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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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