David R. Wiercisiewski, MD
Director, Carolina Sports Concussion
Program at CNSA
Incidence in HS football = 6%-8% per year.
Boy’s + Girl’s soccer = football.
Girl’s basketball 250% greater risk than Boy’s
Sports and recreational injuries with LOC =
300,000 per year.
Sports and recreational injuries with and without
LOC = 1.6 million per year.
process affecting the
brain, induced by
Caused by a direct or indirect blow to the head,
face or neck.
Results in rapid onset of short-lived
impairment of neurological function.
A concussion may or may not involve LOC.
The clinical symptoms reflect a functional
rather than a structural disturbance.
Mechanism of Injury
1st 7-10 days
↑K / ↑Ca / ↑glc / ↑glut
“Period of vulnerability”
Recommendation to abandon the “simple”
versus “complex” nomenclature with no
endorsement of any other specific
PRIMARY AREAS OF FOCUS
Rule out more serious intracranial pathology
Prevent Second Impact Syndrome
Prevent repeat injury during post-concussion
period of “vulnerability”.
Prevent against cumulative effects of injury
Lowered threshold to injury
Majority of injuries will recover spontaneously.
Physical and cognitive rest are required while
When symptom free and improved “functionally”
graduated return to play protocol should be utilized.
Same day return to play—NEVER!!!
Agree on an approach to the management of
concussions with other health care providers on the
Baseline cognitive testing if available.
Use a standardized PCS symptom scale
Perform serial assessments
Identify your referral patterns ahead of time
Symptoms—somatic (headache), cognitive
(feeling like in a fog) and emotional (lability).
Physical signs—LOC and amnesia.
Cognitive impairment—slowed reaction times.
Mental status testing
MENTAL STATUS TESTING
Be familiar with the different screening tools
and their requirements.
Use tools that have been validated and
published in peer-reviewed literature.
Results should be interpreted and integrated
into the other relevant clinical information.
Format allows portability and efficiency.
Each vendor has their unique menu of
cognitive domains that their product measures.
20 – 30 minutes to administer.
Used as a “tool” to measure recovery and not
to make a diagnosis or solely direct
Must assess pertinent “Normal” range
Baseline testing Early return to baseline
while still symptomatic
improves evaluation. Without baseline testing it
can be more difficult to
First sports concussion program in the greater Charlotte area.
Began in February 2007.
First year provided post-injury care only.
Subsequent years we have provided free baseline tests to
middle and high school athletes participating in “high risk”
sports through monies donated by SunTrust Bank.
Baseline testing program currently offered in 5 counties.
Utilize the ImPACT neurocognitive testing tool.
CONCUSSION ASSESSMENT and
COGNITIVE TESTING (ImPACT)
8 separate tests 6 composite scores
Word memory Verbal memory
Design memory Visual memory
X’s and O’s Visual motor speed
Symbol Match Reaction time
Color Match Impulsivity
Three Letters Total symptom score
CONCUSSION SYMPTOM SCALE
with 0-6 scale rating
Developed by Lovell
and Collins in 1998
Sensitive tool to
classified into 3 main
OVERVIEW OF ImPACT
Proven in measures of reliability and validity
Provides useful concussion screening and
Validated with multiple peer-reviewed studies
Does not substitute for medical evaluation and
Does not substitute for comprehensive
ALL ATHLETES ARE NOT
Symptoms—Number, duration (>10 days) and
Signs—Prolonged LOC (>1 min.), amnesia.
Temporal—Frequency (number of
Threshold—Repeated concussions occurring with
less force or slower recovery.
Age—Child and adolescent < 18 years old.
Co-morbidities—Migraine, depression or other
mental health disorders, ADHD, learning
disabilities and sleep disorders.
Medication—Psychoactive drugs and
Behavior—Style of play.
Sport—Contact or collision sport, high-risk.
CHILD AND ADOLESCENT
Clinical evaluation should include academic
performance and behavior in school.
Neurocognitive testing may be performed earlier to
aid in academic accommodations during recovery.
Return to exertion or game play should be slower
when compared to the adult athlete. Also there
should be particular focus on “cognitive rest”.
Never return to play on same day!
ELITE vs. NON-ELITE
Both groups should
follow the same
treatment and return to
is preferred but
providing for non-elite
athletes may be
restricted by financial
RETURN TO PLAY
No activity while symptomatic.
Light aerobic exercise.
Sport-specific exercise—no head impact drills.
Non-contact training drills.
Full contact practice.
Return to game play.
Established in 2009.
No same day return to
practice or game play.
Players encouraged to
be honest and report
opinion for each injury.
> 50 = 5x risk
30-49 = 19x risk
Comparative data from
the Framingham heart
Sports Legacy Institute.
Protein that invades
cortical nerve cells and
shuts them down
effectively killing them.
disease and the
associated with that
disease, the build up of
tau is related to trauma
3 fold risk to have
concussion if have 3
concussions in previous
2 or more concussions
have longer recovery
3 or more concussions:
8 fold risk of LOC
5.5 fold risk of PTA
5.1 risk of confusion
Protective Equipment—Mouthguards and
Risk Compensation—use of protective
equipment results in a behavioral change and
may subsequently result in a paradoxical
increase in injury rates.
Aggression versus violence in sports.
Gender effects on injury, severity and outcome.
Pediatric injury and management paradigms.
Validation of SCAT2 as a sideline assessment tool.
Concussion surveillance using consistent definitions
and outcome measures.
Formal review of “concussion in sport” guidelines
and update prior to December 1, 2012 by panel of
PROTECTING THE “3 LB. UNIVERSE”
OBSERVATIONS FROM CLINIC
Moving the mountain.
Improved awareness and increase in concussion recognition.
Gap in club sports.
Dealing with the devil.
The sickness of our sports culture.
Creating a road map.
Defining expectations of recovery based on the individual’s unique
medical history and mechanism of injury.
Kids are real people too!
Emotional response to the injury.
My “uneasy” chair.
How many is too many?