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Concussion Management: Current Concepts and Clinical Guidelines. Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation University Hospital  SUNY Upstate Medical University Director, CNY Sports Concussion Center

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Concussion management current concepts and clinical guidelines

Concussion Management:Current Concepts and Clinical Guidelines

Brian P Rieger, PhD

Chief Psychologist & Clinical Assistant Professor

Department of Physical Medicine & Rehabilitation

UniversityHospital SUNY Upstate Medical University

Director, CNY Sports Concussion Center

NYSPHSAA Concussion Team & Safety Committee

NYS TBI Coordinating Council  Public Education Committee

February 2009

What is a concussion
What is a concussion?

  • Mild traumatic brain injury

  • A disruption in normal brain function due to a blow or jolt to the head

  • CT or MRI is almost always normal

  • Invisible injury

Definition of concussion american congress of rehabilitation medicine
Definition of ConcussionAmerican Congress of Rehabilitation Medicine

  • Blow or jolt to the head AND

  • Loss of consciousness (≤ 30 min) OR

  • Post-traumatic amnesia (≤ 24 hrs) OR

  • Neurological finding OR

    • Slurred speech, diplopia, etc.

  • Alteration in mental state

    • Dazed or disoriented or confused

  • After 30 minutes, an initial GCS of 13-15

Outdated AAN Criteria forSports-related Concussion

Grade 1 Transient Confusion

Symptoms resolve in <15 minutes


Grade 2 Transient Confusion

Symptoms last >15 minutes


Grade 3 LOC: a) brief

b) prolonged

Prague 2004 Guidelines

(McCrory et al., 2004)

  • Simple concussion

    • LOC < 1 minute

    • resolves in 7-10 days

    • first concussion

  • Complex concussion

    • LOC > 1 minute

    • symptoms last longer than 7 – 10 days

    • history of multiple concussions


Prague 2004 Guidelines

  • No return to play in current game or practice

  • Return to play only when symptom free at rest and with exertion

  • Graduated return to play with exertional challenge

  • Recognition of differences in children

  • Neurocognitive testing recommended

Manage each concussion individually


  • 1.6 to 3.8 million sports concussions each year in the United States

  • Football, hockey, and soccer are the riskiest male team sports

  • Up to 10% of high school football players suffer a concussion each year

  • Soccer and lacrosse are the riskiest female team sports


  • In HS sports played by both sexes, girls have a higher rate of concussion

  • Collegiate athletes have a higher rate of concussion than HS athletes

  • Concussion represents a higher proportion of all injuries in HS athletes vs. collegiate

  • Approximately 10% of sports concussions involve LOC

Multiple Concussions

What are the risks ?

  • Second Impact Syndrome

    • A second concussion within 2 weeks of first

    • Athlete is still symptomatic

    • Mostly males < 21 years old

    • Rapid increase in intracranial pressure

    • Rare but almost always fatal

  • Possible cumulative effects

    • Increasing concussability

    • Prolonged or incomplete recovery

    • Increased risk of later depression or dementia

How many is too many ?

Mechanisms of injury
Mechanisms of Injury

  • A complex physiological process induced by traumatic biomechanical forces

    • sudden chemical changes

    • traumatic axonal injury

  • Structural brain imaging (CT or MRI) is almost always normal

Neurometabolic cascade giza and hovda 2001
Neurometabolic Cascade(Giza and Hovda 2001)

  • Abrupt neuronal depolarization

  • Release of excitatory neurotransmitters

  • Changes in glucose metabolism

  • Altered cerebral blood flow

  • The brain goes into an ENERGY CRISIS that usually last up to 7 – 10 days

symptoms often get worse before they get better

Traumatic axonal injury
Traumatic Axonal Injury

  • Results from rotational and/or acceleration-deceleration forces

  • Typically occurs in specific sites

    • junction of gray and white matter

    • long fibers of the internal capsule

    • corpus callosum

    • upper brainstem

Common Physical Symptoms

  • Headache

  • Nausea and vomiting

  • Clumsiness and poor balance

  • Dizziness and lightheadedness

  • Blurred vision and light sensitivity

  • Fatigue and lack of energy

  • Sleep disturbance

Common Emotional Symptoms

  • Irritability

  • Anxiety

  • More extreme moods

  • Easily overwhelmed

  • Emotional and behavioral outbursts

  • Personality change

  • Lack of motivation

Common Cognitive Symptoms

  • Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’

  • Easily confused

  • Slowed processing

  • Easily distracted

  • Memory problems

  • Trouble reading

  • Poor mental stamina

Exertion effects

  • Symptoms are worsened by . . .

    • mental effort

    • environmental stimulation

    • emotional stress

    • physical activity

9 mos. after injury

6 mos. after injury

Chen et al. (2004)

Recovery from Concussion

  • Full recovery in 7-10 days. . .in most cases

  • About 95% recover in 3 months

  • Symptoms generally thought to have a primarily neurological basis at first

  • When symptoms persist, non-injury factors appear to play an increasingly significant role over time

a ‘miserable minority’ experience complicated recovery

Recovery from sports concussion how long does it take on impact
Recovery From Sports ConcussionHow Long Does it Take on ImPACT?






N=134 High School athletes

Collins et al., 2006, Neurosurgery

Sideline Evaluation

  • Head trauma (blow or jolt)

  • LOC or amnesia for the trauma

  • Focal neurologic finding

  • Signs & Symptoms (SCAT card)

    • confused, wobbly, emotional. . .

  • Assess cognition

    • 3 word recall

    • Months backwards

  • Standardized testing

    • SAC

    • BESS


  • When in doubt—sit ‘em out

Prague Return to Play Guidelines

  • Prague 2004 guidelines recommend that when a player shows ANY symptoms or signs of a concussion:

    • athlete should not return-to-play in the current game or practice

    • Athlete should be monitored for deterioration for 24 hours

    • return-to-play must follow a medically supervised stepwise process

    • athlete must be symptom-free at rest and after exertion

Prague Return to Play Progression

  • No activity, complete rest

  • Light aerobic exercise but no resistance training

  • Sport specific exercise and progressive addition of resistance training

  • Non-contact training drills

  • Full contact training and scrimmage after medical clearance

  • Game play

Also should be symptom-free after mental exertion

and have normal neruocognitive test results

Medical Protocol

  • Any athlete who suffers a concussion needs medical clearance before RTP

  • Anyone with a LOC should be evaluated that day

  • If confused or not fully conscious, transport by EMS with immobilization

  • Follow athlete until asymptomatic

  • First medical clearance is to begin RTP progression

  • If no return of symptoms with exertion, then final clearance for game play

It takes a team. . .

  • Athlete and parents

  • Athletic Trainer

  • Coaches and Athletic Director

  • Physician, school physician, and school nurse

  • Psychologist

  • Teachers and school administrators

Managing Complex Concussion

  • Consider referral to specialized provider or program if . . .

    • History of multiple concussions or other risk factors

    • Prolonged recovery (> 2 weeks)

    • Worsening symptoms

Neuropsychological Testing

In Sports Concussion

  • Computerized tests that measure attention, memory, and processing speed (reaction time)

  • Sensitive to effects of concussion

  • Tests can be repeated multiple times to monitor recovery

  • Ideally, pre-injury baseline testing done for all athletes

  • ImPACT, CogSport, HeadMinder

Unique Contribution of Neurocognitive Testing to Concussion Management

Testing reveals

cognitive deficits

in asymptomatic

athletes within 4

days post-concussion

N=215, MANOVA p<.000000 (Lovell et al., 2004)

Guidelines for Return to School Management

after Concussion

  • Out of school at first if necessary, and then gradual re-entry as tolerated

  • Avoid re-injury in sports, gym classs and crowded hallways or stairwells

  • Provide academic accommodations

  • Communicate and Educate

Academic Accommodations Management

  • Rest breaks during school in a quiet location (not always the nurse’s office)

  • Reduced course and work load

    • Drop unnecessary classes

    • Decrease homework

  • Avoid over-stimulation, (e.g., cafeteria or noisy hallways)

  • Extra time and a quiet location for tests

  • Summary Management

    • CDC now recognizes sports concussion as a significant public health issue

    • Proper recognition and management of concussion can prevent serious problems

    • No RTP in current game or practice

    • No RTP until symptom free, at rest and with exertion

    • Manage every athlete and concussion individually

    • Neurocognitive testing is recommended

    Remember to wear your helmet ! Management

    [email protected]

    Concussion Management Program Management

    & CNY Sports Concussion Center


    Clinical Evaluation and Treatment

    Community Education


    [email protected]