sport related concussion · 2018. 4. 15. · concussion is a problem • cdc estimates 1.6-3.8...
TRANSCRIPT
Sport Related Concussion
Hallie Labrador, MD MSMSPrimary Care Sports Medicine
NorthShore Medical Group
Clinical Educator Family Medicine
University of Chicago, Pritzker School of Medicine
No Disclosures
Overview
• Sport related concussion incidence and risk
• Concussion definition
• New Guidelines
• Treatment of acute injury
• Post-concussive syndrome
• Chronic traumatic encephalopathy
Concussion is a Problem
• CDC estimates 1.6-3.8
million sports-related
concussions annually in
USA
• Increased rates over last
decade
• Underreporting is a
problem
McDonald T. Burghart MA, Nazir N. J Trauma Nurs. 2016: Sept-Oct;23(5): 241-6
Zhang A, et al. The Orthopaedic Journal of Sports Medicine. 2016 Aug; 4(8)
Concussion Underreporting
• 2018 Survey of Former NFL Players
– 50.3% report nondisclosure
– Higher in non-white/ Hispanic players
– Higher post spear-rule change
• 2018 Survey of NCAA D1 Athletes
– Understood concussion risks
– No change in attitudes towards hiding symptoms
• 2017 Survey of High School Athletes
– Athletes at schools with ATCs had more knowledge of concussion
– No change in reporting ratesKerr ZY, et al. Am J Sports Med. 2018 Jan;46(1):22-29
Conway FN, et al. Clin J Sports med. 2018 Jan 11
Wallace J, et al. J Athl Train. 2017 March 52(3): 228-235
Concussion Exists in All Sports
• Sports with majority of
concussions: Football,
Wrestling, Boys’ and Girls’
Soccer, Girls’ Basketball
• Depends how you calculate
Marar M, et al. Am J Sports Med. 2012 Apr;40(4):745-55
Ken ZY, et al. J Athl Train. 2016 Jun 22.
Concussion Incidence
• Incidence (frequency)
– Difficult to compare sports
– Information depends on reporting
– Calculate per year, per team, per AE
• 2013-2014 HS Athletes
– Concussion/ 100,000 AE
– Football, boys’ LAX, girls’ soccer
• 2014-2015 HS School year
– Girls’ soccer
O’Connor KL, et al. J Athl Train. 2017 March 52(3): 175-185
Schallmo S, et al. JBJS. 2017 Aug 2;99(15)1314-1320
Concussion Incidence
• Increased Incidence
– May be more likely to
report symptoms
» More concern about
future impact
» Cultural tendencies
– May be related to
anatomic differences
» Smaller/ weaker muscles
» ↓head mass ↑velocity
Up to 2.5 x more
likely to sustain a
concussion
GIRLS
BOYS
Concussion Guidelines
Expert Consensus Based
• 1st International Conference on concussion in Sport: Vienna – 2001
• 2nd: Prague – 2004
• 3rd: Zurich – 2008
• 4th: Zurich – 2012
• 5th: Berlin – 2016 (published April 26, 2017)
The 11 “R’s” of Concussion
• Recognize
• Remove
• Re-evaluate
• Rest
• Recovery
• Rehabilitation
• Refer
• Return to Sport
• Reconsider
• Residual Effects
• Risk Reduction
Recognize
Definition of Concussion
• A complex pathophysiological process affecting the brain, induced
by biomechanical forces, that may include:
– Direct blow to head/body with force transmitted to head
– Rapid onset of short-lived impairment of neurological function
– Neuropathological changes - functional disturbance
– Graded set of clinical symptoms that may involve loss of consciousness
– Symptoms not explained by drug, alcohol or medication use, other injuries
or other comorbidities
Pathophysiology
• Forces to the brain are linear and/or rotational Causes
cellular damage
Pathophysiology
Skull AcceleratesRelative Motion at
the Skull/ Brain
Interface
Brain Lags
• Linear motion –
pressure gradient
change
• Rotational motion –
sheering force
Pathophysiology
“Metabolic Mismatch”
• Thought to be metabolic dysfunction
• Cells exposed to dramatic changes in intracellular and extracellular environment
• Accompanied by decreased cerebral blood flow = neurovascular constriction
Metabolic Mismatch
• Brain has to work harder to meet the same
demands
• Brain has increased vulnerability in the
post-concussion state
• 2nd injury before brain is recovered may
result in worse cellular changes and
cognitive deficits
• Excessive cognitive or physical activity
before complete recovery may result in
prolonged dysfunction
Second Impact Syndrome
• Second head injury in close succession to initial injury
– Increased brain edema -> brain herniation
– Severe neurocognitive dysfunction/ death
– ? Distinct entity or edema from single traumatic impact
• Incidence is unknown, but rare
– Almost all cases in the literature are athletes <20 years old
• More commonly – prolonged symptoms/ delayed recovery
• Lysted Law
– First law signed to provide guidelines around concussion/ RTP 2009
– Prevents same day return to play Foris LA, Donnally CJ. Second Impact Syndrome. Stat Pearls. 2017 October.
Illinois Concussion Law
• Youth Sports Concussion Safety Act – 2015
– Each school board is required to adopt a student athlete
concussion policy in accordance with those developed by the IHSA
– Each school district must educate coaches, athletes, parent/
guardians
– All public, private or charter schools must convene a Concussion
Oversight Team to develop RTP and RTL protocols
– All coaches and licensed officials required to complete 2 hour
training program every 2 years
Illinois Concussion Law
• IHSA Protocol
– “Any athlete who exhibits signs, symptoms or behavior consistent
with a concussion shall be removed from the contest and shall not
return to play until cleared by an appropriate health care professional”
» Physician
» ATC
» PA
» APN
Research is Challenging
• Most concussion pathophysiology research is done in mouse models
• Imaging used in concussion research: fMRI, PET scan, SPECT, Diffusion tension imaging, MR spectroscopy
• Biomarker research looks at blood proteins from axons, glial cells and neurons
Sports Medicine and Arthroscopy Review. Vol 24(3): September 2016.
Research is Challenging
• Blood test helps detect brain
protein in the blood
• Can help determine if a CT
scan is needed with history of
head trauma
• Might help rule in/ out
structural brain damage
• Does NOT diagnose
concussion
Concussion Diagnosis can be Difficult
• Diagnosis is clinical
– Based on history – mechanism
– Based on symptoms constellation
• Probably results in both over and under diagnosis of concussion
• In any suspected case of concussion, the individual should be removed from the playing field and further evaluated
Signs and Symptoms
Physical
Cognitive
Emotional
Sleep
Signs and Symptoms
Physical
• Headache
• Nausea
• Vomiting
• Balance problems
• Dizziness
• Visual Problems
• Fatigue
• Sensitivity to light
• Sensitivity to noise
• Numbness/tingling
• Dazed
• Stunned
Signs and Symptoms
Cognitive
• Feeling mentally “foggy” – feels like standard
TV, instead of HD TV
• Feeling slowed down
• Difficulty concentrating
• Difficulty remembering
• Forgetful of recent information
• Confused about recent events
• Answers questions slowly
• Repeats questions
Signs and Symptoms
Emotional
• Irritable
• Sadness
• More emotional
• Nervousness
Sleep
• Drowsiness
• Sleeping more or less than usual
• Difficulty falling asleep
Concussion Diagnosis – Validated Tools
• Several tests have been
developed to help clinically
diagnose and manage
concussion
• No single test can reliably
and quickly diagnose
concussion in all cases
• Validated tools may be
helpful
Validated Concussion Tools – PCSSSymptoms None Mild Moderate Severe
Headache 0 1 2 3 4 5 6
Pressure in Head 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or Vomiting 0 1 2 3 4 5 6
Sensitivity to Light 0 1 2 3 4 5 6
Sensitivity to Noise 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred Vision 0 1 2 3 4 5 6
More Emotional 0 1 2 3 4 5 6
Irritable 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or Anxious 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Feeling “in a fog” 0 1 2 3 4 5 6
Difficulty Concentrating 0 1 2 3 4 5 6
Difficulty Remembering 0 1 2 3 4 5 6
“Don’t Feel Right” 0 1 2 3 4 5 6
Feeling Slowed Down 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Fatigue or Low Energy 0 1 2 3 4 5 6
Difficulty Falling Asleep 0 1 2 3 4 5 6
He
ad
ach
eV
estibu
lar
Em
otion
al
Co
gn
itiv
eS
leep
• Objective tool to asses/
monitor symptoms
• Sensitivity of 40.81%
• Specificity of 79.31%
• PPV of 61.33%
• Limitations: wide range of
variability, self reported
• Should not be used in
isolation
Dessy AM, et al. Cureus. December 07, 9(12): e1922
Validated Concussion Tools - SAC
• Should take 5-10 minutes
• Neuropsych test designed for
sideline use
• Sensitivity 80-94%
• Specificity 76-91%
• Can be used to supplement
other tests
Dessy AM, et al. Cureus. December 07, 9(12): e1922
Validated Concussion Tools - SCAT
• Most recent – SCAT5, also child SCAT
• Combines several concussion tools
– PCSS
– SAC
– GCS
– Maddocks Score (Immediate Memory)
– BESS (balance)
– Cervical spine, neurologic/ coordination screen
Validated Concussion Tools - ImPACT
• 20-25 minute computer-based
assessment -> 4 output scores
– Verbal memory
– Reaction time
– Visual-motor speed (most reliable)
– Neuropsych test
– PCSS
• Most widely used test in North America
(NFL, MLB NBA)
• Sensitivity: 81.9-91.4% Specificity: 69.1-
89.4 %
– Increases in asymptomatic athletes attempting
to hide symptomsDessy AM, et al. Cureus. December 07, 9(12): e1922
Validated Concussion Tools
• Concussion Resolution Index (CRI)
– Online neurocognitive and neurobehavioral assessment
» 88% sensitivity; however, this may decline over time
• CogSport
– Series of seven card tasks measuring five composite cognitive
domains
» High correlations with conventional neuropsych testing
» Variability in sensitivity and specificity of composite scores
• King-Devick (KD) Oculomotor Test
– Oculomotor dysfunction is present in 65-90% of patients with TBI
– Athletes read numbers from three cards – done quickly
– Sensitivity: 86%, Specificity: 90% Dessy AM, et al. Cureus. December 07, 9(12): e1922
Galetta KM, et al. Concussion. (2016) 1(2), CNC8
Remove
• When a player shows any signs/ symptoms of concussion:– On-site evaluation – emergency
management
– Assess concussive injury using sideline assessment tool
– Serial monitoring for deterioration during initial few hours after injury
– Player diagnosed with concussion should not be allowed to return to play
Differential Diagnosis
• Concussion symptoms are non-specific. Other problems may
mimic concussion
– Post-traumatic migraine
– Dehydration/ heat exhaustion
– Whiplash
– Depression/ Anxiety
Break Time
Re-evaluate
Who Treats Concussion?Athletic Trainers
ER PhysiciansNeurologists
Neurosurgeons
Primary Care
ProvidersPhysical
Therapists
Neuropsychologists
Primary Care Sports MedicineOrthopedic Surgeons
Re-evaluate
• Follow-up examination should encompass
– Comprehensive history» detailed neurological exam
» cognitive functioning
» sleep/ wake disturbance
» ocular function
» vestibular function
» gait and balance
– Clinical status, including whether there has been improvement or deterioration
» May need additional information from parents, coaches, teammates
– Determination of the need for emergent neuroimaging to exclude more severe brain injury
Neuroimaging – Typically Not Needed
• Imaging is typically normal in concussed athlete
• Head CT
– Used to evaluate for:
»Intracranial bleeding
»Skull fracture
• MRI Brain
– May obtain if prolonged symptoms
Rest
Acute Concussion Management
• Physical rest
– But don’t sit in dark room entire time
– After 24-48 hours, patients encouraged to become gradually and progressively more active
– Early light aerobic activity
• Cognitive rest
– Stay below symptom threshold
– May need school accommodations
• Sleep: 7-9 hours, no naps
• Regular diet and hydration
Return to School is Important
Halstead ME et al. Returning to Learning Following a
Concussion. Pediatrics. 2013 Nov; Vol 132-5: 948-
957.
Headache
Dizziness
Occular Symptoms
(photophobia, blurry vision,
double vision)
• Frequent breaks
• Avoid triggers
• Planned rest breaks
• Allow head down rest
• More time to move through
hallways
• Hat/ sunglasses
• Reduce use of screens/
brightness
• Sit near the center of the room
• Eye patch
Manage symptoms to promote attendance
Phonophobia
Difficulty concentrating/
remembering
Sleep Disturbance
• Limit noisy classes
• Earplugs
• Time to move through hallways
• Avoid major tests/ projects
• Delay standardized tests
•Consider notetaker/ oral exams
• Allow for late start/ shortened
school day
Halstead ME et al. Returning to Learning Following a
Concussion. Pediatrics. 2013 Nov; Vol 132-5: 948-
957.
Recovery
Concussion Recovery
• Majority of concussions resolve in 7-10 days: 80-90%
– May be longer in adolescents/ pediatrics
• Collins et al. Neurosurgery 2006
– 134 High school football players
»40% at week 1
»60% at week 2
»80% at week 3
• Each concussion is unique, even with the same athlete
Pediatric Pathophysiology
• Studies suggest physiologic differences in our younger
athletes
• More prolonged and diffuse cerebral swelling after traumatic
brain injuries
• Immature brain up to 60x more sensitive to glutamate
– Neurotransmitter involved in metabolic cascade following concussion
– Results in longer recovery times
Field M, Collins MW,Lovell MR, Maroon JC. J Pediatr 2003: 142:546-53.
Risk Factors for Prolonged Recovery
• Multiple symptoms at presentation SOR=B
• Memory dysfunction SOR=B
• Migraine symptoms SOR=B
• Longer duration of headache SOR=B
• Age SOR=C
• Also possibly related
– Prior history of concussion with prolonged recovery
– Personal or family history of depression
– Prior history of headache/ migraine
– History of ADHD
Rehabilitation
• Literature has not evaluated early interventions
– Most patients recover in 10-14 days
• A variety of treatments may be required for persistent symptoms
following injury
– Psychological, cervical, ocular and vestibular rehabilitation may be helpful
• Submaximal exercise may help facilitate recovery
Refer
Post-Concussive Syndrome
• Definition
– Neurocognitive disorder which occurs
immediately after the occurrence of a
traumatic brain injury and persists
past the acute post-injury period
• Pathophysiology is unclear
• Depression/ deconditioning may mimic
post-concussive syndrome
Post-Concussive Syndrome
Physiological
Persistent alterations in neuron
depolarization, cell metabolism and
cerebrovascular physiology
Vestibulo-ocular
Isolated dysfunction of central and
peripheral components of the
vestibulo-ocular neurological sub-
system
Cervicogenic
Isolated mechanoceptive, nocioceptive
and proprioceptive dysfunction
within the cervical spine
neurological sub-system
Ellis MJ, Leddy J, Willer B. Frontiers in Neurology.
August 2016;7(136)
Post-Concussive Syndrome
• Physiological
– Global pounding headache at rest
– Dizziness, nausea, fatigue, drowsiness, photophobia/phonophobia
• Vestibulo-ocular
– Headache and eye strain
– Intermittent blurred vision, diplopia, dizziness, fogginess, motion sensitivity, difficulty
focusing or concentrating
– Intermittent vertigo during certain head positions
• Cevicogenic
– Headache elicited/exacerbated by activities with prolonged neck stabilization or
movement
– Neck pain, stiffness, decreased range of motion, dizziness, fogginess and postural
imbalanceEllis MJ, Leddy J, Willer B. Frontiers in Neurology. August 2016;7(136)
Post-Concussive Syndrome Treatment
Guided by
Symptoms
Ocular
Dysfunction● Ocular Rehab
● Glasses
Headache● Analgesics
Cervical Pain● cervical Rehab
Cognitive
Impairment● Stimulants
Sleep
Disturbance● Sedatives
Vestibular
Dysfunction● Vestibular Rehab
Emotional
Dysfunction● Antidepressants
Research on Medication Use in Concussion is Limited
• Medications are used often in acute and
post-concussive syndrome management
– Treatments are extrapolated from
headache research
Medication recommendations for
sport-related concussion treatment
among pediatricians
– 62% - Tylenol
– 54% - NSAIDs
– 20% - Melatonin
– 20% - Tricyclic Antidepressants
– 10% - Amantadine
– 8% - Stimulants
Medication recommendations for
concussion treatment among pediatric
EM physicians
78% - Tylenol
77% - NSAIDs
54% - Ondansetron
7% - Narcotics Halstead, ME. Sports Health. 2016 Jan-Feb; 8(1) 50-52
Graded Aerobic Treadmill Testing
• Can be use to classify PCS sub-types
• Can be used to verify recovery
• Can be used to guide treatment
• Patients perform a standardized incremental
aerobic treadmill test (Buffalo Concussion
Treadmill Test)
• Patients with persistent concussion symptoms not
exacerbated by treadmill test – vestibulo-ocular or
cervicogenic PCD
• Rapid and visible onset of symptom exacerbation
in those not fully recovered
Submaximal Exercise Prescription
• Exercise can be used to treat physiological PCD
– Animal studies: in therapeutic window, aerobic exercise can enhance
neurolgical and neurocognitive recovery
– Clinical studies: both pediatric and adult concussion patients show
high rate of symptom improvement with submaximal exercise
prescription
– Submaximal aerobic exercise programs
• Patients with worsening symptoms may need additional treatment on an
individual basis
Submaximal Exercise Prescription: J Neurosurg
106 Patients with SRC
141 Treadmill Tests
138 (97.9%) Well Tolerated/
Contributed Valuable
Information
65 Patients Tested to Verify
Recovery
63 (96.9%) Recovered
61 Patients Tested to
Classify PCS
58 Physiologic PCS 1 Cervicogenic PCS
2 Indeterminate
41 Patients with Physiologic
PCS Treated with Submax
Exercise Prescription
37 (90.2%) Improved
33 (80.5%)
Return to Sport
7 Migraine Headaches
1 Post-injury Psych D/OCordingley D, et al. J Neurosurg Pediatr. 2016 Dec; 18:693-702
Return to Sport
When Can They Return To Play?
• Improved symptoms
• Normal physical exam
• If NP testing done: Returned to baseline or
normative data
• Off all medications: Symptoms cannot be
masked
• Then athlete can start return to play
protocol: Usually guided by ATC
Graduated RTP Protocol
REHABILITATION STAGEFUNCTIONAL EXERCISE AT EACH STAGE OF
REHABILITATIONOBJECTIVE OF EACH STAGE
1. No activity Symptom limited physical and cognitive rest. Recovery
2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70%
MPHR
No resistance training.
Increase HR
3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact
activities.
Add movement
4.Non-contact training drills Progression to more complex training drills e.g. passing drills in
football and ice hockey.
May start progressive resistance training
Exercise, coordination, and cognitive load
5.Full contact practice Following medical clearance participate in normal training
activities
Restore confidence and assess functional
skills by coaching staff
6.Return to play Normal game play
Reconsider – Special Populations
• Elite athletes – should be
treated the same
• Pediatric – research is needed
– Child: age 5-12
– Adolescent: age 13-18
Residual Effects and Sequelae
Chronic Traumatic Encephalopathy
• Neurodegenerative disorder occurs
as a latent consequence of
cumulative repetitive head impacts
• Accumulation of perivascular tau
protein in the brain
• Only diagnosed post-mortem
• Symptoms include behavioral and
mood changes, and progressive
cognitive impairment
McKee, A, Alosco M, Huber, B. Neurosurgery Clinics of North America. 27 (2016) 529-
535.
Healthy brain, age 65: Former NFL player: Former boxer
Chronic Traumatic Encephalopathy
• First described in boxers “punch
drunk” in 1928
• Symptoms are heterogeneous
and overlap with other
neurodegenerative disorders
• Pathology can overlap with other
disorders
• Proposed 4 stages which
correlate to symptoms and
pathology (unclear if longitudinal)
85 Athlete Autopsies
20% “Pure”
CTE
52% CTE +
Another
Neuropathology
5% No
CTE
24% No
Neuropathology
Chronic Traumatic Encephalopathy
Clinical Presentation
(at least one of 3 domains)
Cognition
• Impaired concentration,
language, memory
• Executive dysfunction
• Visuospatial difficulties
• Dementia
Behavior/ Mood
• Apathy
• Aggression
• Impulsivity
• Depression
• Delusions
• Suicidality
Motor Function
• Dysarthria
• Spasticity
• Ataxia
• Tremors
• Gait disturbance
Chronic Traumatic Encephalopathy
• Heterogeneous symptom presentation
– Dependent on case reports
– Dependent on retrospective next-of-kin interviews
• Limitations
– Biased population
– No review of the medical record
» ? Family h/o mental disorders
» ? Socioeconomic background (retirement)
» ? h/o substance use/ PED
Gardner et al. British Journal of Sports Medicine. Jan 2014;48(2):84-90.
Chronic Traumatic Encephalopathy – Does
Everyone Get It??
Denominator Problem
153 pathology-proven cases
• 69 (45.1%) former boxers
• 63 (41.2%) former amateur/ professional football players
• 5 (3.3%) former hockey players
• 3 (2%) former professional wrestlers
• 7 (4.6%) miscellaneous
Incidence in NFL Players
who commit suicide or
show signs of aggression
?
Incidence in NFL Players
Estimated <4%
Incidence in all At Risk
Athletes
Estimated < 0.01%
Gardner et al. British Journal of Sports Medicine. Jan 2014;48(2):84-90.
Each year….
• 3 million kids play youth football
• 1 million play in HS
• ~70,000 play at collegiate level
• ~2,500 professional players
• “Of the ~44 MILLION PLAYERS, only 63 cases (111) of FB players have
been diagnosed with CTE in the last 10 years”
• Recent study of former High School football players from 1956-1970 did
not show increased risk of dementia
Weighing the childhood risks of contact sports; J Maroon, J Bailes. 1/29/15 The Washington Times
Janssen, PH, et al. Mayo Clinic Proc. 2017 Jan(92)1: 66-71
CTE: Take Home Points
• Mechanism behind the neuropathology and clinical
presentation is unclear
• No prospective or longitudinal studies exist
• CTE may be more than one entity given histopathology and
presentation variation
• Relation between CTE and quality/ quantity of head trauma is
unclear
– Selection bias
– Denominator problem
– Incomplete medical records/ other variables
Risk Reduction
Prevention?
• No evidence that special helmets or mouth guards protect against concussions
• Delaying/ eliminating contact practice is debatable
• Proper technique in their sport/ rule changes
– Football
– Hockey
• Neck strengthening is being researched
• Educate athletes, parents, coaches, administrators, ATCs
• Neck collars to reduce cerebral venous return
Prevention
• Helmets are effective at
reducing skull fractures, scalp
lacerations and intracranial
bleeds
• May help lessen forces and
reduce concussion severity
• Does not reduce concussion
incidence
• May encourage head use
Prevention
• Decreasing contact practices
– There are more concussions during games than practices
– There are many more practices than games during a season
– Reducing the number of contact practices should reduce concussion
incidence
• But:
– Decreasing practice in tackling/ body checking technique could
increase concussion incidence and severity during games
– Decreasing contact practice and teaching technique can be done
simultaneously
Prevention
• Rule Changes
– Football: Spear tackling
– Hockey: Checking from behind
– Soccer: Elbow to the head
• Must be enforced and may require culture change
– Unclear effect of concussion incidence so far
– Zero tolerance for illegal hits
Cervical Collar
Smith, et al. 2013 Orthopedic
Journal of Sports Medicine
High school sports played at
higher altitude – 31%
reduction in concussion
incidence
Slosh Mitigation
Theory
Adjustment to altitude
may increase
intracranial blood
volume – “tighter fit” of
the brain in the cranium
Jugular vein compression –
Increased volume of the
venous capacitance vessels of
the cranium
Gregory D Myer et al. Br J Sports Med doi:10.1136/bjsports-
2016-096134
Summary
– Recognize – concussions are common, occur in all sports
– Remove – a player with concussion should not be allowed back in the game until evaluated
– Re-evaluate – several tools are available to assess and monitor concussion
– Rest – Initial rest is often needed, but return to school/ work is important
– Recovery – most concussions resolve in 1-4 weeks, younger patients may take longer
– Rehabilitation – Vestibular, ocular and cervical rehab can be helpful for post-concussive symptoms depending on the subtype
– Refer – Concussion specialists should be consulted if concussion symptoms persist past the expected recovery period
– Return to Sport – Done in a 6 step, graded fashion, symptom-dependent
Summary
• Reconsider – Special populations such as elite athletes and
pediatric patients
• Residual Effects/ Sequelae – More research is needed to
evaluate the relationship between CTE and head trauma
• Risk Reduction – No known equipment, therapy or devices
can prevent concussion. Rule changes at the youth and
professional level may help
Questions?