Update on Concussion
Felicia Gliksman , DO, MPH
Pediatric Neurology
Joseph M. Sanzari Children’s Hospital
Hackensack University Medical Center
Assistant Professor
Seton Hall University-Hackensack
Meridian SOM
Objectives
-Incidence of concussion
-biomechanism of concussion
-signs and symptoms of concussion
-sideline evaluation of concussion
-possible short/long term effects
-when is further specialist evaluation needed?
-recommended testing/treatment/management
AAN, CDC, Zurich guidelines and
recommendations
Concussion Definition
(5th International Consensus Conference on Concussion in Sport)
AKA: mild traumatic brain injury
clinical syndrome of biomechanically
induced alteration of brain function,
typically affecting memory and
orientation, which may involve loss of
consciousness (LOC).
Features of Concussion
 May be caused by blow to head, face, neck, or elsewhere on
body with an impulsive force transmitted to the head
 Typically results in the rapid onset of short-lived impairment
of neurological function that resolves spontaneously. However,
in some cases, signs and symptoms evolve over a number of
minutes to hours.
 May result in neuropathological changes, but the acute clinical
signs and symptoms largely reflect a functional disturbance
rather than a structural injury and, as such, no abnormality is
seen on standard structural neuroimaging studies
Features of Concussion
 Results in a range of clinical signs and symptoms that may or
may not involve loss of consciousness. Resolution of the
clinical and cognitive features typically follows a sequential
course. However, in some cases symptoms may be prolonged.
 Clinical signs and symptoms cannot be explained by drugs,
alcohol, or medications, or other injuries such as:
 cervical injuries
 peripheral vestibular dysfunction
 other comorbidities: psych, co-existing medical conditions
Biomechanics
 Possible mechanisms of injury include:
 during trauma, the brain moves, twists, and experiences forces that cause
movement of brain matter.
 This sudden movement or direct force applied to the head can set the brain
tissue in motion even though the brain is well protected in the skull
 This motion squeezes, stretches and sometimes tears the neural cells.
 The stretching and squeezing of brain cells from these forces can change how
the brain processes information.
Biomechanics
All of the different mechanisms may result in
biochemical changes related to perfusion, energy
demand, and utilization at the site of injury and are
entirely well understood
Although the stretching and swelling of the axons
may seem relatively minor or microscopic, the
impact on the brain’s neurological circuits can be
significant. Even a “mild” injury can result in
significant physiological damage and cognitive
deficits.
(Giza & Hovda, 2001)
500
Calcium
% of normal
400
K+
300
Glucose
200
Glutamate
100
50
0
2
6
12
20
minutes
30
6
24
hours
3
6
days
Cerebral Blood Flow
UCLA Brain Injury Research Center
10
 Physical forces disrupts brain function
 Cascade for ionic, metabolic, and pathophysiological events
 Microscopic axonal injury
Increased energy demand
 Decreased cerebral blood flow
 Mitochondrial dysfunction
decreased energy supply
Brain Metabolism following mTBI
 Proton magnetic resonance





spectroscopy
Recovery of neuronal
metabolism marker in 40
athletes following concussion
N-acetylaspartate/creatinecontaining compounds
ratio
Concussive head injury
window of brain vulnerability
from cellular energetic
metabolism impairment
Symptom recovering 3-15 days.
Normalized metabolism by
30 days
Brain 2010;133(11):3232-3242
Concussion Recovery
Brain Metabolism
30
Concussive
Symptoms
15
Ion Imbalance
4
0
8
15
Time (days)
23
30
38
Concussion Recovery Timeline
Repeat Injury
DYSFUNCTION
Typical Concussion
Onset
TIME
Resolution
Signs of concussion
 Features of concussion frequently observed
 − Vacant stare
 − Delayed verbal and motor responses
 − Confusion and inability to focus attention
 − Disorientation
 − Slurred or incoherent speech
 − Gross observable incoordination
 − Emotions out of proportion to circumstances
 − Memory deficits
 − Any period of loss of consciousness
Symptoms of concussion
− Early (minutes and hours)
− Headache
− Dizziness or vertigo
− Lack of awareness of surroundings
− Nausea or vomiting
Late (days to weeks):
 − Persistent low grade headache
 − Light-headedness
 − Poor attention and concentration
 − Memory dysfunction
 − Easy fatigability
 − Irritability and low frustration
tolerance
 − Intolerance of bright lights or
difficulty focusing vision
 − Intolerance of loud noises,
sometimes ringing in the ears
 − Anxiety and/or depressed mood
 − Sleep disturbance
National TBI Estimates
 In 2013, about 2.8 million emergency department (ED) visits,
hospitalizations, or deaths were associated with TBI—either
alone or in combination with other injuries—in the United
States.


TBI contributed to the deaths of more than 50,000 people.
30% of all injury deaths
 In 2012, an estimated 329,290 children (age 19 or younger)
were treated in U.S. EDs for sports and recreation-related
injuries that included a diagnosis of concussion or TBI.
 from 2001-2012 rate of ED visits for sports and red-related
injuries dx with concussion or TBI more than doubled
TBI
 Concussions or other forms of mild TBI account for about 75% of TBIs that
occur each year
 Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults
aged 65 years and older are most likely to sustain a TBI.
 From 2007-2013, TBI related ED visits increased by 47%, hospitalization rates
decreased 2.5% and death rates decreased by 5%.
 CDC and Prevention estimates that 300,000 concussions are sustained during
sports-related activity in the United States, and more than 62,000 concussions
are sustained each year in high-school contact sports
Concussion
Increasing incidence of sports-related
concussion

Due to increase number of young athletes

Due to increase awareness and reporting of concussions

Variability in care provider experience and training,
coupled with an explosion of published reports related to
sports concussion and mTBI, has led to some uncertainty
and inconsistency in the management of these injuries.
Epidemiology: Boys Sports
19
0.75
Lincoln
Castile
0.00

Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med.
2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school
athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among
United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755
Epidemiology: Girls Sports
20
0.40
0.30
0.20
0.10
Lincoln
Cast
0.00
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med.
2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school
athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United
States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755
Concussion Epidemiology
21
Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports
Med. 2012;40(4):747–755
Risk Factor for Sports Concussions
Increased Risk of
Concussion
Prolonged Recovery
 Past concussion
 Number, severity and duration
 Female athletes
of symptoms
 H/o migraines, depression,
mood disorders, or anxiety, and
developmental disorders
(learning disabilities, ADHD)
 Youth
 Certain sports, positions and
individual playing styles
Harmon KG, et al. Br J Sports Med 2013;47:15–26
How to minimize the risk of concussion through
primary prevention
 Teach safe techniques in practice and play (coaches,
AT)
 Encourage recognition and reporting of concussion
symptoms
 Be aware that injuries are more common in younger
athletes
 Use available assessment tools (sideline, office)
 Monitor developments at advanced levels of play and
legislative efforts
 Head and spine injury prevention programs
 A PLAYER TAKES A HIT TO THE HEAD...
 ...ON SITE/SIDELINE EVALUATION WHEN A
CONCUSSION IS SUSPECTED...
Sideline testing
25
 Various tools
 Sport Concussion Assessment Tool 5 ([SCAT5]
includes SAC, BESS, others).
 Cannot be performed correctly under 10 minutes
 Standardized Assessment of Concussion (SAC)
 Symptom Assessment
 Balance Error Scoring System (BESS)
 Domains that may add to the clinical utility of the
SCAT tool include clinical reaction time,
gait/balance assessment, video-observable signs
and oculomotor screening.
SCAT5
• A standardized method of evaluating injured athletes for concussion and can be used in
athletes aged from 10 years and older.
• Assessment Includes:
• Symptoms: 22 possible
•
Cognitive & Physical Assessment
• LOC?
• Glasgow coma scale: eye, verbal, motor
• Orientation: Month, Date, Day of the week, year, time?
• Immediate Memory recall: 5 word recall: (elbow, apple, carpet, saddle,
bubble)
• Concentration:
• Repeat Digits Backwards: 3-9-7, 4-6-1-0, 2-9-6-1-4
• Months of the year in reverse order
• Balance
• Coordination
• *Now available to download as an app onto a smart phone.
Balance Error Scoring System (BESS)
27
Medical Workup of concussion
Neurologic Examination
Mental status
Cranial nerves (EOM, pupillary response
etc)
Motor: strength/weakness
DTRs
Cerebellar/Balance (FNF, Romberg)
Sensation
Common with Concussion
 Mental Status: may be impaired
 Balance: Impaired tandem gait or





single leg balance, abnormal BESS
CN: nystagmus, saccades
Strength: Normal, symmetric
DTR: normal
FTN: may be slightly abnormal
GAIT: tandem gait my be ataxic,
casual gait should be normal.
May Indicate more Serious
injury
 Mental Status: significantly impaired
 Balance: Romberg, postural instability
 CN: unequal or fixed pupils, visual




field deficit, abnormal EOM
Strength: asymmetric, focal weakness
DTR: hyper-reflexia, Babinski, clonus,
FTN: uncoordination
GAIT: ataxic
Red Flags for ED referral / Urgent work up
 Glascow Coma Score < 14
 Concern for intracranial process
 Evidence of a skull fracture
(bruising under eyes, behind
ears, or swelling of the head)
 Concern symptoms are not
related to recent minor head
trauma
 Severe or progressively







worsening headache
Seizure activity
Unusual behavior
Lethargy
Unsteady casual gait/ataxia
Slurred speech
Weakness or numbness in
extremities
Focal neurologic examination
CLIN PEDIATR October 2015 vol. 54no. 11 1031-1037
If abnormal neurological exam…
• May include:
• CT or MRI scanning
• Recommended in all instances where headache or other associated
symptoms worsen or persist longer than one week.
• should not be used to diagnose sport-related concussion but might be
obtained to rule out more serious TBI such as an intracranial hemorrhage
in athletes with a suspected concussion who have loss of consciousness,
posttraumatic amnesia, persistently altered mental status (Glasgow Coma
Scale <15), focal neurologic deficit, evidence of skull fracture on
examination, or signs of clinical deterioration
• PECARN algorithm
• Terminating the season for player is mandated by any abnormality on CT
or MRI scan (brain swelling, contusion, bleed etc)
• CT imaging and Neurosurgical evaluation or transfer to a trauma center
• Prolonged unconsciousness, persistent mental status alterations,
worsening postconcussion symptoms, or abnormalities on neurologic
examination
NeuroImaging
CT
 Not recommended for
routine concussion
evaluation
 Sensitive for skull fracture
and intracranial
hemorrhage
 Test of choice in first 2448 hours after injury
 Will not rule out chronic
subdural or
neurobehavioral
dysfunction
MRI
 Not recommended for routine
concussion evaluation
 More sensitive for cerebral
contusion, petechial
hemorrhage, white matter
injury, posterior fossa
abnormalities
 Gradient Echo and perfusion
and diffusion tensor imaging
may detect white matter injury
better but clinical usefulness is
not established.
Secondary Conditions Associated with Concussions
 Intracranial Hemorrhage
 Skull Fracture
 Epidural Hemorrhage
 Subdural Hemorrhage
 Intracerebral Hemorrhage
 Cerebral Hyperemia
 Cerebral Edema
 Seizures
 Migraine Headaches
Intracranial Hemorrhage
Intracranial bleeding
Venous bleeding
Slow, insidious onset
Arterial bleeding
S/S apparent within a few
hours
Intracranial Hemorrhage
Early S/S
 Severe head pains
 Dizziness
 Nausea
 Unequal pupil sizes
 Sleepiness
Severe S/S
 Deteriorating
consciousness
 Neck rigidity
 Slow pulse
 Slow respiration
 Convulsions
Epidural Hemorrhage
 A blow to the head causes a
tear in one of the arteries of in
the dural membrane that
covers the brain
 Hematoma forms extremely
fast
 Within 10 – 20 minutes
after injury
 Requires surgery to relieve the
pressure created by the
hematoma
 Death or permanent disability
may result
Subdural Hemorrhage
 A blow to the head causes
a tear in one of the veins
located between the dura
mater and the brain
 Hematoma forms slowly
 S/S may not be appear
until hours after injury
 Commonly occurs
following a contrecoup
injury
 May or may not require
surgery
Cerebral Hyperemia
 Vasodilation of cerebral blood vessels following a
head/brain injury
 Causes an increase in intracranial blood pressure
 Develops within minutes after the injury
 S/S: headache, vomiting, sleepiness
 S/S usually resolve within 12 hours after the injury
Cerebral Edema
 Localized swelling of the brain at the injury site
 Develops within 12 hours after the injury
 S/S: headache, seizures (occasionally)
 Cerebral edema may remain for as long as 2 weeks
following the injury
Intracerebral Hemorrhage
 A blow to the head may cause bleeding within the
brain itself
 Usually results due to a compressive force applied
to the brain
 Rapid deterioration in neurological function
 Requires immediate hospitalization
ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)
What is available?
 ImPACT (5-11yo, 12+)
 Axon Sports (playing cards test)
 Concussion vital signs
 Automated Neuropsychological Assessment
Metrics ([ANAM] primarily military)
 HeadMinder
 Formal pencil and paper testing with
neuropsychologists
Issues with available tests
42




Standard for Assessment

How often? Testing while symptomatic?

“We suggest initial evaluation 24–72 hours after injury. Consult a
physician for interpretation of ImPACT test results…second post-injury
test should be administered 1–2 weeks after the initial post-injury test. We
strongly discourage testing more than once a week.”
Baseline vs No Baseline
Cost
Who will interpret?
Neuropsychological testing
43
 May be a part of a comprehensive concussion evaluation
program
 May help identify the ‘not so forthcoming’ athlete
 For more concrete and specific neurocognitive evaluation,
especially when considering significant or prolonged school
adjustments → involve neuropsychologist for more formal testing
 can be used as a starting point for a plan of rehabilitation.
 It can assist brain injury professionals in identifying specific
cognitive areas that have been damaged, as well as those areas
still intact.
 Used as basis for CBT
“
Other testing???
 “Advanced neuroimaging, fluid biomarkers, and
genetic testing are important research tools but
require further validation to determine clinical utility
in evaluation of SRC”
Assessments
45
 DO NOT Predict
length of recovery.
 Provide prognosis for future problems.
 Act as the sole determining factor for return to
play.
 Act as a red light/green light.
Putting it all together
46
 Same assessments that are done on the field may
not be as helpful in the office
 SCAT5―“S” is for “Sideline”
 Symptom score checklists
 Neurological examination
 Concussion history
 Balance assessments
 Most helpful first 3 days
 Vestibular system assessments
 School difficulties
Outcomes
 TBI can cause a wide range of functional short- or
long-term changes affecting thinking, sensation,
language, or emotions.
 Thinking (i.e., memory and reasoning);
 Sensation (i.e., touch, taste, and smell);
 Language (i.e., communication, expression, and
understanding); and
 Emotion (i.e., depression, anxiety, personality
changes, aggression, acting out, and social
inappropriateness).
Outcomes
 TBI can also cause epilepsy
 Increase the risk of Alzheimer’s disease, Parkinson’s
disease, and other brain disorders that become more
prevalent with age.
 Repeated mild TBIs occurring over an extended
period of time (i.e., months, years) can result in
cumulative neurological and cognitive deficits.
 Repeated mild TBIs occurring within a short period
of time (i.e., hours, days, or weeks) can be
catastrophic or fatal.
Outcomes
 A repeat concussion that occurs before the brain
recovers from the first—usually within a short period
of time (hours, days, or weeks)—can slow recovery or
increase the likelihood of having long-term problems.
 In rare cases, repeat concussions can result in edema
(brain swelling), permanent brain damage, and even
death =second impact syndrome
Outcomes
50
 Photo courtesy of Boston University, McKee Lab
Prevention in Sports
 Preseason: concussion policy
players sign “concussion contract”
 trainers and coaches take mandatory concussion training
course

 Action plan if concussion occurs:
remove from play until evaluated by healthcare professional
 Inform the athlete’s parents or guardians about the possible
concussion and give them the fact sheet on concussion.

 Educate coaches, athletes, parents
 Monitor the health of the athletes
Prevention
 Safety first
 Safe playing techniques, good sportsmanship, protective
equipment
 Teach athletes it’s not smart to play with a
concussion.
Rest is key
 wrongly believe that it shows strength and courage to play
injured.
 Discourage others from pressuring injured athletes to play.
 Don’t let the athlete convince you that they’re “just fine.”

Prevention
 Prevent long-term problems.
 If an athlete has a concussion, their brain needs time to heal.
 No return to play until cleared by health care professional
 Work closely with league or school officials.
 Be sure that appropriate individuals are available for injury
assessment and referrals for further medical care
Consensus Statement on Period of Rest
• There is currently insufficient evidence that prescribing complete rest
achieves outcome objectives.
• After a brief period of rest during the acute phase (24–48 hours) after
injury, patients can be encouraged to become gradually and
progressively more active while staying below their cognitive and
physical symptom-exacerbation thresholds (ie, activity level should
not bring on or worsen their symptoms).
• It is reasonable for athletes to avoid vigorous exertion while they are
recovering.
• The exact amount and duration of rest is not yet well defined in the
literature and requires further study.
Recovery
 May be slow!!!
 Majority (80-90%) resolve in short (7-10 day)
period
 May take longer in children and adolescents (4
weeks!)
 Everyone “feels fine”
 Always ask:
1.“On a scale of 0 to 100%, how do you feel?”
2.“what makes you not 100%?”
3. Symptom Checklist – SCAT5 (only good for first few
days)
Recovery
57
• May need time away from school, untimed testing, less
homework, modified school day
 Avoid doing anything that could cause another blow or
jolt to the head.
 Reaction time slower
 Should not drive, ride a bike, etc
 Write things down if having a hard time remembering.
 May need help to re-learn skills that were lost.
 May
need CBT (cognitive behavior therapy)
Possible recommendations
 No significant classroom or standardized testing at
this time.
 Check for the return of symptoms when doing
activities that require a lot of attention or
concentration.
 Take rest breaks during the day as needed.
 Request meeting of 504 or School Management
Team to discuss this plan and needed supports.
 Refer to: Neurosurgery/Neurology/Sports
Medicine/Physiatrist/Psychiatrist/ Refer for
neuropsychological testing
59
RETURN TO LEARN
BEFORE
RETURN TO PLAY
Return to Play
60
Do not allow to return to game/practice if
suspected or diagnosed concussion on day of
injury (need to wait 24 hours)
Do not allow return to play until asymptomatic at
rest
Not a defined, set time frame (ie, 7 days, 2 weeks,
etc.) but need to be symptom-free from at least a
week (and off meds!)
Progressive, step-wise approach to return to play
Full return to school first
Criteria to Return to Play
 Normal neurological function
 Normal vasomotor functions
 Normal balance
 Free of headaches
 Free of lightheadedness
 Free of dizziness
 Free of seizures
Recovery
• SRCs can result in diverse symptoms and problems,
can be associated with concurrent injury to the
cervical spine and peripheral vestibular system.
• The literature has not evaluated early interventions, as
most individuals recover in 10–14 days.
• A variety of treatments may be required for ongoing or
persistent symptoms and impairments following
injury.
• The data support interventions including
psychological, cervical and vestibular rehabilitation.
Recovery
• Closely monitored active rehabilitation programs- involving
controlled sub-symptom-threshold, submaximal exercise have
been shown to be safe and may be of benefit in facilitating
recovery.
• A collaborative approach to treatment, including controlled
cognitive stress, pharmacological treatment, and school
accommodations, may be beneficial.
Post-concussion syndrome
Failure of normal clinical recovery
• symptoms that persist beyond expected time
frames
• >10–14 days in adults
• >4 weeks in children
Treatment
Treatment should be individualized and target-specific medical,
physical and psychosocial factors identified on assessment. There is
preliminary evidence supporting the use of:
a an individualized symptom-limited aerobic exercise program in
patients with persistent post-concussive symptoms associated
with autonomic instability or physical deconditioning, and
b a targeted physical therapy program in patients with cervical
spine or vestibular dysfunction
c a collaborative approach including cognitive behavioral therapy
to deal with any persistent mood or behavioral issues.
Active Recovery- 4 Steps
Active treatment does not mean players immediately return to play. To ensure
the best recovery, post-concussion, activity should be:
• Supervised. Activity should be guided by an expert.
• Low-level. The level of exertion should vary from person to person, but overall, activity
should use less than 60 percent of the body's total exertion.
• Progressive. People should start recovery by engaging in a small amount of activity and
increase activity as symptoms allow.
• Individually tailored. Adapt therapy to suit individual symptoms and needs.
• ex: person who has dizziness and vertigo after a concussion should engage in balancebased exercises.
• Patients who have trouble moving their eyes should be prescribed vision therapy, with
exercises and tools designed to improve focusing and other eye functions.
Although new research supports the benefit of this protocol, the experts say more research is
needed, including clinical trials, to build on these findings.
Management of Symptoms
67
 No evidence for efficacy and safety of nonsteroidal antiinflammatory drugs (NSAIDs) or other medication in
management of sport concussion
 May be helpful for symptoms of post-concussive symptoms
(typically all off-label uses)
 Sleep aids, attention-deficit disorder (ADD)
medications, non-conventional headache medications,
antidepressives
 Athlete must be off medication and symptom-free before
return to sports
 “Where pharmacological therapy may be begun during the management of an SRC, the
decision to return to play while still on such medication must be considered carefully by
the treating clinician.”
Withdrawal from season/sport
68
No magic number
Consider for prolonged symptoms, multiple
concussions
Involve someone experienced in sport concussion
management
Graded Return To Play Protocol
Rehabilitation Stage
Functional Exercise at each stage
1. No activity
Complete physical and cognitive rest
(stage may be the longest
2. Light aerobic activity
Walk, swim, stationary bike, keep
intensity<70% of max HR, no
resistance training
3.Sport- specific exercise
Skating drill (ice hockey), running
(soccer), no head impact activities
4. Non-contact training skills
Progression to more complex training
drills. May start resistance training
5. full-contact practice
After medical clearance, participate in
normal training activities
6. Return to play
Normal game play
 Each stage is AT LEAST 24 HOURS
 Therefore should take >5 days to complete
“Modifiers” that can prolong recovery
Factors
Modifiers
Symptoms
number, duration >10days, severity
Signs
LOC >1min, amnesia
Sequelae
Concussive convulsions
Temporal
Frequency (repeated conc), timing (close in time),
“recency”
Threshold
Repeated conc. Occurring with progressively less
impact or slower recovery after each successive
conc
Age
<18yo
Comorbidity/premorbity
Migraine, depression, other, ADHD, LD, sleep
disorder
Medication
Psychoactive drugs, anticoag
Behavior
Dangerous style of play
Sport
High-risk, contact/collision/high sporting level
Where to get resources
 www.cdc.gov/concussion
 www.aan.com
Available Tools
Take home points for players
 Don’t hide it
 Report it
 Take time to recover
 It’s best to miss one game than the whole season
Facts on Helmets
 Bicycle helmets are 85% effective in reducing
traumatic brain injuries
Only 40% of cyclists wear
helmets
www.thinkfirst.org
There is no such thing as a concussion proof helmet
“The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time”.
Any Questions???