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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Outdated AAN Criteria forSports-related Concussion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


Outcome after concussion is difficult to predict

  • Early markers weakly related to recovery
    • LOC
    • GCS score
    • PTA
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

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

  • 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


  • 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 !


Concussion Management Program

& CNY Sports Concussion Center


Clinical Evaluation and Treatment

Community Education