Assessment of Concussion from the Sideline to

Your Clinic
Eugene Hwang, M.D., M.S.
June 10, 2010
Family Medicine, Emory University
School of Medicine, PGY-3
Sports Medicine, University of Nevada
Las Vegas, PGY-4 Fellow
Ahhhh memories or lack there of
Definition
Mild traumatic brain injury
(mTBI)
Abrupt
acceleration/deceleration of the
brain transient loss of brain
function physical, cognitive,
or emotional signs/symptoms
< 10 % concussions involve
LOC
300,000 concussions/year
3% to 9% of high school and
college football injuries involve
concussions
Pathophysiology
Linear/rotational forces of
acceleration and deceleration on or
within the brain
Microscopic level:
neuron depolarization
ion regulation
membrane channels
axon integrity
glucose metabolism
cell membrane stability
production of oxidative free radicals
Rare to see skull fractures, cerebral
edema, intracranial bleeds, and
epidural/subdural hematomas
Cantu Classification Guidelines, 1986

Grade 1: No loss of consciousness, Post-traumatic
amnesia for fewer than 30 minutes

Grade 2: Loss of consciousness for fewer than 5
minutes OR Post-traumatic amnesia for more
than 30 minutes

Grade 3: Loss of consciousness for more than 5
minutes OR Post-traumatic amnesia for more
than 24 hours
Colorado Medical Society Guidelines,
1991

Grade 1: No loss of consciousness, No post-traumatic
amnesia, Confusion

Grade 2: No loss of consciousness, Post-traumatic
amnesia, Confusion

Grade 3: Loss of consciousness of any duration


American Academy of Neurology
Guidelines, 1997

Grade 1: No loss of consciousness, Concussion
symptoms for fewer than 15 minutes

Grade 2: No loss of consciousness, Concussion
symptoms for more than 15 minutes

Grade 3: Loss of consciousness of any duration
Classification of Concussion
According to the Zurich Conference in 2008:

Concussion grading scales should no longer be used

Terms simple and complex no longer used

Concussion now considered as a single entity that can be
affected by various modifying factors
Definition (Consensus Statement on Concussion in Sport: 3
rd

International Conference on Concussion in Sport, Zurich,
November 2008)
Caused by direct blow to head, face, neck, or elsewhere on the body with an
impulsive force to the head

Results in rapid onset of short-lived neurological impairment that resolves
spontaneously

May result in neuropathological changes, but acute clinical symptoms reflect
functional disturbance rather than structural injury

Results in graded set of symptoms that may or may not involve loss of
consciousness. Resolution of symptoms typically follows sequential course

No abnormality is seen on standard neuroimaging
Concussion Assessment
Assessment of acute concussion is multifactorial
Assess signs, symptoms, behavior, and abnormal brain function
Test memory
What team are we playing?
Who scored last?
Test cognitive functioning
Word recall (cat, pen)
Digit recall (say 4-2-5 backwards)
Months in order (recall months in backward order)
Neurological exam is paramount
Speech, eye motion, pupils, pronator drift, balance testing
Presence of one or more of these factors indicate high probability of concussion
and should necessitate removal from field
Sport Concussion Assessment Tool (SCAT)
Quick standardized tool for concussion assessment
Sideline evaluation
(1.) ABCs

(2.) Exclude cervical spine injury

(3.) Evaluate concussion, use
standardized tools (i.e. SCAT) if
available

(4.) Do not leave the player alone
Serial monitoring for initial few hours
following injury to observe for
deterioration

(5.) Player not allowed to return to
field on day of injury
Exception: certain elite adult athletes
ED/Clinic Setting
Do a complete H+P

Do a comprehensive neurological exam

Monitor for worsening signs/symptoms

Obtain additional info from other sources (parents, coaches, trainers,
etc.)

Emergent neuroimaging only if there is concern for severe brain injury
or abnormality
Neuroimaging

CT
Study of choice
Greater accessibility
Good for intracranial hemorrhage, contusion, or herniation

MRI
More sensitive and specific than CT in identifying small cerebral contusions, edema,
and small non-hemorrhagic lesions
Prohibited by: cost, availability, claustrophobia, metal hardware in body

Other imaging studies
Functional MRI (f MRI)
Diffusion tensor imaging (DTI)
Positron Emission Tomography (PET)
Single Photon Emission Computerized Tomography (SPECT)
Near Infrared Spectroscopy (NIRS)
Concussion Management
Patience is key!

Physical AND cognitive rest until symptoms resolve.

When symptomatic, restrict/prohibit physical activity and activities involving
attention and concentration.

Emphasize delay in recovery if athlete resumes these activities too soon.

Do not overlook depression, anxiety, or mood disturbances.

Recovery should be based on the individual, NOT tables or guidelines.

Several factors will modify concussion management (Table 2).

Concussion Modifiers
TABLE 2. Concussion Modifiers

Factors: Modifier:
Symptoms Number
Duration (>10 days)
Severity

Signs Prolonged LOC (>1 min), amnesia

Sequelae Concussive convulsions

Temporal Frequency - repeated concussions over time
Timing - injuries close together in time
Recency - recent concussion or TBI

Threshold Repeated concussions occurring with
progressively less impact force or slower
recovery after each successive concussion

Concussion Modifiers (Table 2,
Continued)
Factors: Modifier:
Threshold Repeated concussions occurring with
progressively less impact force or slower
recovery after each successive concussion

Age Child and adolescent (< 18 years old)

Co- and Pre-morbidities Migraine, depression or other mental health
disorders, attention deficit hyperactivity
disorder (ADHD), learning disabilities (LD),
sleep disorders

Medication Psychoactive drugs, anticoagulants

Behaviour Dangerous style of play

Sport High-risk activity, contact and collision sport,
high sporting level

Cantu Concussion Guidelines, Return
to Play
Management based on first concussion:
Grade 1: Athlete may return to play if asymptomatic for one week
(if athlete is totally asymptomatic, return to play on
same day may be considered).

Grade 2: Athlete may return to play if asymptomatic for one
week.

Grade 3: Athlete may not return to play for at least one month;
athlete may then return to play if asymptomatic for one
week.
Colorado Medical Society Guidelines,
Return to Play
Management based on first concussion:
Grade 1: Athlete may return to play if asymptomatic for 20
minutes.

Grade 2: Athlete may return to play if asymptomatic for one
week.

Grade 3: Athlete should be transported to a hospital
emergency department; athlete may return to play
one month after injury if asymptomatic for two
weeks.
American Academy of Neurology
Guidelines, Return to Play
Management based on first concussion:
Grade 1: Athlete may return to play if asymptomatic for 15
minutes.

Grade 2: Athlete may return to play if asymptomatic for one
week.

Grade 3: Athlete should be transported to a hospital emergency
department; if athlete had brief loss of consciousness
(i.e., seconds), may return to play when asymptomatic for
one week; if athlete had prolonged loss of consciousness
(i.e., minutes), may return to play when asymptomatic for
two weeks.
Graduated Return to Play Protocol
Step-wise process

Each step = 24 hours

Progress to next step if
asymptomatic for at least 24
hours at that current level

If symptomatic, rest for 24
hours, then drop athlete down
to previous asymptomatic step
and try to progress again
Graduated Return to Play Protocol
TABLE 1. Graduated Return to Play Protocol

Rehabilitation Stage Functional Exercise at Each Stage of Rehabilitation Objective of Each Stage
1. No activity Complete physical and cognitive rest Recovery

2. Light aerobic exercise Walking, swimming or stationary cycling keeping Increase HR
intensity, <70% MPHR; no resistance training

3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; Add movement
no head impact activities

4. Non-contact training drills Progression to more complex training drills, eg, Exercise, coordination, and
cognitive passing drills in football and ice hockey; may load
start progressive resistance training

5. Full contact practice Following medical clearance, participate in normal Restore confidence and assess
training activities functional skills by coaching staff

6. Return to play Normal game play
Pharmacology
Helps to manage symptoms including anxiety, depression, insomnia, and
headache
Acute anxiety BZDs
Depression SSRIs
Insomnia BZDs, TCAs
Cognitive slowing/Fatigue psychostimulants (i.e. Provigil), dopaminergic agents
(i.e. Levodopa)
Mania/Psychosis typical/atypical antipsychotics (i.e. Risperdal)

Prior to returning to play, athlete needs to be symptom-free and off these
medications (except for antidepressants)

Initiation of these medications need close monitoring
Neuropsychological Testing
Provides a way to assess information relating to neurological deficits suffered
post-concussion when compared to baseline neurological function

Adjunct to clinical decision making process

Expense ($750-$4,000) and time factor (30 min to 3 hours) limits widespread
use

Trained neuropsychologists are needed to assess findings

Examples:
Immediate Post Concussion Assessment and Cognitive Testing
(ImPACT)
Balance Error Scoring System (BESS)
Automated Neuropsychological Assessment Metrics (ANAM)
Genetics
Current investigations ongoing to evaluate the association of
genotypes, alleles, and genetic biomarkers to concussions
S100B
predicts long-term disability from a head injury
Apo E4
risk factor for Alzheimers
G-219T polymorphism of ApoE promoter
increased risk for Alzheimers and unfavorable post-concussive
outcomes
Tau mutation on Chromosome 17
frontotemporal dementia
Pediatric Athlete
Not a little adult!

Growth and development make
concussion assessment and
management very difficult

Less neck and shoulder
musculature less capable of
transferring kinetic energy at the
head throughout the body

Neurological development at risk
Ability to focus
Sustain attention
Memory recall
Rapid information processing
Pediatric Athlete
No set timetable for recovery

Need to be conservative on return to play protocol

Consider extending out time of one or more steps

Emphasize cognitive rest and longer recovery period

Studies still limited in terms of the pediatric population

Repeated Concussive Injury
http://espn.go.com/video/clip?categoryid=3060647&id=5163151





Repeated Concussive Injury
Concern for Second Impact Syndrome (SIS)
Athlete sustains head injury while still symptomatic from a previous head
injury
Second head injury leads to metabolic disruption and loss of autoregulation
of cerebral blood supply
Results in cerebral vascular engorgement, cerebral edema/swelling,
increased intracranial pressure, cerebral/brainstem herniation, and
ultimately, coma and death

Rare, but is of great concern in pediatric population due to immaturity
of the brain

Contact sports (i.e. football, hockey) increase risk of SIS
Ongoing research
Pediatric population

Genetic/biomarker testing

Second Impact Syndrome

Male vs. female athlete

Protective equipment (i.e.
helmets, mouthgards)
Take Home Points
In terms of concussions, treat each athlete or patient as an individual

Be thorough in the initial evaluation and subsequent follow-up

Neuroimaging valid when suspicious for serious brain injury, otherwise
no imaging needed

Be conservative on return to play

Be even more conservative with pediatric athletes
The End
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