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Outpatient Management of Concussion
David Lessman MD FAAP CAQSM
Primary Care Sports Medicine
Advocate Childrenrsquos Hospital ndash Park Ridge
Objectives
Define recognize and diagnose a patient with a concussion
Understand and implement ldquoReturn-to-Learnrdquo and ldquoReturn-to-Playrdquo guidelines
Primary Care Sports Medicine
AKA
Nonsurgical orthopedics
Musculoskeletal Medicine
Training Residency FM Pediatrics IM ER PM amp R
Fellowship (1-2 years)
Certificate of Added Qualification (CAQ)
Primary Care Sports Medicine
Focus on treating the patient to prevent injury improve performance and enhance overall health
Advocate Concussion Program
Team physicians
Advocate Lutheran General Hospital Primary Care Sports Medicine
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Nesset and Yacktman Pavilion
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Objectives
Define recognize and diagnose a patient with a concussion
Understand and implement ldquoReturn-to-Learnrdquo and ldquoReturn-to-Playrdquo guidelines
Primary Care Sports Medicine
AKA
Nonsurgical orthopedics
Musculoskeletal Medicine
Training Residency FM Pediatrics IM ER PM amp R
Fellowship (1-2 years)
Certificate of Added Qualification (CAQ)
Primary Care Sports Medicine
Focus on treating the patient to prevent injury improve performance and enhance overall health
Advocate Concussion Program
Team physicians
Advocate Lutheran General Hospital Primary Care Sports Medicine
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Nesset and Yacktman Pavilion
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Primary Care Sports Medicine
AKA
Nonsurgical orthopedics
Musculoskeletal Medicine
Training Residency FM Pediatrics IM ER PM amp R
Fellowship (1-2 years)
Certificate of Added Qualification (CAQ)
Primary Care Sports Medicine
Focus on treating the patient to prevent injury improve performance and enhance overall health
Advocate Concussion Program
Team physicians
Advocate Lutheran General Hospital Primary Care Sports Medicine
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Nesset and Yacktman Pavilion
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Primary Care Sports Medicine
Focus on treating the patient to prevent injury improve performance and enhance overall health
Advocate Concussion Program
Team physicians
Advocate Lutheran General Hospital Primary Care Sports Medicine
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Nesset and Yacktman Pavilion
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Advocate Lutheran General Hospital Primary Care Sports Medicine
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Nesset and Yacktman Pavilion
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Yacktman Pavilion ndash Pediatrics
Nesset Pavilion - FM
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Phil Skiba DO
Kara Vormittag MD
David Lessman MD
Yacktman
Nesset
Oct 6
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Just a little historyhellip
International Symposia for Concussion in Sport
Vienna Austria in 2001
Prague Czech Republic 2004
Zurich Switzerland 2008
Zurich Switzerland 2012
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Legislation
Zackery Lystedt Law (2009)
Washington became the first state to pass a concussion law
Since 2009 all 50 states and Washington DC have developed concussion laws [last was Mississippi Jan 30 2014]
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Illinois State Law July 2011 HB0200
School boards to work with IHSA to educate coachesathletesparents about concussions
Info sheet to be signed prior to participation Suspected concussions removed from play
immediately No return to play until evaluated by a licensed
health care provider trained in the evaluation and management of concussions and head injuries and the student athlete receives written clearance to return to play from that health care provider
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
HOW DO YOU DEFINE CONCUSSION
Traumatically induced transient
disturbance of brain function that
involves a complex pathophysiologic
process
Harmon 2013
Concussion is recognized as a
clinical syndrome of biomechanically
induced alteration of brain function
typically affecting memory and
orientation which may or may not
involve loss of consciousness
(LOC)Giza 2013 AAN
A complex
pathophysiological process
affecting the brain induced
by biomechanical forces
McCrory 2012
ldquoConcussionrdquo was found to be
unintentionally communicating to
parents that a brain injury had not
occurred resulting in less than
adequate follow-up
DeMatteo CA My child doesnrsquot have a brain injury he only has a concussion Pediatrics 2010
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
What is a Concussion
1 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
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Definition
2 Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously However in some cases symptoms and signs may evolve over a number of minutes to hours
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Definition
3 Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such no abnormality is seen on standard structural neuroimaging studies
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Definition
4 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 some cases symptoms may be prolonged
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport
held in Zurich November 2012 Clin J Sport Med 201323 (2)89ndash117
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Signs and Symptoms
Physical HA nausea vomiting
dizziness photophobia phonophobia balance problems
Cognitive lsquofoggyrsquo memory problems
confusion
Emotional Irritability sadness
Sleep Drowsiness difficulty
falling asleep
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
ldquoIf yoursquove seen one concussion yoursquove seen ONE concussionrdquo (Herring Seattle)
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Neuronal Disruption
Increased Demand for
ATP amp Glucose
Potassium Efflux
Calcium Influx
Release of Glutamate
Increased Potassium Efflux
ldquoMetabolic Crisisrdquo
Pathophysiology
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Epidemiology
CDC estimates 16-38 million concussion per year in US sports
1997-2007 ER visits for sports concussion doubled (8-13 yrs)
Increased by greater than 200 (14-19 yrs) (Peds 2010)
Recurrence Risk 4-6x increase for 2nd injury
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Epidemiology Boys Sports
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
0
01
02
03
04
05
06
07
Footb
all
Hockey
Lacr
osse
Socc
er
Wre
stlin
g
Basketb
all
Baseball
Swim
Dive
Lincoln
Castile
Marar
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Epidemiology Girls Sports
0
005
01
015
02
025
03
035
04
Socc
er
Lacr
osse
Basketb
all
Softb
all
Field
Hock
ey
Cheerleadin
g
Volleyb
all
Swim
Dive
Gymnas
tics
Lincoln
Castile
Marar
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
201139(5)958ndash963 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 201246(8)603ndash610 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 201240(4)747ndash755
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Concussion Epidemiology
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J
Sports Med 201240(4)747ndash755
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Common Symptoms
0
20
40
60
80
100
Headach
e
Dizzin
ess
Difficu
lty C
oncentra
ting
Confusio
n
Visual C
hanges
Amnesia LO
C
Meehan
Castile
Meehan WP 3rd drsquoHemecourt P Comstock RD et al High school concussion in the 2008-2009 academic year mechanism symptoms and management A J Sports Med 201038(12)2405ndash2409 Castile L Collins CL McIlvain NM et al The epidemiology of new versus recurrent sports concussions among high school athletes 2005-2010 Br J Sports Med 201246(8)603ndash610
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Dangers of Concussion
Second Impact Syndrome
Chronic Traumatic Encephalopathy
Post-concussion syndrome
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Second Impact Syndrome
Cerebral swelling from a second concussion while the patient is still symptomatic from an earlier concussion
Disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased intracranial pressure leading to herniation
Leads to death or devastating neurological injury
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Second Impact Syndrome
Symptoms usually immediately following second impact and progress rapidly
Dilated pupils
Altered mental status
Loss of consciousness
Coma
Death
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Chronic Traumatic Encephalopathy (CTE)
ldquoPunch Drunkrdquo
Martland 1928
Symptom complex result of repeated sublethal blows to the head
ldquoDementia Pugilisticardquo
Millpaugh
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
CTE
Progressive degenerative disease of the brain found in those with a history of repetitive brain trauma
The symptoms of CTE are insidious first manifest by deteriorations in attention concentration and memory as well as disorientation and confusion and occasionally accompanied by dizziness and headaches
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
CTE
Build-up of abnormal Tau protein
Only seen on staining post-mortem
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Just when you think awareness is improvinghellipJust when you think awareness is improvinghellip
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Referral to Emergency Dept
LOC ndash length of time
Focal neurological signs
Worsening headaches
Worsening mental status
Seizures
Repeated emesis
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Assessment in the Office
HISTORY
Baseline ADHD
Mood disorder
Sleep disturbances
Medications
History of concussion
Symptom score
School difficulties
PHYSICAL
Complete neuro exam
Balance assessment BESS
Vestibular assessment
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Neurocognitive Testing
ImPACT testing
Automated Neuropsychological Assessment Metrics (ANAM) ndash military
Concussion vital signs
Headminder
King-Devick testing
Neuropsychologist referral
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Treatment
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
BRAIN REST
Physical Restriction of activity
PErecess
Athletics
Working out
Cognitive May require time off
school
ldquoScreen timerdquo
Driving
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Recovery From Concussion
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Weeks Post Concussion
R
ec
ov
ere
d
Series1
Collins M Lovell MR Iverson GL et al Examining concussion rates and return to play in high school football players wearing helmet
technology a three-year prospective cohort study Neurosurgery 200658(2)275ndash286
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Risk Factors for Prolonged Recovery Following Sports Concussion
Age Field Lovell Collins et al J of
Pediatrics 2003
(Pellman Lovell et al Neurosurgery 2006
Guskiewicz 2011 Pm R
Previous concussion Collins Lovell et al
Neurosurgery 2004
Iverson Lovell Collins Brit J Sport Med 2006
Hollis 2009 Am J of SM
Migraine History Lipton JAMA 2004
Genetics APOE e4 Tierney Clin J
Sport Med 2010
Gender Differences Females have higher rate of
concussion 171 Females more prone to post-
concussion symptoms Neck strength differences
Lovell Clin Sports Med 28 (2009) 95-11
Mood Disorders Kontos Arch Phys Med
Rehab 2012
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Return to Learn
Team Concept
Family Team
Medical Team
School Teams
academic team
504 plan
IEP
physical activity team
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Guidance for Determining Student Readiness to Return to Learning
Student tolerance of cognitive stimulation or concentration
SYMPTOM ONSETlt30-45 minutes
SYMPTOM ONSETgt30-45 minutes
REST AT HOMEEncourage sleep
School Attendance
Light mental activityLight reading or light TV
Light interaction with family
ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION
45 min of instruction15 min rest period
Additional instruction as tolerated
No driving no employment no malls decreased screen timesocial
networksvideo gamescomputer work
Late startearly dismissal plannedas needed rests increase activity as tolerated no extracurricular until back to full curricular program For missed instruction consider class notes easing assignments reduced course load etc
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Return to Play
Progressive step-wise approach
Must be completely asymptomatic at rest
Cognitive return to baseline with school
Asymptomatic with removal of any medication to treat symptoms
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Return to Play Protocol
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Return to Learn Protocol
Brown NJ et al Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms Pediatrics 6 Jan 2014 online 101542peds2013-2125
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Clinical Trajectories - UPMC
CognitiveFatigue
Vestibular
Ocular
Post-traumatic Migraine
Cervical
AnxietyMood
Collins MW Kontos AP Reynolds E Murawski CD Fu FH A comprehensive targeted approach to the clinical care of
athletes following concussion Knee Surgery Sports Traumatology Arthroscopy Feb 2014 22(2)235-46
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
From Rethinkconcussionscom
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Where do we go from here
Prevention
Medications
Disqualification
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Vitamin Regimen
Cognitive Function
Fish OilOmega3
Zinc
Gingko Biloba
Headaches
Coenzyme Q
Riboflavin
Mg Oxide
Insomnia
Melatonin
DepressionAnxiety
St Johns Wort
Branched Chain AA
Zinc
Alpha Lipoic Acid
N-Acetyl Cysteine
TurmericCurcumin(Polyphenols)
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
Additional Resources
Center for Disease Control and Prevention
cdcgovconcussion ndash Heads Up program
Rethinkconcussionscom - UPMC
pediatriccareonlineorg
REAP concussion program - Colorado
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928
References
Master CL Gioia GA Leddy JJ Grady MF Importance of lsquoreturn-to-learnrsquo in pediatric and adolescent concussion Pediatr Ann 201241(9)1ndash6
McGrath N Supporting the student athletersquos return to the classroom after a sport-related concussion J Athl Train 201045(5)492ndash498
McCrory P Meeuwisse W Aubry M et al Consensus statement on concussion in sportmdashthe 4th International Conference on Concussion in Sport held in Zurich November 2012 Clin J Sport Med 2013 23(2)89ndash117
Halstead ME Walter KD Council on Sports Medicine and Fitness American Academy of Pediatrics Clinical reportmdash sport-related concussion in children and adolescents Pediatrics 2010126(3) 597ndash615
Marar M McIlvain NM Fields SK Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Giza CC1 Hovda DA The new neurometabolic cascade of concussion Neurosurgery 2014 Oct75 Suppl 4S24-33
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 201139(5)958ndash963
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 201246(8)603ndash610
Marar M McIIvain NM Fields SK et al Epidemiology of concussions among United States high school athletes in 20 sports Am J Sports Med 201240(4)747ndash755
Martland HS Punch drunk JAMA 911103ndash1107 1928