sport related concussion pathology (patients with mtbi who died of other causes) • microscopic...

Sport Related Concussion

Andy Peterson MD MSPH FAAP

Disclosures

• I have no financial or personal interests in

products discussed today

• I may briefly discuss off-label use of

medications for the treatment of post-

concussion symptoms.

• I will discuss only 1 brand of NCT. Several

others are available on the market.

• Definitions

• Basic Pathophysiology (and CTE)

• Basic Epidemiology

• Iowa Concussion Law

• Common Misconceptions

• Review of Recent Concussion Guidelines

• (Concussion Clinic Protocol and Evidence Base)

• Recognition / Evaluation / Return to Play

Covered Today

boring

not boring

471 concussion review articles in past 5 years!

• Definitions






• Concussion Clinic Protocol and Evidence Base


Covered Today

Concussion definitions:

• 1966 Congress of Neurological Surgeons

– Concussion is a clinical syndrome

characterized by immediate and transient

impairment of neural functions, such as

alteration of consciousness, disturbance of

vision, equilibrium, etc, due to mechanical

forces


• American Academy of Neurology:

– Trauma-induced alteration in mental status that

may or may not involve loss of consciousness.


• Zurich Statement – Concussion is defined as a complex pathophysiological process affecting the

brain, induced by traumatic biomechanical forces. Several common features that

incorporate clinical, pathologic and biomechanical injury constructs that may be

utilized in defining the nature of a concussive head injury include:

• Concussion may be caused either by a direct blow to the head, face, neck or elsewhere

on the body with an “impulsive” force transmitted to the head.

• Concussion typically results in the rapid onset of short-lived impairment of neurologic

function that resolves spontaneously.

• Concussion may result in neuropathological changes, but the acute clinical symptoms

largely reflect a functional disturbance rather than a structural injury.

• Concussion results in a graded set of clinical symptoms that may or may not involve loss

of consciousness. Resolution of the clinical and cognitive symptoms typically follows a

sequential course; however, it is important to note that, in a small percentage of cases,

post-concussive symptoms may be prolonged.

• No abnormality on standard structural neuroimaging studies is seen in concussion.

Common features: • May be caused by direct blow or transmitted blow to the head.

• Rapid onset of short-lived neurologic impairment that resolves

spontaneously.

• May cause neuropathological changes but symptoms usually

due to functional rather than structural injury.

• Typically follows a graded and sequential course.

• Usually does not involve loss of consciousness.

• Normal structural neuroimaging studies

Common symptoms

• Headache or head pressure

• Balance disturbance or dizziness

• Nausea

• Felling “dinged,” “foggy” or “stunned”

• Visual problems

• Hearing problems

• Irritibility or emotionality

Common cognitive features

• Unaware of score of game, period,

opposition

• Confusion

• Amnesia

• Loss of consciousness

Common physical signs • Transient impaired consciousness (GCS < 15)

• Poor coordination or balance

• Seizure

• Slow to answer questions or follow directions

• Easily distracted, poor concentration

• Inappropriate emotions

• Vomiting

• Vacant stare/glassy eyed

• Slurred speech

• Personality changes

• Inappropriate behavior

• Decreased playing ability

• Definitions








Covered Today

Gross/micro pathology (patients with MTBI who died of other causes)

• Microscopic axonal injury

• Axon retraction bulbs

• Microglial clusters

• (Tau deposition)

Pathophysiology • Cortical contusions

• Axonal rupture/stretch/shear

• Cell membrane permeability

• Release of excitatory neurotransmitters from injured axons impairs function of nearby cells – Acetylcholine

– Glutamate

– Aspartate

• ENERGETICS!

Farkas O, Lifshitz J, Povlishock JT. J Neurosci. 2006 Mar

A-C Neurons flooded with both dextrans revealing cellular injury with irregular distorted profiles

and vacuolization (arrows) Most severe show uptake in nucleus (double arrow)

D – Other double labeled axons demonstrate little or no pathologic damage

Chronic Traumatic Encephalopathy

Tau stain: NL 65yo John Grimsley 46yo 79yo former WC

boxer w/ dementia

Dave Duerson (and 153+ others)

Maroon et al. PLOS ONE. 2015.

• Definitions








Covered Today

Epidemiology

• Difficult due to underreporting

• Probably 1.6 to 3.8 million per year

• ~65% in 5-18yo

• Most do not come to clinical attention Nonfatal traumatic brain injuries from sports and recreation activities--United States, 2001-2005. MMWR Morb Mortal Wkly Rep.

Jul 27 2007;56(29):733-737.

McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention.

Clin J Sport Med. Jan 2004;14(1):13-17.

Lincoln AJSM 2011

Marar AJSM 2012

Zuckerman AJSM 2015

What do these have in common?

Football

Boxing

Hockey

Wrestling

Soccer

Rugby

Baseball

McKee Acta Neuropathol (2014) 127:29-51

2015 NCAA Wrestling Rule Change

Rule 6.1.5 – Referee Timeout, Concussion Evaluation Timeout

In the case of a possible concussion, the referee shall stop the

match for a concussion evaluation. The medical staff shall have

unlimited and unimpeded time to evaluate the participants. In

cases of uncertainty, the medical staff shall be granted the ability

to remove the participant from the wrestling area to perform the

concussion evaluation. During the evaluation, the match will be

suspended until a decision is rendered. The referee, the coaches

of both participants and the non-injured wrestler are to remain on

the mat. A concussion evaluation timeout shall not count towards

the contestant’s injury timeout or recovery timeout. Coaching of

the contestant being evaluated is not permitted.

• Definitions








Covered Today

Iowa Concussion Law BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

Section 1. NEW SECTION. 280.13C Brain injury policies.

1. a. The Iowa high school athletic association and the

Iowa girls high school athletic union shall work together to

distribute the guidelines of the centers for disease control

and prevention of the United States department of health and

human services and other pertinent information to inform and

educate coaches, students, and the parents and guardians

of students of the risks, signs, symptoms, and behaviors

consistent with a concussion or brain injury, including

the danger of continuing to participate in extracurricular

interscholastic activities after suffering a concussion or

brain injury and their responsibility to report such signs,

symptoms, and behaviors if they occur.

b. Annually, each school district and nonpublic school shall

provide to the parent or guardian of each student a concussion

and brain injury information sheet, as provided by the Iowa

high school athletic association and the Iowa girls high

school athletic union. The student and the student’s parent

or guardian shall sign and return the concussion and brain

injury information sheet to the student’s school prior to the

student’s participation in any extracurricular interscholastic

activity for grades seven through twelve.

Iowa Concussion Law

2. If a student’s coach or contest official observes signs,

symptoms, or behaviors consistent with a concussion or brain

injury in an extracurricular interscholastic activity, the

student shall be immediately removed from participation.

Iowa Concussion Law

3. a. A student who has been removed from participation

shall not recommence such participation until the student has

been evaluated by a licensed health care provider trained in

the evaluation and management of concussions and other brain

injuries and the student has received written clearance to

return to participation from the health care provider.

b. For the purposes of this section, a “licensed health care

provider” means a physician, physician assistant, chiropractor,

advanced registered nurse practitioner, nurse, physical

therapist, or athletic trainer licensed by a board designated

under section 147.13.

c. For the purposes of this section, an “extracurricular

interscholastic activity” means any extracurricular

interscholastic activity, contest, or practice, including

sports, dance, or cheerleading.

Iowa Concussion Law

Unintended Consequences?? (so far there is no evidence on either side)

• Incentive to under-report

• False sense of security

– Untrained coaches/officials

– Uncertainty about who can clear

• Bypass ATC?

• Transfer of liability

• Cost

• Second guessing officials

• Definitions








Covered Today

Johnny doesn’t have a concussion.

He didn’t get knocked out and had

a normal CT scan

Berrington et al. Projected Cancer Risk from Computed Tomographic Scans Performed in the United States in 2007. Arch Intern Med.

2009;169(22).

OK, when should I image? • In the hours after an injury if:

– Worsening symptoms

– Declining level of consciousness

– Worsening amnesia

– Progressive balance disturbance

– Focal neurologic deficits

• Later if:

– Seizures

– Declining mental status

What’s coming

• PET

• SPECT

• (fMRI)

• DTI with Tractography

Fractional Anisotropy

Wilde EA et al. Neurology. 2008 Mar

Free diffusion Diffusion in one direction

Singh Met al. Magn Reson Imaging. 2010 Jan

Qualities for an ideal biomarker?

1. Sample source (CSF, serum, saliva, urine)

2. Sensitivity and specificity

3. Signal vs background

Biomarkers of Brain Injury Biochemical

Marker

Physiologic Role Location Comment

Neuron Specific

Enolase

(NSE)

Involved in

increasing neuronal

chloride levels

Cytoplasm of

neurons, platelets,

RBC’s

Detectable within 6

hours, serum half

life of 24 hours

S100B

Calcium binding

protein, may inhibit

synaptic plasticity

Astroglia, bone

marrow, fat, skeletal

muscle

Detectable almost

immediately after

injury, ½ life 60 min

Myelin Basic Protein

(MBP)

Abundant protein in

myelin

Myelin Increased only after

severe TBI, peaks

48-72 hours

Cleaved Tau

(c-tau)

Microtubule

associated protein in

axons

Axons in the CNS Poor marker in

pediatric population

Glial Fibrillary Acidic

Protein

(GFAP)

Intermediate protein

of astroglial skeleton

Astroglial skeleton Peaks in 24-48

hours found only in

CNS

The more I rest now, the quicker I

will recover.

Moser, Glatts and Schatz. Jpeds. 2012.

49 high school and college athletes. Rest for 1 or 2 weeks

when concussed. Measured ImPACT.

Moser, Glatts and Schatz. Jpeds. 2012.

Thomas, et al. Pediatrics. 2015.

Silverberg, et al. JAMA Pediatrics. 2016.

I just got Johnny this sweet

mouthguard. It will protect him from

concussions.

John Stenger DDS

Notre Dame dentist

1964

5 case reports of players

who were concussion

prone before mouthguard

but not after

Wisniewski DDS

Guskiewicz PhD

2004

large NCAA dataset

506,297 exposures

369 concussions

McGuine PhD

Brooks MD

2014

large high school dataset

2287 players

134,437 exposures

211 concussions

“Unfortunately, no helmet can prevent a concussion”

“Unfortunately, no helmet can prevent acconcussion”

What does work?

• Limit hitting

• Limit hitting

• Limit hitting

• Limit hitting

• Maybe changing the way people hit

Pellman et al. Neurosurgery. 2004

Broglio, et al. JAT. 2016

Followed rule change – unlimited tackling to tackling 2x per week.

Broglio, et al. JAT. 2016

Johnny just got his third

concussion. I already told him that

this means he has to quit sports.

Number of Concussions

Am

ount

of

Bad

nes

s

When to consider disqualification

• Multiple lifetime concussions

• Persistent diminished performance

• Persistent post concussive symptoms

• Progressively prolonged recoveries

• Easy concussability

I sure am glad little Suzy doesn’t play such dangerous sports.

Marar AJSM 2012

I’m going to make

sure Billy doesn’t

start playing

football too early.

Gotta protect his

brain

OR 1.93 (1.74-2.15)

1.7% concussion 3.3% concussion

Increased risk PCS with mTBI2 1. Nation et al. Football-Related Injuries Among 6- to 17-Year-Olds Treated in US Emergency Departments 1990-2007. Clin Pediatr. 2011

Mar;50(3):200-7.

2. Falk et al. The specificity of post-concussive symptoms in the pediatric population. J Child Health Care. 2009 Sept;13(3):227-38.

Peterson et al. In press. OJSM. 2016.

• Definitions








Covered Today

My doctor told me that I have a

grade 2 concussion and can return

to play in a week.

What about LOC?

Does not predict severity,

neuropsychological test results,

duration of symptoms or balance test

results.

• Maroon JC, Lovell MR, Norwig J, Podell K, Powell JW, Hartl R. Cerebral concussion

in athletes: evaluation and neuropsychological testing. Neurosurgery. Sep

2000;47(3):659-669; discussion 669-672.

• Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. Mar

1 1975;1(7905):480-484.

• Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon JC. Does loss of

consciousness predict neuropsychological decrements after concussion? Clin J

Sport Med. Oct 1999;9(4):193-198.

• Leininger BE, Gramling SE, Farrell AD, Kreutzer JS, Peck EA, 3rd.

Neuropsychological deficits in symptomatic minor head injury patients after

concussion and mild concussion. J Neurol Neurosurg Psychiatry. Apr

1990;53(4):293-296.

• Erlanger D, Saliba E, Barth J, Almquist J, Webright W, Freeman J. Monitoring

Resolution of Postconcussion Symptoms in Athletes: Preliminary Results of a Web-

Based Neuropsychological Test Protocol. J Athl Train. Sep 2001;36(3):280-287.

• McCrory PR, Ariens T, Berkovic SF. The nature and duration of acute concussive

symptoms in Australian football. Clin J Sport Med. Oct 2000;10(4):235-238.

Zemek et al. JAMA. 2016.

• 9 large peds ER (PERC)

• 2 years

• 46 item derivation

• 2006 participants

• 9 item validation

• 1057

Low cut point

• Sensitivity 95%

• Specificity 18.1%

• NPV 85%

• PPV 36%

High cut point

• Sensitivity 20%

• Specificity 93%

• NPV 70%

• PPV 60%

Prague subtypes:

• Simple concussion

• Complex concussion

McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport,

Prague 2004. Br J Sports Med. Apr 2005;39(4):196-204.

Zurich subtypes:

McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in

Sport held in Zurich, November 2008. Br J Sports Med. May 2009;43 Suppl 1:i76-90.

McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich,

November 2012. Br J Sports Med 2013;47:250–258

1. Harmon KG, et al. American Medical Society for Sports Medicine Position Statement:

Concussion in Sport. Br J Sports Med. Jan 2013;47:15-26.

2. McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International

Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med

2013;47:250–258

3. Herring S, et al. Concussion (Mild Traumatic Brain Injury) and the Team Physician: A

Consensus Statement – 2011 Update. Med Sci Sports Exerc. Dec 2011;43(12):2412-22.

4. McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in

Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November

2008. Br J Sports Med. May 2009;43 Suppl 1:i76-90.

5. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the

2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. Apr

2005;39(4):196-204.

6. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First

International Conference on Concussion in Sport, Vienna 2001. Recommendations for the

improvement of safety and health of athletes who may suffer concussive injuries. Br J

Sports Med. Feb 2002;36(1):6-10.

7. Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association

Position Statement: Management of Sport-Related Concussion. J Athl Train. Sep

2004;39(3):280-297.

8. Concussion (mild traumatic brain injury) and the team physician: a consensus statement.

Med Sci Sports Exerc. Nov 2005;37(11):2012-2016.

Second Impact Syndrome

• By 1998, there had been 17 published cases. A review (McCrory 1998) demonstrated that only 5 of these were likely to be second impact syndrome

• Numerous case reports published in late 1990’s/early 2000’s. Validity of claims not rigorously reviewed.

17/138 had recent concussion!

What to know about Zurich 1. Don’t grade concussions

2. Symptoms are key (signs are less helpful)

3. LOC does not predict outcome

4. Amnesia poorly predicts outcome

5. Seizures do not predict outcome

6. Repeat concussions are probably bad

7. Kids aren’t just little adults

8. Elite athletes should not be treated differently

9. Use a graduated return to play McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich,


• Definitions








Covered Today

Concussion Clinic Protocol • Preseason Preparation

• Concussion Recognition

• Initial Concussion Evaluation

• Initial Rest

• Monitor Symptoms

• +/- Neurocognitive testing

• +/- All sorts of rehabilitation techniques

• Graduated return to play

Graduated RTP 1. Complete physical and cognitive rest.

2. Aerobic exercise (e.g. walking, swimming, stationary bike,

etc.) First easy, then harder.

3. Sport-specific exercise (e.g. skating, running, etc.)

4. Non-contact training drills (e.g. passing drills in football or

hockey)

5. Full contact practice

6. Normal game play



Preseason Assessment

• Concussion predicts concussion

• Girls are at higher risk

• Sport, position and style of play are strongest

predictors of risk

• Genetics - ???

• Mood, Learning and Attention Disorders

• Migraine headaches

Marar AJSM 2012

Pellman et al. Neurosurgery. 2004

Genetics • ApoE promoter (g-219T) homo

• OR 2.7 (1.1-6.8)1,2

• Tau ser53pro homo

• OR 8.4 (1.03-68.79)1

• Apo E2 + E4 + promoter

• OR 9.8 (1-96.6)1

• Previous concussion

• OR 1.75 (1.11-2.76)3

• Family History?

• Largest prospective cohort shows no association (Terrell,

unpublished ongoing research)

1. Terrell et al. APOE, APOE Promoter, and Tau Genotypes and Risk for Concussion in College Athletes. Clin J Sport Med. Jan 2008;18(1):10-17.

2. Tierney et al. Apolipoprotein E Genotype and Concussion in College Athletes. Clin J Sports Med. Nov 2010;20(6):464-468.

3. Hollis et al. Incidence, risk and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players. Am J Sports Med. Dec

2009;37(12):2328-33.

Migraine

Gordon et al. BJSM. 2006




• Initial Rest





Concussion Recognition (47.3% of concussions in HS football players unreported)

McCrea et al. CJSM. 2004.

Initial Evaluation

(most use SCAT3)

BJSM 2013

1. GCS

2. Maddocks sideline assessment score

3. Concussion Symptom Severity Score

4. Cognitive assessment

5. Neck Examination

6. Balance examination (Double, Single, Tandem

stance)

7. Coordination examination (FNF)

8. Delayed recall

Symptom Score Checklists

Lots of different scales and different items

Research still being conducted on usefulness

How many items?

Which questions?

Sensitivity/Specificity?

Predictability?

How to administer?

Clusters of scores?

17 64

X X

Time

Sym

pto

ms

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

To

tal S

co

re

Day

a2605F

Peterson, et al. CJSM 2014

-70

-60

-50

-40

-30

-20

-10

0

10

20

30

40

50

60

70

0 10 20 30 40 50 60 70 80 90 100

Sc

ore

Dif

fere

nc

e

Mean Day Score

Within Day score SD: 11.4 (95%CI: 9.9, 13.4 Repeatability coefficient: +/- 31.5 (two scores on the same day will differ within this limit 95% of the time.

Peterson, et al. CJSM 2014

BESS – Our best validated test??

Sensitivity 34-64%

Specificity 91%

Assuming 2/10000 concussion rate

99.8% of positive screening will be false

positive

McCrea. J Int Neuropsychological Soc. 2005

McCrea. JAMA. 2003

Guskiewicz. AJSM. 2000

Barr. J Int Neuropsychological Soc. 2001

BESS

Video 23 football athletes

7 scorers

18.9 15.4

-3.5 (“meaningful

difference” is 4)

95%CI -6.2 - 0.67

IRR 0.745, 0.653

Mathiasen et al. CJSM 2013

All Players

1st Test Mean (Std)

(n = 48)

2nd Test Mean (Std)

(n=48)

Mean ∆ (95% CI)

p-value

Cumulative BESS Score 20.3 (6.1)

16.8 (6.4)

-3.55 (-5.27 – -1.82)

0.0001

Cumulative Firm Score 5.0

(4.0) 3.6

(3.2) -1.36

(-2.35 – 0.38) 0.0079

Cumulative Foam Score 15.4 (4.0)

13.2 (4.4)

-2.18 (-3.66 – -0.71)

0.0047

Peterson and Slayman, CJSM 2014

King-Devick Test

King Devick

Lots of small recent studies

Methods can be questioned in many of the studies with conclusions being made No description of how unwitnessed concussions are being diagnosed

Unsure if there is applicability over time

Questions on confounding variables to performance Fatigue, learning effect, effort on test

Big PR machine for this test currently

“King-Devick Test in association with Mayo Clinic” Website says can be used for concussions, learning and reading

disabilities, dyslexia, sleep deprivation, ALS, Parkinson’s, MS, hypoxia

May have utility as one of the TOOLS in the toolbox but not conclusive evidence at this point that it can be a sole determinant for sideline evaluation of concussion

Not immune from sandbagging

Clinical Reaction Time Test

May be a ‘poor man’s’ neurocognitive

alterative to assessing reaction time

Good correlation with computerized reaction

times

Vestibular/Ocular Motor Screen (VOMS)

Worse symptoms?

Smooth Pursuit

Horizontal Saccade

Vertical Saccade

Convergence

Horizontal VOR

Visual Motion

Distance

Near Point Convergence

Mucha. AJSM 2015

Kontos. AJSM 2015

264 unconcussed college athletes

Similar test-retest reliability as Mucha

11% false positive rate men

33% false positive rate women

77% false positive rate if history of motion

sickness

Other

C3 Logix

BrainScope

Pupilometer

Eye tracking / saccade tools

Balance tools (iPad, Wii, biosway)

Visual evoked potential tools

Abnormal speech recognition tools

Who should perform the concussion

evaluation in competition?

Should coaches be present?




• Initial Rest





Rest/Monitor

• Mood

• Meds

• Activity




• Initial Rest





ImPACT Immediate Postconcussion Assessment and Cognitive Testing

• Computer based NCT

• 30-45 minutes (compared to 3h)

• Increases sensitivity for persistent

concussion symptoms (VanKampen

2006)

ImPACT

• Concussion Symptom Severity Score

• Word memory = learning and retention

• Design memory = learning and retention

• X&O’s = visual working memory and cognitive speed

• Symbol match = memory and visual motor speed

• Color match = impulse inhibition and visual motor speed

• Three letter memory = verbal working memory and cognitive speed

1. Schatz et al. Sensitivity and Specificity of the ImPACT Test Battery for Concussion in Athletes. Arch Clin Neuropsychol. 2006

Jan;21(1):91-9.

2. McCrea et al. Standard Regression-Based Methods for Measuring Recovery After Sport-Related Concussion. J Inter Neuropsychol Soc.

2005 Jan;11(1):58-69.

Remember, cNCT only improves sensitivity!




• Initial Rest





• NSAID for headache?2

• Triptans for migraines3

• Melatonin for sleep4,5

• TCA for somatic symptoms6,7

• SSRI or TCA for depression8-10

• Stimulants for distractability11

• Psychology for coping12-14

No medications really fix the problem1

1. Beauchamp et al. Pharmacology of traumatic brain injury: where is the “golden bullet”.

Mol Med 2008;14:731–40.

2. Lenaerts ME, Couch JR. Posttraumatic headache. Curr Treat Options Neurol 2004;6:507–

17.

3. Haas DC. Chronic post-traumatic headaches classified and compared with natural

headaches. Cephalalgia 1996;16:486–93.

4. Samantaray et al. Therapeutic potential of melatonin intraumatic central nervous system

injury. J Pineal Res 2009;47:134–42.

5. Maldonado et al. The potential of melatonin in reducing morbidity-mortality after

craniocerebral trauma. J Pineal Res 2007;42:1–11.

6. Tyler et al. Treatment of post-traumatic headache with amitriptyline. Headache

1980;20:213–6.

7. Dinan TG, Mobayed M. Treatment resistance of depression after head injury:

8. a preliminary study of amitriptyline response. Acta Psychiatr Scand 1992;85:292–4.

9. Fann et al. Cognitive improvement with treatment of depression following mild

traumatic brain injury. Psychosomatics 2001;42:48–54.

10. Silver JM, McAllister TW, Arciniegas DB. Depression and cognitive complaints

following mild traumatic brain injury. Am J Psychiatry 2009;166:653–61.

11. Whyte et al. Effects of methylphenidate on attention deficits after traumatic brain injury:

a multidimensional, randomized, controlled trial. Am J Phys Med Rehabil 2004;83:401–

20.

12. Tsaousides T, Gordon WA. Cognitive rehabilitation following traumatic brain injury:

assessment to treatment. Mt Sinai J Med 2009;76:173–81.

13. Cicerone KD. Remediation of “working attention” in mild traumatic brain injury. Brain

Inj 2002;16:185–95.

14. Ho MR, Bennett TL. Efficacy of neuropsychological rehabilitation for mildmoderate

traumatic brain injury. Arch Clin Neuropsychol 1997;12:1–11.

Leddy and Willer. Use of graded exercise testing in concussion and return to activity management. Curr Sports Med

Reports. 2013;12(6):370-6.




• Initial Rest





Graduated RTP 1. Complete physical and cognitive rest.

2. Aerobic exercise (e.g. walking, swimming, stationary bike,

etc.) First easy, then harder.

3. Sport-specific exercise (e.g. skating, running, etc.)

4. Non-contact training drills (e.g. passing drills in football or

hockey)

5. Full contact practice

6. Normal game play



OR, to frame as

covered, not-

covered

Covered

Things we all agree on

Things we kind of agree on

Areas of controversy / disagreement

Most common sideline tests

Guided discussion:

Sideline evaluation

Graduated RTP

Disqualification / retirement

Things we agree on

Concussions are probably bad.

Injured athletes should be removed from play

No same day RTP

Symptomatic athletes should not RTP

Graduated RTP

There is little to no role for protective equipment

If you are going to do testing, having a baseline

makes it more useful

Things we kind of agree on

All sideline concussion tests have significant limitations

Biomarkers, imaging and physiologic tests might be the

future, but aren’t ready for prime time

Sub-symptom aerobic exercise can safely be used when

the athlete is still symptomatic

Rest doesn’t really help that much.

Rules and legislation make a difference

No number of concussions threshold

Number of Concussions

Am

ount

of

Bad

nes

s

Things we disagree on / don’t know

cNCT

Role of sensors

Natural history

Risk stratification

Role of coincident mood disorder on persistent symptoms

Sport vs Blast vs MVA

Independent evaluators

Disqualification / retirement

Athletes who have ever had ICH

sport related concussion pathology (patients with mtbi who died of other causes) • microscopic...

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