Management of Sports Concussion
and The ImPACT Program
Mark Lovell PhD, FACPN, D.Sci
Micky Collins, PhD
Jon French, PsyD
Chairman and CEO
Software Developer
ImPACT Applications, Inc.
University of Pittsburgh Medical Center
Department of Orthopaedic Surgery
Department of Neurological Surgery
Program Director
UPMC Sports Concussion Program
Co-Founder, ImPACT Applications
University of Pittsburgh Medical Center
Department of Orthopaedic Surgery
Clinical Fellow and Neuropsychologist
UPMC Sports Concussion Program
Workshop Goals

To Provide Background Information Regarding
Concussion Management

To Present Data Pertaining to Outcomes and Risk
Factors Associated with Sports Concussion

To Discuss Academic Needs for Recovering
Student Athlete with Concussion

To Review the Utility of Computerized
Neurocognitivie Testing and ImPACT as a Tool for
Effective Concussion Management

To Review Clinical Case Material
Concussion 101: Biomechanics,
Pathophysiology, Definition
Micky Collins, PhD
Associate Professor and Director
UPMC Sports Medicine Concussion
Program
Copyright © 2011
Neurometabolic Cascade
Following Cerebral Concussion/MTBI
500
(Giza & Hovda, 2001)
Calcium
% of normal
400
K+
300
Glucose
200
Glutamate
100
50
2
6
0
Cerebral Blood Flow
12
minutes
20
30
6
hours
24
3
6
days
UCLA Brain Injury Research Center
10
Concussion Management: Areas of Focus
Rule out more serious intracranial pathology
•
CT, MRI, neurologic examination primary diagnostic tests
Prevent against Second Impact Syndrome
Prevent against cumulative effects of injury
•
Less biomechanical force causing extension of injury
Prevent presence of Post-Concussion Syndrome
Most Commonly Reported Symptoms
– 1-7 days following concussion
SYMPTOM
PERCENT
#1
Headache
75%
#2
Difficulty Concentrating
57 %
#3
Fatigue
52 %
#4
Drowsiness
51 %
#5
Dizziness
49 %
#6
Foggy
47 %
#7
Feeling Slowed Down
46 %
#8
Light Sensitivity
45 %
#9
Balance Problems
39 %
# 10
Difficulty with Memory
38 %
Kontos, Elbin, French Collins, Data Under Review; N = 1,438
Post-Concussion
Symptom
Groups
•
•
•
•
•
•
•
•
•
Headaches
Visual Problems
Dizziness
Noise/Light Sensitivity
Nausea
N=327, High School and
University
Athletes Within
7 Days of Concussion
More emotional
Sadness
Nervousness
Irritability
•
•
•
•
•
Attention Problems
Memory dysfunction
“Fogginess”
Fatigue
Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
(Pardini, Lovell, Collins, et al. 2004)
The Evolving Definition of Concussion
CDC Physicians Toolkit 2007
A concussion (or mild traumatic brain injury) is a complex
pathophysiological process affecting the brain, induced by traumatic
biomechanical forces secondary to direct or indirect forces to the head.
Disturbance of brain function is related to neurometabolic dysfunction,
rather than structural brain injury, and is typically associated with
normal structural imaging findings (CT Scan, MRI). Concussion may or
may not involve a loss of consciousness. Concussion results in a
constellation of physical, cognitive, emotional, and sleep-related
symptoms. Recovery is a sequential process and symptoms may last
from several minutes to days, weeks, months, or even longer in some
cases.”
Management of MTBI:
Topics of Concern
Grading systems ineffective/not data based.
CT and MRI insensitive to subtleties of injury.
Self-report predicates management directives.
Variability in clinician recommendations.
Lack of education and awareness of injury.
Inadequate/Improper recommendations from
ED/Trauma Departments.
23
Return to Play Following mTBI:
In some cases (not all), athletes will minimize difficulties
Athletes are naïve to the subtleties of the injury
Young athletes lack insight into self-assessment of MTBI
symptoms
Studies suggest that up to 50% of athletes experience
concussion symptoms per year but only 10 % report
having an injury
Need for comprehensive understanding
of athletes recovery status
Computer-Based Neurocognitive Testing
Cogsport (Axon)
Headminders (CRI)
ANAM
CNS Vital Signs
ImPACT
ImPACT
Mark Lovell, PhD, FACPN, Dsci, Software Developer, ImPACT
Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery
Joseph Maroon, MD - UPMC Dept. of Neurological Surgery
ImPACT: Post-Concussion Evaluation
Demographic / Concussion History Questionnaire
Concussion Symptom Scale
 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)
8 Neurocognitive Measures
 Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary
Scores
Detailed Clinical Report
 Outlines Demographic, Symptom, Neurocognitive Data
 Automatically Computer Scored
Internal baseline validity checks built into program
Desktop and On-Line Versions Available
 Extensive normative data available from ages 11-60
Over 100 peer-reviewed research articles/books/chapters, published since
2000
 Extensive data published on reliability, validity, sensitivity/specificity of test
Neurocognitive Testing: What it is and Isn’t
IS a tool to help determine recovery from injury.
IS a tool to help manage concussion (e.g. return to
academics, return to exertion return to play).
IS a tool to help communicate post-concussion
status to coaches, parents, clinicians.
IS NOT a substitute for medical evaluation /
treatment
Baseline
Testing
Supervised
at School
Or clinic
Concussion
Remove
From Play
First
Follow-Up
Evaluation
Follow-up
Testing
as needed
Return to Play
Measuring
Neurocognitive
Recovery from
Sports mTBI
Authors
Sample
Size
Population
Tests Utilized
Total Days Cognitive
Resolution
Total Days Symptom
Resolution
Lovell et al.
2005
95
Pro (NFL)
Paper and Pencil NP
1 day
1 day
McCrea et al.
2003
94
College
SAC
<1 Day
7 days
McCrea et al.
2003
94
College
Paper and
Pencil NP
5-7 days
7 days
Echemendia
2001
29
College
Paper and Pencil
NP
3 days
3 days
Guskiewicz et al.
2003
94
College
Balance
BESS
3-5 Days
7 Days
Bleiberg et al.
2005
64
College
Computer
NP (ANAM)
3-7 days
Did Not
Evaluate
Iverson et al.
2006
30
High School
Computer
NP (ImPACT)
10 days
7 Days
McClincy et al.
2006
104
High School
Computer
NP (ImPACT)
14 days
7-10 Days
Lovell, Collins et al
2008
208
High School
Computer
NP (ImPACT)
26 days
17 Days
Covassin et al
2011
72
High School
Computer
NP (ImPACT)
21 days
7 Days
Maugans et al
2011
12
Ages 11-15
Computer
NP (ImPACT)
30 days
14 Days
Three-year prospective study in Western PA.
17 high school football teams (2,141 total sample)
134 athletes with diagnosed concussion (6.2%)
All athletes referred for evaluation at UPMC
Recovery determined by “Back to Baseline” on computer
neurocognitive test scores & symptom inventory
Determined by Reliable Change Index Scores-RCI’s)
100
90
80
70
60
50
40
30
20
10
0
WEEK 1
WEEK 2
WEEK 3
WEEK 4
WEEK 5
80%
RECOVERED
60%
RECOVERED
N=134 High School Male
Football Athletes
40%
RECOVERED
1
3
5
All Athletes
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
No Previous Concussions
1 or More Previous Concussions
Over 200 High School Athletes Studied using fMRI
Tested w/in 7 days of concussion and at point of clinical recovery
Hyperactivation predicts CLINICAL recovery time
Resolution of hyperactivation correlates with recovery on ImPACT
Lovell et al., Neurosurgery, 2007
(Lovell, Pardini, Collins et al; Neurosurgery 2007)
Mean Age: 16.2 yrs
Gender: 78% male
Days to Recover
Range
4 – 211 days*
Mean
26.2 days
* End of study period
N = 208
Cumulative Percent Recovery
15 days
25%
26 days
50%
45 days
75%
92 Days
90%
Prognosticating Concussion
Outcomes:
An Evidence-Based Analysis
Micky Collins, Ph.D.
University of Pittsburgh Medical Center
Associate Professor
Department of Orthopaedic Surgery
Department of Neurological Surgery
Director
UPMC Sports Concussion Program
Helps to set up clear communication to player, coaches, and
medical personnel regarding recovery expectations
May help to alleviate some pressure on RTP issue
May help to immediately provide individualized clinical
management recommendations (e.g. need for academic
accommodations/physical rest, etc.)
Begins to create a risk profile for sports concussion and
may set stage to effectively research treatment and
rehabilitation strategies.
Because it is the next stage in our scientific
understanding of this injury….
Which On-Field Symptoms
Predict Protracted
Recovery
(i.e. Post-Concussion Syndrome)?
Which On-Field Symptoms Increase Risk of
Post Concussion Syndrome in High School Football Players?
176 Male HS Football Players (Mean Age = 16.2 years)
Athletes had baseline ImPACT testing and were revaluated within 3 days of injury.
All followed until clinical recovery (Mean = 4.1 evaluations)
Within RCI of baseline on ImPACT for neurocognitive/symptom scores
32% of sample required < 7 days until recovery (N =56) “Rapid Recovery” (Mean = 4.9 days)
39% of sample required 7-14 days until recovery (N = 68)
17% of sample required > 21 days until recovery (N = 31) “Protracted Recovery”
(Mean = 33.2 days)
12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21)
MANOVA used to determine differences between rapid/> 3 week recovery
ATC’s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache,
dizziness, etc)
Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011
Which On-Field Markers/Symptoms Predict 3 or More
Week Recovery from MTBI In High School Football Players
On-Field Marker
N
Chi2
P
Odds Ratio
95% Confidence Interval
Posttraumatic Amnesia
92
1.29
0.257
1.721
0.67-4.42
Retrograde Amnesia
97
.120
0.729
1.179
0.46-3.00
Confusion
98
.114
0.736
1.164
0.48-2.82
LOC
95
2.73
0.100
0.284
0.06-1.37
On-Field Symptom
N
Chi2
P
Odds Ratio
95% Confidence Interval
Dizziness**
98
6.97
0.008
6.422
1.39-29.7
Headache
98
0.64
0.43
2.422
0.26-22.4
Sensitivity LT/Noise
98
1.19
0.28
1.580
0.70-3.63
Visual Problems
97
0.62
0.43
1.400
0.61-3.22
Fatigue
97
0.04
0.85
1.080
0.48-2.47
Balance Problems
98
0.28
0.59
0.800
0.35-1.83
Personality Change
8
0.86
0.35
0.630
.023-1.69
Vomiting
97
0.68
0.41
0.600
0.18-2.04
The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees
of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number
of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.
**p<.01
Lau, Kontos,
Collins, Lovell
, AJSM 2011
On-Field Symptom Summary
Brief LOC (<30 sec) not predictive of subacute or protracted
outcomes following sports-concussion
Amnesia important for sub-acute presentation, but may not be
as predictive of protracted recovery
On-Field dizziness best predictor of protracted recovery and
“post concussion syndrome”
Etiology of dizziness?
•
•
•
•
•
Migraine variant?
Central Vestibular Dysfunction?
Peripheral Vestibular Dysfunction?
Cervico-genic?
Psychiatric?
Which Subacute
Symptoms
Predict Protracted
Recovery?
108 concussed high school football players
• Athletes had baseline ImPACT testing and were revaluated within 3
days of injury (Mean = 2.2 days)
• All followed until clinical recovery
- Within Reliable Change Score of baseline for neurocognitive/symptom
scores
•
43.5% of sample recovered < 10 days = “Quick”
- Mean = 5.9 Days
•
56.5% of sample required >10 days until recovery = “Protracted”
- Mean = 29.2 Days
• MANOVA conducted on which individual symptoms and
neurocognitive domains predicted “quick” versus “protracted”
recovery
Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21
Current Symptoms
 Headache
 Nausea
 Vomiting
 Balance Problems
 Dizziness
 Fatigue
 Trouble falling asleep
 Sleeping more than usual
 Sleeping less than usual
 Drowsiness
 Sensitivity to light
 Sensitivity to noise
 Irritability
 Sadness
 Nervousness
 Feeling more emotional
 Numbness or tingling
 Feeling slowed down
 Feeling mentally foggy
 Difficulty concentrating
 Difficulty remembering
 Visual problems (blurry or double vision)
FOGGY
NAUSEA
LIGHT SENS
DIFF CONC
HEADACHE
NOISE SENS
VOMIT
SLOWNESS
NUMBNESS
DIZZY
BALANCE
2
1.5
1
0.5
0
Expressed as Effect Sizes (Cohen’s D). Only includes symptoms with large (greater
than .80) effect sizes. Sample is composed of 108 male HS football athletes.
“It is like going from a high definition TV world
to standard TV world”
“Feeling one step removed from my surroundings”
“It is like my vision is impaired, but it isn’t”
“Feeling like I am underwater”
Factor Analysis,
Post-Concussion
Symptom Scale
(Pardini, Lovell,
Collins et al. 2004)
•
•
•
•
•
•
•
•
•
Headaches
Visual Problems
Dizziness
Noise/Light Sensitivity
Nausea
N=327, High School
and University
Athletes Within
7 Days of Concussion
More emotional
Sadness
Nervousness
Irritability
•
•
•
•
•
Attention Problems
Memory dysfunction
“Fogginess”
Fatigue
Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
Variables
Fogginess
Difficulty Concentrating
Vomit
Dizziness
Nausea
Headache
Slowness
Balance
Light Sensitivity
Noise Sensitivity
Numbness
Trouble Sleeping
Classification
Cognitive
Cognitive
Migraine
Migraine
Migraine
Migraine
Cognitive
Migraine
Migraine
Migraine
Migraine
4.3*
2.46
2.391*
2.09
1.96
1.71
1.53
1.53
1.52
1.52
1.46
Sleep
1.231*
0.97
Visual Problems
Difficulty Remembering
Sleeping Less
Drowsiness
Fatigue
Emotional
Migraine
Cognitive
Sleep
Cognitive
Cognitive
Neuropsychiatric
Irritability
Sadness
Nervousness
Neuropsychiatric
Neuropsychiatric
Neuropsychiatric
Sleeping More
Z-Score (Simple vs. Complex)
Cognitive
0.93
.52
0.5
0.48
0.37*
0.3
0.09
-0.03
-0.05
*Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.
The Role of Sub-Acute
Migraine-Symptoms in Determining
Outcomes Following Concussion
Kontos AP, Elbin RJ, Simensky S, French J, Collins
MW; data in preparation for publication
Post-traumatic Migraine (PTM)
Defined
• Post-traumatic Migraine
– Headache, nausea, AND sensitivity to
light OR noise (International Headache Society
Guidelines)
• Determined by utilizing PCSS at 1-7
days post-concussion
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
Study Overview
•
174 high school athletes with a concussion
– No prior hx of LD, moderate TBI, psychiatric disorder
•
Athletes followed until recovery
– Neurocognitive scores returned to baseline (w/in RCI)
– Symptom free and rest and exertion
•
97 athletes met Rapid or Protracted Criteria for Recovery:
– Rapid (≤7 days)= 61
– Protracted (≥21 days)= 36
•
Recovery studied for three groups
–
–
–
•
No headache group
Headache only group
Post-traumatic migraine group (headache with nausea and/or light and noise
sensitivity)
Data Analysis
–
–
Chi-square analysis with Odds Ratios for Recovery Time Groups
Repeated measures ANOVAs for ImPACT scores across 3 time periods
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
How does PTM compare to No Headache and Headache groups
in predicting Protracted (>21 days) Recovery from Sports
Concussion? (N= 97)
Variable
Wald
p
Odds
Ratio
Headache v. No
Headache
2.20
.14
2.83
0.72-11.20
PTM v. Headache
3.93
.04
2.57
1.10-6.54
PTM v. No
Headache
7.60
.006
7.29
1.80-29.91
95% CI
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
Comparison of Recovery for PTM, Headache, No Headache/PTM groups (χ2= 9.05,
p= .009, n= 97)
ImPACT
Visual Memory
Raw Score
PTM =
Post Traumatic
Migraine
N = 97 HS Athletes with concussion
Comparison of ImPACT Visual Memory scores for PTM, Headache, and No PTM or Headache
groups (λ= .88, F= 4.24, p= .002, η2 = .06)*
*PTM significantly different than both groups at 1-7 and 8-14 days
PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)
ImPACT
Reaction Time
Raw Score
PTM =
Post-Traumatic
Migraine
Comparison of Reaction Time scores for PTM, Headache, and No PTM or Headache groups (λ=
.87, F= 4.96, p= .001, η2= .07)
*PTM significantly different than both groups at 1-7 and 8-14 days
PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)
Conclusion
“It’s more than just a headache”:
– Athletes with migraine-type symptoms
(headache with nausea and/or light-noise
sensitivity) exhibit more protracted recovery
than with athletes with headache only
– 81% of post-traumatic migraine group also
reported dizziness (post-traumatic
vestibular migraine??)
– Important to assess for quality and type of
headache in athletes with concussion
Sensitivity and Specificity of ImPACT in Classifying
Athletes with Concussion
Schatz P, Pardini J, Lovell MR, Collins MW. Archives of Clinical Neuropsychology 2005:21;91-99.
N = 138 controls/
concussed athletes
Discriminate Function Analysis
Statistical classification of Concussed (physician dx)/Control subjects
No Clinician Input
Testing completed within 3 days post injury
Positive Predictive Value (90%)
(Probability that that a concussion is present when test is positive)
Negative Predictive Value (82%)
(Probability that a concussion is not present when test is negative)
Determination of
Neurocognitive Cutoff
Scores that Predict
Protracted Recovery
(at 2 days post injury)
Lau B, Collins MW, Lovell MR
Neurosurgery 2012;Feb 70(2):371-79.
108 concussed HS and Collegiate Athletes
Athletes had baseline computerized NP testing and were revaluated
within 3 days of injury (Mean = 2.2 days)
All followed until clinical recovery
Within Reliable Change Score of baseline for neurocognitive/symptom
scores
43.5% of sample recovered < 14 days = “Quick”
Mean = 5.9 Days
56.5% of sample required >14 days until recovery = “Protracted”
Mean = 33.0 Days
ImPACT composite cutoff scores statistically calculated at 75%, 80%,
and 85% sensitivity to predict protracted recovery (i.e. 1 month or
longer for clinical recovery)
Lau B, Collins MW, Lovell MR. Neurosurgery In Press
Cutoff Values of ImPACT Neurocognitive Scores at 2 Days
Post Injury That Predict Protracted Recovery
75%
80%
85%
Sensitivity Sensitivity Sensitivity
Neurocognitive Domain
Cutoff
Cutoff
Cutoff
Verbal Memory
66.5
64.5
60.5
Visual Memory
48
46
44.5
Processing Speed
24.5
23.5
22.5
Reaction Time
0.72
0.78
0.86
Sensitivity is defined as the ability of the cutoff to
accurately identify protracted recovery (>14 days;
Mean = 1 month) in an athlete.
Lau B, Collins MW,
Lovell MR.
Neurosurgery 2012.
Predicting Quick versus Protracted Recovery from
Sports mTBI
- At three days post-injury, if athlete exhibit three or more
RCI changes on ImPACT composite scores (relative to
baseline), there is a 94% chance that recovery will
require >10 days.
- Exhibiting a high symptom score did not improve
classification accuracy over neurocognitive test scores
in isolation.
- Athletes with prior history of concussion were not
statistically more likely to have “protracted” recovery
from concussion.
Other Recent Peer Reviewed Research
Examining Neurocognitive Testing
Use of Computerized Neurocognitive Testing
In High School Athletes (Meehan et al, 2011)

41.2% of US High Schools that employ at least 1 ATC utilized computerized
neurocognitive testing during 2009-2010 academic year (25.7% in 20082009 year)

93% use ImPACT

100% of schools utilizing testing reported that scores were utilized in
making RTP decisions

86% of these schools performed baseline testing

Athletes who underwent computerized NP tesing were less likely to be
returned to play within 10 days of injury (38.5% vs 55.7%, p < .01) and
were more likely to be returned to play by a physician (60.9% vs 45.6%, p
<.01)
Established (?) Constitutional Risk Factors
For More Complicated Recovery
Age
-
Field, Lovell, Collins et al. J of Pediatrics, 2003
Pellman, Lovell et al. Neurosurgery, 2006
Migraine History &
Symptoms
-
Mihalik, Collins,Lovell et al, J Neurosurgery, 2006
Learning Disability
-
Collins, Lovell et al, JAMA, 1999
Kontos, Elbin, Collins, Data submitted for publication
Repetitive Concussion?
-
Collins, Lovell et al, Neurosurgery, 2004
Iverson et al, CJSM, 2004
Moser et al, JCEN, 2011
Gender?
-
Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009
Covassin et al, CJSM, 2009
Outcomes are highly variable
Vestibular-related symptoms following injury predict
more protracted recoveries
Migraine-type symptoms (and potentially preexisting
history of migraine) may place individuals at increased
risk of injury and longer recovery
Neurocognitive testing is valuable in determining
prognosis and recovery in sports-related mTBI
Clinical management key to preventing poor outcomes
The “mild” injuries may become severe and the
“severe” injuries may become mild
Sports Concussion
Scientific Evolution and Building
Consensus: Where are we Headed?
CDC Physician Toolkit
(Collins, Gioia, et al. 2007)
Recommended Sports Concussion Management
Post-Injury Management
Removal from contest if concussion suspected-no RTP in same game
No return to play while symptomatic or if symptomatic with exertion
Carefully monitored and graded increase in exertion over time
Need to be mindful of cognitive exertion on role of recovery
Need for conservative management in children/adolescents
Neurocognitive testing recommended for athletes sustaining concussion
Criteria for Return to Play
1.
2.
3.
Symptom-Free at Rest
Symptom-Free with Cognitive/Physical Exertion
Normal Neurocognitive Data/Objective Evaluation
- “Conservative” approach to management of concussion
- Out of play for game/practice with any LOC, amnesia, or confusion
- Out of play for game/practice if new and persistent dizziness, headache (particularly if
accompanied by photo/phonophobia, dizziness, nausea, or vomiting) or any other
persistent symptoms of concussion
- Follow up evaluation to be conducted by team physician as well as
independent “neurological consultant ”
- Clearance for RTP required by both
- Baseline and post-injury neurocognitive testing mandated by league
- No return to play until athlete exhibits normal neurological evaluation
and is… 1) asymptomatic at rest
2) asymptomatic with progressive exertion, and
3) neurocognitive test scores back to baseline (within RCI indices on ImPACT)
Copyright © 2011
- Institutions must have concussion plan on file
- Any athlete exhibiting signs/symptoms of concussion shall be removed
from practice/game and evaluated by healthcare practitioner with training
in management of concussion-no RTP until formal clearance
- Neuropsychological testing is an important component of an institutional
concussion management plan.
- “Best Practices” should include a baseline/post injury assessment using,
at minimum, sideline tool (e.g. symptom checklist, SAC, SCAT, BESS), and,
optimally, formal computerized or paper and pencil neurocognitive testing
- Education necessary- Dept of Education will post concussion
educational information; Student/parents must sign form prior
to participation that they have reviewed concussion fact sheet.
Coaches must complete concussion management training
course on yearly basis. Informational school meetings are
encouraged that educate on concussion management and
importance of baseline assessments that can aid in evaluation
and management of injury.
- Any athlete exhibiting signs/symptoms of concussion shall be
removed from practice/game and no RTP on day of injury.
Medical clearance must occur from: Physician trained in
concussion management OR licensed physician designee
trained in concussion management, OR licensed
neuropsychologist (fellowship trained) who has specific
training in concussion management. Penalties occur with any
infraction.
Copyright © 2011