0. James W. Bryan IV, MD Little Rock, AR
Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines
James W. Bryan IV, MD
Little Rock, AR

1. Concussion defined
Concussion is a brain injury and is defined a a complex pathophysiological process affection the brain, induced by biomechanical forces.
Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive injury include:
Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

2. Concussion defined: common features
Caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head
Typically results in the rapid onset of short-lived neurological function that resolves spontaneously
Symptoms and signs may evolve over minutes to hours
May result in neuropathological changes
Reflect a functional disturbance rather than a structural injury
No abnormalities are typically seen on standard neuroimaging studies
Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

3. Concussion defined: Neurometabolic cascade
Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

4. Concussion defined: Neurometabolic cascade
Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

5. Concussion defined: common features
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
In some cases the symptoms may be prolonged
The majority of cases resolve in a 7-10 day period
The recovery time frame may be longer in children and adolescents
Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

6. Background
*First concussion symposium: Vienna, International Ice Hockey Association, FIFA (soccer), and the International Olympic Committee *Second symposium: Prague, Sideline assessment tool (SCAT) *Third symposium: Zurich, SCAT revised (SCAT 2) -Designed to follow US NIH consensus criteria *Each produced a summary-and-agreement statement on concussion in sport.

7. Background The Fourth Conference: Zurich 2012
Used the same format as previously:
32 international experts
2 full days of new research presentations
Extensive structured discussion
Drafted a consensus paper, edited until all were in agreement
Updated version of SCAT (SCAT 3)-with 3 distinct tools
Final drafting of 12 critical review papers, co-published in multiple journals

8. British Journal of Sports Medicine April 2013; 47: 250-258
Panel included Stanley Herring and Margot Patukian from AMSSM

9. American Medical Society for Sports Medicine position statement: concussion in sport
Kimberly G Harmon, Jonathan A Drezner, Matthew Gammons, Kevin M Guskiewicz*, Mark Halstead, Stanley A Herring, Jeffrey S Kutcher*, Andrea Pana, Margot Putukian*, William O Roberts
Endorsed by the National Trainers’ Athletic Association and the American College of Sports Medicine
Press release December 13, 2012
British Journal of Sports Medicine April 2013, 47, 15-26
Clinical Journal of Sport Medicine Jan 2013, 23 issue 1, 1-18
[Asterisk indicates Zurich 2012 participants]

10. AMSSM Position Statement: concussion in sport --Purpose--
To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion
To establish the level of evidence, knowledge gaps and areas requiring additional research

11. AMSSM Position Statement: concussion in sport --Importance--
While directed toward sports physicians, it may help other health care providers in the care of concussed patients
Care is ideally performed those with specific training and experience—not dictated by specialty
Sports physicians are trained to provide care from the time of injury to return-to-play

12. Pathophysiology
Both human and animal studies support the concept of postconcussion vulnerability
A second blow sustained before recovery results in worsening metabolic changes within the neuron
This concept is distinct from “second impact syndrome”
The concussed brain is less responsive to usual neuron activation
Prolonged dysfunction may result from premature cognitive activity or vigorous physical activity
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

13. Incidence 3.8 million sports related concussions annually in the USA
Estimated that up to 50% are unreported or unrecognized
Concussions occur in all sports
Football, hockey, rugby , soccer, and basketball
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

14. Risk factors for sports-related concussion
History of previous concussion
The greater the number, severity, and duration of symptoms predict a prolonged recovery
In sports with similar rules, female athletes experience a higher incidence of concussion
Certain positions within a sport present a greater exposure risk
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

15. Risk factors for sports-related concussion
Pre-injury mental health conditions complicate the diagnosis and management of concussion
Youth athletes have additional considerations
More prolonged recovery
Greater susceptibility to concussion accompanied by catastrophic injury
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

16. Diagnosis of concussion
Concussion is a clinical diagnosis
Diagnosis is ideally made by a healthcare provider who is
familiar with the athlete
knowledgeable in the recognition and evaluation of concussion
Graded symptoms checklists [e.g. SCAT3]
Objective tool for assessing a variety of symptoms
Useful in tracking the severity of symptoms over serial exams
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

17. Diagnosis of concussion
Standardized assessment tools
Can provide a helpful structure in evaluation
Limited valuation of the assessment tools is available
Examples include
The Maddocks Questions
Standardized Assessment of Concussion (SAC)
Balance Error Scoring System (BESS, modified BESS)
SCAT2, SCAT3, SCAT3 Child, CRT (lay person)
NFL Sideline Concussion Assessment Tool
Glasgow Coma Score
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

18. Diagnosis of concussion
SCAT3
SCAT3-CHILD
Pocket Concussion Recognition Tool

19. Neuropsychological testing
NP testing is an objective measure of brain-behavior relationships
More sensitive for subtle cognitive impairment than clinical exam
Should be used as part of a comprehensive management strategy and not relied upon alone
Ideal timing, frequency and type of NP testing is not established
Unknown if NP testing helps prevent recurrent concussion, catastrophic injury, or long-term complications
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

20. Neuropsychological testing
Paper and pencil NP tests
Can be more comprehensive
Can test different domains and assess for other conditions which may mask or complicate the assessment of concussion
May provide added value to assess cognitive function and recovery
Helpful in the management of patients with prolonged symptoms and complicated courses
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

21. Neuropsychological testing
Computerized NP testing should be interpreted by providers trained and familiar with
The type of the test
The individual test limitations
The reliable change index
The baseline variability
False-positive and false-negative rates
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

22. Neuropsychological testing CPT ® codes
96118 Neuropsychological testing, interpretation and reporting per hour by a psychologist ($92/unit)
96119 Neuropsychological testing per hour by a technician ($74/unit)
96120 Neuropsychological testing by a computer, including time for the psychologist’s interpretation and reporting ($103)
Formal NP testing, scoring, interpretation and conference may require up to 4-8 hours
accessed 5/14/13

23. Return to class Students will require a period of cognitive rest
May require academic accommodations
Reduced workload
Extended time to complete tests
Protections afforded under Section 504 / ADA
AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

24. Education Arkansas ACT 1435 Signed April 23, 2013
Sen. David Sanders/SB1158
Rep. Gary Deffenbaugh
Signed April 23, 2013
Requires the State Department of Health to develop concussion protocols to all youth athletes involved in youth athletic activities
Based on existing AAA guidelines for sanctioned sports in grades 7-12 enacted in 2012
As of April 2013, 47 states have enacted legislation

25. Education NFLEvolution.com “Heads Up” Tool Kit for Youth Sports CDC
Promotion of the Lystedt Law’s three tenets
Inform and educate youth athletes, their parents and guardians and require them to sign a concussion information form
Removal of a youth athlete who appears to have suffered a concussion from play or practice at the time of the suspected concussion
Requiring a youth athlete to be cleared by a licensed health care professional trained the evaluation and management of concussions before returning to play or practice.
“Heads Up” Tool Kit for Youth Sports
CDC
Coaches, athletes and parents
Online videos
Fact sheets, wallet cards

26. Education
AMSSM
2014 AMSSM 23rd Annual Meeting
April 5-9, 2014
Hyatt Regency New Orleans
New Orleans, LA
Advance Team Physicians Course
Cosmopolitan Hotel 
Las Vegas, NV
December 5-8, 2013
2013 AAFP Scientific Assembly: Concussion and Minimal Brain Injury
Thursday, September 26, 2013, San Diego Convention Center

27. Summary of evidence-based guideline update: Evaluation and management of concussion in sports
Neurology; Published online before print March 18, 2013
Christopher C. Giza, MD, Jeffrey S. Kutcher, MD, Stephen Ashwal, MD, FAAN, Jeffrey Barth, PhD, Thomas S.D. Getchius, Gerard A. Gioia, PhD, Gary S. Gronseth, MD, FAAN, Kevin Guskiewicz, PhD, ATC, Steven Mandel, MD, FAAN, Geoffrey Manley, MD, PhD, Douglas B. McKeag, MD, MS, David J. Thurman, MD, FAAN and Ross Zafonte, DO
Objective: To update the 1997 AAN practice parameter regarding sports concussion focusing on 4 questions

28. AAN Guideline Update: 4 questions
1. What factors affect risk?
2a.What diagnostic tools identify those with concussion and (2b)those at increased risk?
3.What clinical factors identify those at increased risk for severe/ prolonged early impairments, neurological catastrophe, recurrent concussion, or chronic impairment?
4.What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae?
Neurology, Mar 18, 2013

29. AAN Concussion Guidelines
Preparticipation Counseling
Number and type of previous concussions
Symptoms and duration
Other neurologic conditions (e.g. seizures)
Assessment
Post-Concussion Symptom Scale or Graded Symptom Checklist
Standardized Assessment of Concussion
Neuropsychological testing
Balance Error Scoring System
Sensory Organization Test
Combination of measures
Neurology, Mar 18, 2013

30. AAN Concussion Guidelines Management of suspected concussion
Train inexperienced licensed HCPs to use a standardized assessment tool
Use standardized assessment tools
Warm handoff from sideline HCP and clinical HCP
Obtain baseline scores
Remove athlete from play
No RTP without clearance by licensed HCP
Don’t perform imaging to make concussion diagnosis
Do perform imaging to rule out suspected TBI
Neurology, Mar 18, 2013

31. AAN Concussion Guidelines: DIAGNOSED CONCUSSION
No RTP until resolved & asymptomatic
Conservative approach for youth and high school
Assessment tools specific for preteens
Consider NP testing
Individualize management plan
No indication for “absolute rest”
Neurology, Mar 18, 2013

32. AAN Concussion Guidelines: Multiple concussions
Professional athletes:
Refer for neurologic and neuropsychological evaluation
Contact-sports with chronic impairment: RETIREMENT
Amateur athletes:
Formal neurologic/cognitive assessment
Offer risk factor counseling
Neurology, Mar 18, 2013

33. Conclusions
Numerous organizations have published guidelines regarding the management of sports-related concussions
Emerging consensus that education is a key factor
Treatment considerations differ slightly between youth, adolescent, and adult/professional athletes
Inconclusive data regarding long-term risk