1. Update on Concussion Felicia Gliksman , DO, MPH Pediatric Neurology
Joseph M. Sanzari Children’s Hospital
Hackensack University Medical Center
Assistant Professor
Seton Hall University-Hackensack Meridian SOM

2. Objectives -Incidence of concussion -biomechanism of concussion
-signs and symptoms of concussion
-sideline evaluation of concussion
-possible short/long term effects
-when is further specialist evaluation needed?
-recommended testing/treatment/management
AAN, CDC, Zurich guidelines and recommendations

3. AKA: mild traumatic brain injury
Concussion Definition
(5th International Consensus Conference on Concussion in Sport)
AKA: mild traumatic brain injury
clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness (LOC).

4. Features of Concussion
May be caused by blow to head, face, neck, or elsewhere on body with an impulsive force transmitted to the head
Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
May result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies

5. Features of Concussion
Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.
Clinical signs and symptoms cannot be explained by drugs, alcohol, or medications, or other injuries such as:
cervical injuries
peripheral vestibular dysfunction
other comorbidities: psych, co-existing medical conditions

6. Biomechanics Possible mechanisms of injury include:
during trauma, the brain moves, twists, and experiences forces that cause movement of brain matter.
This sudden movement or direct force applied to the head can set the brain tissue in motion even though the brain is well protected in the skull
This motion squeezes, stretches and sometimes tears the neural cells. 
The stretching and squeezing of brain cells from these forces can change how the brain processes information.

7. Biomechanics
All of the different mechanisms may result in biochemical changes related to perfusion, energy demand, and utilization at the site of injury and are entirely well understood
Although the stretching and swelling of the axons may seem relatively minor or microscopic, the impact on the brain’s neurological circuits can be significant.  Even a “mild” injury can result in significant physiological damage and cognitive deficits. 

8. K+ Calcium Glucose Cerebral Blood Flow 2 6 12 20 30 24 3 10 minutes
(Giza & Hovda, 2001) 2 6 12 20 30 24 3 10
minutes
hours
days
500
400
300
200 50
100
% of normal
Calcium K+
Glucose
Glutamate
Cerebral Blood Flow
UCLA Brain Injury Research Center

10. Physical forces disrupts brain function
Cascade for ionic, metabolic, and pathophysiological events
Microscopic axonal injury
Increased energy demand
Decreased cerebral blood flow
Mitochondrial dysfunction
decreased energy supply

11. Brain Metabolism following mTBI
Proton magnetic resonance spectroscopy
Recovery of neuronal metabolism marker in 40 athletes following concussion
N-acetylaspartate/creatine- containing compounds ratio
Concussive head injury window of brain vulnerability from cellular energetic metabolism impairment
Symptom recovering 3-15 days.
Normalized metabolism by 30 days
Brain 2010;133(11):

12. Concussion Recovery

13. Concussion Recovery Timeline
Typical Concussion
Repeat Injury
DYSFUNCTION
Resolution
Onset
TIME

14. Signs of concussion Features of concussion frequently observed
− Vacant stare
− Delayed verbal and motor responses
− Confusion and inability to focus attention
− Disorientation
− Slurred or incoherent speech
− Gross observable incoordination
− Emotions out of proportion to circumstances
− Memory deficits
− Any period of loss of consciousness

15. Symptoms of concussion
− Early (minutes and hours)
− Headache
− Dizziness or vertigo
− Lack of awareness of surroundings
− Nausea or vomiting
Late (days to weeks):
− Persistent low grade headache
− Light-headedness
− Poor attention and concentration
− Memory dysfunction
− Easy fatigability
− Irritability and low frustration tolerance
− Intolerance of bright lights or difficulty focusing vision
− Intolerance of loud noises, sometimes ringing in the ears
− Anxiety and/or depressed mood
− Sleep disturbance

16. National TBI Estimates
In 2013, about 2.8 million emergency department (ED) visits, hospitalizations, or deaths were associated with TBI—either alone or in combination with other injuries—in the United States. 
TBI contributed to the deaths of more than 50,000 people.
30% of all injury deaths
In 2012, an estimated 329,290 children (age 19 or younger) were treated in U.S. EDs for sports and recreation-related injuries that included a diagnosis of concussion or TBI.
from rate of ED visits for sports and red-related injuries dx with concussion or TBI more than doubled

17. TBI
Concussions or other forms of mild TBI account for about 75% of TBIs that occur each year
Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. 
From , TBI related ED visits increased by 47%, hospitalization rates decreased 2.5% and death rates decreased by 5%.
CDC and Prevention estimates that 300,000 concussions are sustained during sports-related activity in the United States, and more than 62,000 concussions are sustained each year in high-school contact sports

18. Increasing incidence of sports-related concussion
Due to increase number of young athletes
Due to increase awareness and reporting of concussions
Variability in care provider experience and training, coupled with an explosion of published reports related to sports concussion and mTBI, has led to some uncertainty and inconsistency in the management of these injuries.

19. 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 ;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

20. Epidemiology: Girls 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. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

21. 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. 2012;40(4):747–755

22. Risk Factor for Sports Concussions
Increased Risk of Concussion
Prolonged Recovery
Past concussion
Female athletes
Certain sports, positions and individual playing styles
Number, severity and duration of symptoms
H/o migraines, depression, mood disorders, or anxiety, and developmental disorders (learning disabilities, ADHD)
Youth
Harmon KG, et al. Br J Sports Med 2013;47:15–26

23. How to minimize the risk of concussion through primary prevention
Teach safe techniques in practice and play (coaches, AT)
Encourage recognition and reporting of concussion symptoms
Be aware that injuries are more common in younger athletes
Use available assessment tools (sideline, office)
Monitor developments at advanced levels of play and legislative efforts
Head and spine injury prevention programs

24. A PLAYER TAKES A HIT TO THE HEAD...
...ON SITE/SIDELINE EVALUATION WHEN A CONCUSSION IS SUSPECTED...

25. Sideline testing Various tools
Sport Concussion Assessment Tool 5 ([SCAT5] includes SAC, BESS, others).
Cannot be performed correctly under 10 minutes
Standardized Assessment of Concussion (SAC)
Symptom Assessment
Balance Error Scoring System (BESS)
Domains that may add to the clinical utility of the SCAT tool include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening.

26. SCAT5
A standardized method of evaluating injured athletes for concussion and can be used in athletes aged from 10 years and older.
Assessment Includes:
Symptoms: 22 possible
Cognitive & Physical Assessment
LOC?
Glasgow coma scale: eye, verbal, motor
Orientation: Month, Date, Day of the week, year, time?
Immediate Memory recall: 5 word recall: (elbow, apple, carpet, saddle, bubble)
Concentration:
Repeat Digits Backwards: , ,
Months of the year in reverse order
Balance
Coordination
*Now available to download as an app onto a smart phone.

27. Balance Error Scoring System (BESS)

28. Medical Workup of concussion
Neurologic Examination
Mental status
Cranial nerves (EOM, pupillary response etc)
Motor: strength/weakness
DTRs
Cerebellar/Balance (FNF, Romberg)
Sensation

29. Common with Concussion May Indicate more Serious injury
Mental Status: may be impaired
Balance: Impaired tandem gait or single leg balance, abnormal BESS
CN: nystagmus, saccades
Strength: Normal, symmetric
DTR: normal
FTN: may be slightly abnormal
GAIT: tandem gait my be ataxic, casual gait should be normal.
Mental Status: significantly impaired
Balance: Romberg, postural instability
CN: unequal or fixed pupils, visual field deficit, abnormal EOM
Strength: asymmetric, focal weakness
DTR: hyper-reflexia, Babinski, clonus,
FTN: uncoordination
GAIT: ataxic

30. Red Flags for ED referral / Urgent work up
Glascow Coma Score < 14
Concern for intracranial process
Evidence of a skull fracture (bruising under eyes, behind ears, or swelling of the head)
Concern symptoms are not related to recent minor head trauma
Severe or progressively worsening headache
Seizure activity
Unusual behavior
Lethargy
Unsteady casual gait/ataxia
Slurred speech
Weakness or numbness in extremities
Focal neurologic examination
CLIN PEDIATR October 2015 vol. 54no. 11 

31. If abnormal neurological exam…
May include:
CT or MRI scanning
Recommended in all instances where headache or other associated symptoms worsen or persist longer than one week.
should not be used to diagnose sport-related concussion but might be obtained to rule out more serious TBI such as an intracranial hemorrhage in athletes with a suspected concussion who have loss of consciousness, posttraumatic amnesia, persistently altered mental status (Glasgow Coma Scale <15), focal neurologic deficit, evidence of skull fracture on examination, or signs of clinical deterioration
PECARN algorithm
Terminating the season for player is mandated by any abnormality on CT or MRI scan (brain swelling, contusion, bleed etc)
CT imaging and Neurosurgical evaluation or transfer to a trauma center
Prolonged unconsciousness, persistent mental status alterations, worsening postconcussion symptoms, or abnormalities on neurologic examination

32. NeuroImaging CT MRI Not recommended for routine concussion evaluation
Sensitive for skull fracture and intracranial hemorrhage
Test of choice in first hours after injury
Will not rule out chronic subdural or neurobehavioral dysfunction
Not recommended for routine concussion evaluation
More sensitive for cerebral contusion, petechial hemorrhage, white matter injury, posterior fossa abnormalities
Gradient Echo and perfusion and diffusion tensor imaging may detect white matter injury better but clinical usefulness is not established.
Ataxia is best evaluated with MRI even acutely.

33. Secondary Conditions Associated with Concussions
Intracranial Hemorrhage
Skull Fracture
Epidural Hemorrhage
Subdural Hemorrhage
Intracerebral Hemorrhage
Cerebral Hyperemia
Cerebral Edema
Seizures
Migraine Headaches

34. Intracranial Hemorrhage
Intracranial bleeding
Venous bleeding
Slow, insidious onset
Arterial bleeding
S/S apparent within a few hours

35. Intracranial Hemorrhage
Early S/S
Severe head pains
Dizziness
Nausea
Unequal pupil sizes
Sleepiness
Severe S/S
Deteriorating consciousness
Neck rigidity
Slow pulse
Slow respiration
Convulsions

36. Epidural Hemorrhage
A blow to the head causes a tear in one of the arteries of in the dural membrane that covers the brain
Hematoma forms extremely fast
Within 10 – 20 minutes after injury
Requires surgery to relieve the pressure created by the hematoma
Death or permanent disability may result

37. Subdural Hemorrhage
A blow to the head causes a tear in one of the veins located between the dura mater and the brain
Hematoma forms slowly
S/S may not be appear until hours after injury
Commonly occurs following a contrecoup injury
May or may not require surgery

38. Cerebral Hyperemia
Vasodilation of cerebral blood vessels following a head/brain injury
Causes an increase in intracranial blood pressure
Develops within minutes after the injury
S/S: headache, vomiting, sleepiness
S/S usually resolve within 12 hours after the injury

39. Cerebral Edema Localized swelling of the brain at the injury site
Develops within 12 hours after the injury
S/S: headache, seizures (occasionally)
Cerebral edema may remain for as long as 2 weeks following the injury

40. Intracerebral Hemorrhage
A blow to the head may cause bleeding within the brain itself
Usually results due to a compressive force applied to the brain
Rapid deterioration in neurological function
Requires immediate hospitalization

41. Axon Sports (playing cards test) Concussion vital signs
Neurocognitive testing ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)
What is available?
ImPACT (5-11yo, 12+)
Axon Sports (playing cards test)
Concussion vital signs
Automated Neuropsychological Assessment Metrics ([ANAM] primarily military)
HeadMinder
Formal pencil and paper testing with neuropsychologists

42. Issues with available tests
Standard for Assessment
How often? Testing while symptomatic?
“We suggest initial evaluation 24–72 hours after injury. Consult a physician for interpretation of ImPACT test results…second post-injury test should be administered 1–2 weeks after the initial post-injury test. We strongly discourage testing more than once a week.”
Baseline vs No Baseline
Cost
Who will interpret?

43. Neuropsychological testing
May be a part of a comprehensive concussion evaluation program
May help identify the ‘not so forthcoming’ athlete
For more concrete and specific neurocognitive evaluation, especially when considering significant or prolonged school adjustments → involve neuropsychologist for more formal testing
can be used as a starting point for a plan of rehabilitation. 
It can assist brain injury professionals in identifying specific cognitive areas that have been damaged, as well as those areas still intact.
Used as basis for CBT

44. Other testing???
“Advanced neuroimaging, fluid biomarkers, and genetic testing are important research tools but require further validation to determine clinical utility in evaluation of SRC” “

45. Assessments Predict length of recovery.
DO NOT-
Predict length of recovery.
Provide prognosis for future problems.
Act as the sole determining factor for return to play.
Act as a red light/green light.

46. Putting it all together
Same assessments that are done on the field may not be as helpful in the office
SCAT5―“S” is for “Sideline”
Symptom score checklists
Neurological examination
Concussion history
Balance assessments
Most helpful first 3 days
Vestibular system assessments
School difficulties

47. Outcomes
TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.
Thinking (i.e., memory and reasoning);
Sensation (i.e., touch, taste, and smell);
Language (i.e., communication, expression, and understanding); and
Emotion (i.e., depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

48. Outcomes TBI can also cause epilepsy
Increase the risk of Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.
Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits.
Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

49. Outcomes
A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems.
In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death =second impact syndrome

50. Outcomes
Photo courtesy of Boston University, McKee Lab

51. Preseason: concussion policy
Prevention in Sports
Preseason: concussion policy
players sign “concussion contract”
trainers and coaches take mandatory concussion training course
Action plan if concussion occurs:
remove from play until evaluated by healthcare professional
Inform the athlete’s parents or guardians about the possible concussion and give them the fact sheet on concussion.
Educate coaches, athletes, parents
Monitor the health of the athletes

52. Prevention Safety first
Safe playing techniques, good sportsmanship, protective equipment
Teach athletes it’s not smart to play with a concussion.
Rest is key
wrongly believe that it shows strength and courage to play injured.
Discourage others from pressuring injured athletes to play.
Don’t let the athlete convince you that they’re “just fine.”

53. Prevention Prevent long-term problems.
If an athlete has a concussion, their brain needs time to heal.
No return to play until cleared by health care professional
Work closely with league or school officials.
Be sure that appropriate individuals are available for injury assessment and referrals for further medical care

54. Consensus Statement on Period of Rest
There is currently insufficient evidence that prescribing complete rest achieves outcome objectives.
After a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms).
It is reasonable for athletes to avoid vigorous exertion while they are recovering.
The exact amount and duration of rest is not yet well defined in the literature and requires further study.

55. Sleep
Sleep is commonly disrupted with a concussion
Naps are fine as long as it does not disrupt sleep
Educate patient and family on sleep hygiene if not improving
Education/Communication:
Provide anticipatory guidance and concussion education
Educate patient and family on avoiding symptom exacerbation
Provide letter to school documenting injury, restrictions, and accommodations
Close follow up until full recovery.
Nutrition
Encourage adequate fluid intake (athletes are often only used to drinking water during practice)
Dehydration and poor nutrition can mimic many concussive symptoms.
Mood
Monitor for signs of depression (particularly in athletes with prolonged recovery)
Encourage counseling/treatment if present

56. Recovery
May be slow!!!
Majority (80-90%) resolve in short (7-10 day) period
May take longer in children and adolescents (4 weeks!)
Everyone “feels fine”
Always ask:
1.“On a scale of 0 to 100%, how do you feel?”
2.“what makes you not 100%?”
3. Symptom Checklist – SCAT5 (only good for first few days)

57. Recovery
May need time away from school, untimed testing, less homework, modified school day
Avoid doing anything that could cause another blow or jolt to the head.
Reaction time slower
Should not drive, ride a bike, etc
Write things down if having a hard time remembering.
May need help to re-learn skills that were lost.
May need CBT (cognitive behavior therapy)

58. Possible recommendations
No significant classroom or standardized testing at this time.
Check for the return of symptoms when doing activities that require a lot of attention or concentration.
Take rest breaks during the day as needed.
Request meeting of 504 or School Management Team to discuss this plan and needed supports.
Refer to: Neurosurgery/Neurology/Sports Medicine/Physiatrist/Psychiatrist/ Refer for neuropsychological testing

59. RETURN TO LEARN
BEFORE
RETURN TO PLAY

60. Return to Play
Do not allow to return to game/practice if suspected or diagnosed concussion on day of injury (need to wait 24 hours)
Do not allow return to play until asymptomatic at rest
Not a defined, set time frame (ie, 7 days, 2 weeks, etc.) but need to be symptom-free from at least a week (and off meds!)
Progressive, step-wise approach to return to play
Full return to school first

61. Criteria to Return to Play
Normal neurological function
Normal vasomotor functions
Normal balance
Free of headaches
Free of lightheadedness
Free of dizziness
Free of seizures

62. Recovery SRCs can result in diverse symptoms and problems,
can be associated with concurrent injury to the cervical spine and peripheral vestibular system.
The literature has not evaluated early interventions, as most individuals recover in 10–14 days.
A variety of treatments may be required for ongoing or persistent symptoms and impairments following injury.
The data support interventions including psychological, cervical and vestibular rehabilitation.

63. Recovery
Closely monitored active rehabilitation programs- involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery.
A collaborative approach to treatment, including controlled cognitive stress, pharmacological treatment, and school accommodations, may be beneficial.

64. Post-concussion syndrome
Failure of normal clinical recovery
symptoms that persist beyond expected time frames
>10–14 days in adults
>4 weeks in children

65. Treatment
Treatment should be individualized and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of:
a an individualized symptom-limited aerobic exercise program in patients with persistent post-concussive symptoms associated with autonomic instability or physical deconditioning, and
b a targeted physical therapy program in patients with cervical spine or vestibular dysfunction
c a collaborative approach including cognitive behavioral therapy to deal with any persistent mood or behavioral issues.

66. Active Recovery- 4 Steps
Active treatment does not mean players immediately return to play. To ensure the best recovery, post-concussion, activity should be:
Supervised. Activity should be guided by an expert.
Low-level. The level of exertion should vary from person to person, but overall, activity should use less than 60 percent of the body's total exertion.
Progressive. People should start recovery by engaging in a small amount of activity and increase activity as symptoms allow.
Individually tailored. Adapt therapy to suit individual symptoms and needs.
ex: person who has dizziness and vertigo after a concussion should engage in balance-based exercises.
Patients who have trouble moving their eyes should be prescribed vision therapy, with exercises and tools designed to improve focusing and other eye functions.
Although new research supports the benefit of this protocol, the experts say more research is needed, including clinical trials, to build on these findings.

67. Management of Symptoms
No evidence for efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDs) or other medication in management of sport concussion
May be helpful for symptoms of post-concussive symptoms (typically all off-label uses)
Sleep aids, attention-deficit disorder (ADD) medications, non-conventional headache medications, antidepressives
Athlete must be off medication and symptom-free before return to sports
“Where pharmacological therapy may be begun during the management of an SRC, the decision to return to play while still on such medication must be considered carefully by the treating clinician.”

68. Withdrawal from season/sport
No magic number
Consider for prolonged symptoms, multiple concussions
Involve someone experienced in sport concussion management

69. Graded Return To Play Protocol
Rehabilitation Stage
Functional Exercise at each stage
1. No activity
Complete physical and cognitive rest (stage may be the longest
2. Light aerobic activity
Walk, swim, stationary bike, keep intensity<70% of max HR, no resistance training
3.Sport- specific exercise
Skating drill (ice hockey), running (soccer), no head impact activities
4. Non-contact training skills
Progression to more complex training drills. May start resistance training
5. full-contact practice
After medical clearance, participate in normal training activities
6. Return to play
Normal game play

70. Each stage is AT LEAST 24 HOURS
Therefore should take >5 days to complete

71. “Modifiers” that can prolong recovery
Factors
Modifiers
Symptoms
number, duration >10days, severity
Signs
LOC >1min, amnesia
Sequelae
Concussive convulsions
Temporal
Frequency (repeated conc), timing (close in time), “recency”
Threshold
Repeated conc. Occurring with progressively less impact or slower recovery after each successive conc
Age
<18yo
Comorbidity/premorbity
Migraine, depression, other, ADHD, LD, sleep disorder
Medication
Psychoactive drugs, anticoag
Behavior
Dangerous style of play
Sport
High-risk, contact/collision/high sporting level

72. Where to get resources

73. Available Tools

74. Take home points for players
Don’t hide it
Report it
Take time to recover
It’s best to miss one game than the whole season

75. Facts on Helmets Only 40% of cyclists wear helmets
Bicycle helmets are 85% effective in reducing traumatic brain injuries
Only 40% of cyclists wear helmets

76. There is no such thing as a concussion proof helmet
“The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time”.

77. Any Questions???