easily confused
 Slowed processing
 Easily distracted
 Memory problems
 Trouble reading
 Poor mental stamina
Exertion effects
 Symptoms are worsened by . . .
 mental effort
 environmental stimulation
 emotional stress
 physical activity
Zurich 2012 Guidelines
 No grading of injury
 Treat every
concussion seriously
4th International Conference on Concussion in Sport
FIFA
IOC
IIHF
Zurich Concussion Guidelines
Any athlete who show ANY symptoms or
signs of a concussion:

athlete should not return-to-play in the
current game or practice

Athlete should be monitored for
deterioration for 24 hours

return-to-play must follow a medically
supervised stepwise process

athlete must be symptom-free at rest
and after exertion
When in doubt – sit ‘em out
Medical Protocol

Any athlete who suffers a concussion
should undergo medical evaluation
within 24 hours

Anyone with loss of consciousness
should be evaluated that day

If confused or not fully conscious,
transport by EMS with immobilization

Follow athlete until asymptomatic

First medical clearance is to begin
return- to-play progression

If no return of symptoms with exertion,
then final clearance for game play
Zurich Return to Play Progression
1. No activity, complete rest
2. Light aerobic exercise but no
resistance training
3. Sport specific exercise and progressive
addition of resistance training
4. Non-contact training drills
5. Full contact training and scrimmage
after medical clearance
6. Game play
Also should be symptom-free after mental exertion
and have normal neruocognitive test results
Sideline Evaluation



Standardized tools available

SCAT 3

SAC
Signs & symptoms
Evaluation of cognition is an
essential component



Standard orientation questions are
unreliable
Postural stability testing is a
valid addition to assessment
Serial testing recommended
NYSPHSAA
Concussion Checklist

First completed by coach or trainer on the
sideline

Follows athlete until cleared to RTP

Reviewed by trainer and school medical
director after doctor clearance

Improves communication

Enforces proper protocol
Recovery from
Concussion
 Full recovery in 7-10 days. . .in most cases
 Symptoms can last weeks or months
 Symptoms can significantly disrupt
academic abilities
 Risk of depression and anxiety
a ‘miserable minority’ experience persistent symptoms
Preventing Concussion
 Don’t tolerate dangerous play
 Late and unprotected hits
 Checks to the head
 Helmet properly fitted and worn
Recommendations
for coaches

Educate players, parents and staff

Zero tolerance for hiding symptoms

If you’re suspicious of concussion, pull
the player off the field for evaluation

Have a plan (e.g., who will evaluate the
player, and how ?)

Clear communication with athlete,
parents, other coaching staff, etc.

No return to play without proper
clearance
When in doubt – sit ‘em out
Heads Up
High School Soccer Players With Concussion
Education Are More Likely to Notify Their
Coach of a Suspected Concussion
Bramley et al. 2012 Clinical Pediatrics
72% of athletes who had acknowledged receiving
concussion training responded that they would always
notify their coach of concussion symptoms, as compared
with 36% of the players who reported having no such
training (P = .01)
Managing Complex Concussion
 Consider referral to specialized provider or
program if . . .
 History of multiple concussions or other risk
factors
 Prolonged recovery (> 2 weeks)
 Worsening symptoms
Guidelines for Return to School
after Concussion
 Out of school at first if necessary, and
then gradual re-entry as tolerated
 Avoid re-injury in sports, gym classs
and crowded hallways or stairwells
 Provide academic
accommodations
 Communicate and
Educate
Academic Accommodations
 Rest breaks during school in a quiet
location (not always the nurse’s office)
 Reduced course and work load
 Decrease homework
 Avoid over-stimulation, (e.g., cafeteria or
noisy hallways)
 Extra time and a quiet location for tests
Provide reassurance and support
Resources

Free Educational Materials
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Safe Kids USA www.safekids.org/sports
CDC Heads up in High School Sports kits
NFHS-CDC web-based training video for
coaches
SUNY Upstate Concussion in the Classroom
video and brochure on-line
Summary
 CDC now recognizes sports concussion as
a significant public health issue
 Proper recognition and management of
concussion can prevent serious problems
 Avoid re-injury and over-exertion until
recovered
 No return to play until symptom-free and
cleared by a trained professional
 Everyone involved in sports needs to be
educated about concussion
Thanks !
upstate.edu/concussion
riegerb@upstate.edu