Jeffrey L. Tanji, MD
Associate Medical Director, Sports Medicine, UC Davis Health System
Melita Moore, MD
Head Team Physician, UC Davis Intercollegiate Athletics
Mindgame
Disclosures
 I have no relevant financial relationships to any
products discussed in this talk
 I do not intend to talk about an
unapproved/investigative use of a commercial product
in this presentation
Rationale
 Standards of care for sport concussion have changed
dramatically over the last two years
 New state law mandates certain actions in the
management of concussion
 Sport concussion is under-recognized and underreported
 Community education and awareness are paramount
Objectives
 Define a sport concussion
 List the key symptoms and findings of concussion
 Demonstrate the key aspects of the history and
physical in the evaluation of concussion
 Define the three steps of medical clearance to begin
rehab after concussion
Objectives
 List the four steps of progression between medical
clearance and true return to play
 Discuss several controversies in concussion
management
 Mindgame is a multi-health system integrated
approach to youth concussion care (Kaiser, Dignity
Health, Sutter, UC Davis) in the Sacramento Valley
Definition
 Mild traumatic brain injury (TBI)
 Metabolic, functional (not structural) damage from
direct or indirect trauma
 Classically, attention, vision, balance, headache,
memory are affected but only short term with
relatively rapid recovery
Useful data
 1.5 to 4 million concussions/year in sport
 80-90% -no- LOC
 80-90% return to full activity in 1 week (NCAA data)
 We seek to avoid second impact syndrome which is
associated with long term issues
 Younger and female athletes take longer to recover, the
younger, the slower to return, discussion that high
school athletes may need two weeks minimum
Second impact syndrome
 A second concussion while still symptomatic
 Generally within the same season
 Mild trauma can have dramatic effect and long
recovery
 Major brain injury in sport concussion is almost always
associated with second impact
Sport and concussion
 Football
 Ice hockey
 *Women’s soccer*
 Youth soccer
 Field hockey and lacrosse
 Wrestling
Lingering metabolic effects
 30 days of vascular spasm and decreased cerebral flow
 Hyperglycemia
 K and Ca channels are disrupted
 Generally a bleed is not found on MRI or CT
 The “neurometabolic cascade” Hovda DA and Giza CC,
Clin Sport Med 2011:30(1):33-48
Neurometabolic cascade
Concussion: signs
 LOC less than 10-20%
 Headache
 Visual difficulties
 Nausea/vomiting
 Balance issues
 Memory loss/confusion
No return to play that day
 California AB 25 (2012) for a suspected concussion,
there will be no return to play that day
 Medical clearance by a licensed professional must be
given before return to activity
 California AB 2127 (Cooley law) Jan 1, 2015: 7 day
mandatory no return to play and to follow protocols
Role of advanced imaging
 Excludes severe bleed, critical structural damage
 Does not clear an athlete to return to play
 Misconception by family and athlete
 “I was told my concussion was normal and I was
cleared to play”
 When they were told that they could go home and that
the imaging study was normal
Follow up
 No need to keep waking a person up hourly
 Tylenol is ok, no ASA or NSAIDs
 Worsening status -> ED
 1-2 workday follow up through Mindgame Sacramento
 Rest and cognitive rest
Concussion: established treatment
 Cognitive rest
 No cell phones, no games, no texting
 No television, no reading
 No physical activity
 www.cdc.gov/concussion
Follow up symptoms
 Symptoms:
 Headache
 Visual issues
 Balance
 Sleep
 Emotions (short fuse?)
 Concentration
Follow up physical findings
 Orientation, EOM and pupillary response
 Finger -> nose, heel to shin, rapid alternating
movements
 Heel to toe walking
 Romberg
Physical findings
No Sx and examination WNL
 Neurocognitive testing (NCT):
 Ideally a baseline test has been done
 If no baseline, compare with age related norms, > 20
percentile
Computer based NCT
Three steps to clearance
 No symptoms
 Normal focused neurological examination
 Return to baseline or appropriate scores on
neurocognitive testing
 Then work with coach or athletic trainer for the
progressions to full competition
Rehab progression
 Run, jog 20 minutes without symptoms
 Wait one day
 Sprint, interval speed work without Sx
 Wait one day
 Return to the field with no contact
 Wait one day
 Return to the field with full contact
Variations in progression timing
 Zurich consensus conference 2013: one day between
stages
 University of Pittsburgh: two days between stages
 National Basketball Association: one hour between
stages
Complex cases
 Persistent symptoms
 Formal neuropsychological assessment, work with a
vestibular physical therapist
 ? ENG studies (as if for acoustic neuroma)
 Debate about gentle walking
 Formal neurologist, neuropsychologist or physiatrist
evaluation
Vestibular PT
Take Home Points
 No return to play the same day
 Neurocognitive testing (NCT) is becoming the
standard of care
 No symptoms, normal exam, normal NCT clears to
begin the progression
 Progression: aerobic, sprint, on-field no contact and
finally on-field with contact
ED take home points
 The findings of a normal imaging study do not clear an
athlete to return to play
 Must keep follow up outpatient visit for clearance
(state law AB25)
 No symptoms, normal physical exam and a normal
neurocognitive test are needed
 Then an athlete begins a rehab progression before
clearance to play
Resources
 McCrory P, Meeuwisse W, Aubry M, et al. Consensus





statement on concussion in sport, Br J of Sports Med
2013; 47:250-258.
www.cdc.gov/concussion
www.sacramentovalleyconcussion.com
www.aroundthecapitol.com/bills/AB25
www.aroundthecapitol.com/bills/AB2127
www.sacramentovalleyconcussion.com