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Concussion or Mild Traumatic Brain Injury mTBI in the Athlete


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									                                        GUIDELINE 2i
     Concussion or Mild
     Traumatic Brain Injury
     (mTBI) in the Athlete
                                               account for a significant percentage
     million concussions occur from            of injuries in men’s and women’s
     participation in sports- and              basketball, women’s lacrosse, and
     recreation-related activities every       other sports traditionally             men’s basketball 0.6, accounting
                                               considered “noncontact.”
     injuries are often difficult to detect,                                          the injuries for these sports as
     with athletes often underreporting        The incidence in helmeted versus       reported by the NCAA Injury
     their injury, minimizing their            nonhelmeted sports is also similar.    Surveillance Program by the
     importance or not recognizing that        In the years 2004 to 2009, the rate    Datalys Center.
     an injury has occurred. At the            of concussion during games per
                                                                                      Assessment and management of
     college level, these injuries are
                                                                                      concussive injuries, and return-to-
     more common in certain sports,
                                               men’s ice hockey 2.4, for women's      play decisions remain some of the
     such as football, ice hockey, men’s
                                               ice hockey 2.2, for women's soccer     most difficult responsibilities
     and women’s soccer, and men’s
                                                                                      facing the sports medicine team.
     lacrosse. However, they also
                                                                                      There are potentially serious
                                                                                      complications of multiple or severe
                                                                                      concussions, including second
                                                                                      impact syndrome, postconcussive
                                                                                      syndrome, or post-traumatic
                                                                                      encephalopathy. Though there is
                                                                                      some controversy as to the
                                                                                      existence of second impact
                                                                                      syndrome, in which a second
                                                                                      impact with potentially
                                                                                      catastrophic consequences occurs
                                                                                      before the full recovery after a first
                                                                                      insult, the risks include severe
                                                                                      cognitive compromise and death.
                                                                                      Other associated injuries that can
                                                                                      occur in the setting of concussion
                                                                                      include seizures, cervical spine
                                                                                      injuries, skull fractures and/or
                                                                                      intracranial bleed. Due to the
                                                                                      serious nature of mild traumatic
                                                                                      brain injury, and these serious
52                                                                                    potential complications, it is
imperative that the health care        injuries of skull fracture,              noted. These sideline tests should
professionals taking care of           intracranial bleeding and seizures,      be performed and repeated as
athletes are able to recognize,        when there is concern for structural     necessary, but do not take the place
evaluate and treat these injuries in   abnormalities or when the                of other comprehensive
a complete and progressive             symptoms of an athlete persist or        neuropsychological tests.
Executive Committee adopted a                                                   Once an injury occurs and an
                                       Concussion is associated with            initial assessment has been made, it
policy that requires NCAA
                                       clinical scenarios that often clear      is important to determine an initial
institutions to have a concussion
                                       spontaneously, and may or may not        plan of action, which includes
management plan on file. (See
                                       be associated with loss of               deciding on whether additional
information box on page 55.)
                                       consciousness (LOC).                     referral to a physician and/or
Concussion or mild traumatic brain                                              emergency department should take
                                       The sideline evaluation of the
injury (mTBI) has been defined as                                               place, and determining the follow-
                                       brain-injured athlete should include
“a complex pathophysiological                                                   up care. The medical staff should
                                       an assessment of airway, breathing
process affecting the brain, induced                                            also determine whether additional
                                       and circulation (ABCs), followed
by traumatic biomechanical                                                      observation or hospital admission
                                       by an assessment of the cervical
forces.” Although concussion most                                               should be considered.
                                       spine and skull for associated
commonly occurs after a direct
                                       injury. The sideline evaluation          Follow-up care and instructions
blow to the head, it can occur after
                                       should also include a neurological       should be given to the athlete, and
a blow elsewhere that is transmitted
                                       and mental status examination and        ensuring that they are not left alone
to the head. Concussions can be
                                       some form of brief neurocognitive        for an initial period of time should
defined by the clinical features,
                                       testing to assess memory function        be considered. Athletes should
pathophysiological changes and/or
                                       and attention. This can be in the        avoid alcohol or other substances
biomechanical forces that occur,
                                       form of questions regarding the          that will impair their cognitive
and these have been described in
                                       particular practice or competition,      function, and also avoid aspirin and
the literature. The neurochemical
                                       previous game results, and remote        other medications that can increase
and neurometabolic changes that
                                       and recent memory, and questions         their risk of bleeding.
occur in concussive injury have
                                       to test the athlete’s recall of words,
been elucidated, and exciting                                                   As mentioned previously,
                                       months of the year backwards and
research is underway describing the                                             conventional imaging studies such
                                       calculations. Special note should
genetic factors that may play a role                                            as MRI and CT scans are usually
                                       be made regarding the presence
in determining which individuals                                                normal in mTBI. However, these
                                       and duration of retrograde or
are at an increased risk for                                                    studies are considered an adjunct
                                       anterograde amnesia, and the
sustaining brain injury.                                                        when any structural lesion, such as
                                       presence and duration of confusion.
Most commonly, concussion is           A timeline of injury and the             an intracranial bleed or fracture, is
characterized by the rapid onset of    presence of symptoms should be           suspected. If an athlete
cognitive impairment that is self
limited and spontaneously resolves.
                                                                           Table 1
The acute symptoms of concussion,
                                                         SIGNS AND SYMPTOMS OF mTBI
listed below, are felt to reflect a
                                         Loss of consciousness (LOC)            Visual Disturbances
functional disturbance in cognitive
                                         Confusion                                 (Photophobia, blurry Phono/
function instead of structural
                                         Post-traumatic amnesia (PTA)              photophobia vision,
abnormalities, which is why
                                         Retrograde amnesia (RGA)                  double vision)
diagnostic tests such as magnetic
                                         Disorientation                         Disequilibrium
resonance imaging (MRI) and
                                         Delayed verbal and motor               Feeling “in a fog,” “zoned out”
computerized tomography (CT)                responses                           Vacant stare
scans are most often normal.             Inability to focus                     Emotional lability
These studies may have their role        Headache                               Dizziness
in assessing and evaluating the          Nausea/Vomiting                        Slurred/incoherent speech
head-injured athlete whenever there      Excessive drowsiness
is concern for the associated                                                                                           53
     experiences prolonged loss of
     consciousness, confusion, seizure             1. NCAA Concussion Fact Sheets and Video for Coaches
     activity, focal neurologic deficits or        and Student-Athletes
                                                   Available at www.NCAA.org/health-safety.
     persistent clinical or cognitive
                                                   2. Heads Up: Concussion Tool Kit
     symptoms, then additional testing             CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.
     may be indicated.                             3. Heads Up Video
                                                   NATA. Streaming online at www.nata.org/consumer/headsup.htm.
     There are several grading systems
     and return-to-play guidelines in the
     literature regarding concussion in
                                                                                      needed to understand the complete
     sport (AAN, Torg, Cantu). However,       Zurich Conference, NATA ‘04).           role of neuropsychological testing.
     there may be limitations because
     they presume that LOC is associated      Several recent publications have        Given these limitations, it is
     with more severe injuries. It has        endorsed the use of neurocognitive      essential that the medical care team
     been demonstrated that LOC does          or neuropsychological testing as the    treating athletes continue to rely on
     not correlate with severity of injury    cornerstone of concussion               its clinical skills in evaluating the
     in patients presenting to an             evaluation. These tests provide a       head-injured athlete to the best of its
     emergency department with closed         reliable assessment and                 ability. It is essential that no athlete
     head injury, and has also been           quantification of brain function by     be allowed to return to participation
     demonstrated in athletes with            examining brain-behavior                when any symptoms persist, either
     concussion (Lovell ‘99). It has been     relationships. These tests are          at rest or during exertion. Any
     further demonstrated that retrograde     designed to measure a broad range       athlete exhibiting an injury that
     amnesia (RGA), post-traumatic            of cognitive function, including        involves significant symptoms, long
     amnesia (PTA), and the duration of       speed of information processing,        duration of symptoms or difficulties
     confusion and mental status changes      memory recall, attention and            with memory function should not be
     are more sensitive indicators of         concentration, reaction time,           allowed to return to play during the
     injury severity (Collins ‘03), thus an   scanning and visual tracking ability,   same day of competition. The
     athlete with these symptoms should       and problem solving ability. Several    duration of time that an athlete
     not be allowed to return to play         computerized versions of these tests    should be kept out of physical
     during the same day. These athletes      have also been designed to improve      activity is unclear, and in most
     should not return to any                 the availability of these tests, and    instances, individualized return-to-
     participation until cleared by a         make them easier to distribute and      play decisions should be made.
     physician. More recent grading           use. Ideally, these tests are           These decisions will often depend
     systems have been published that         performed before the season as a        on the clinical symptoms, previous
     attempt to take into account the         “baseline” with which post-injury       history of concussion and severity
     expanding research in the field of       tests can be compared. Despite the      of previous concussions. Additional
     mTBI in athletes. Though it is           utility of neuropsychological test      factors include the sport, position,
     useful to become familiar with these     batteries in the assessment and         age, support system for the athlete
     guidelines, it is important to           treatment of concussion in athletes,    and the overall “readiness” of the
     remember that many of these              several questions remain                athlete to return to sport.
     injuries are best treated in an          unanswered. Further research is
                                                                                      Once an athlete is completely
                                                                                      asymptomatic, the return-to-play
                                         Table 2                                      progression should occur in a step-
             SYMPTOMS OF POST-CONCUSSION SYNDROME                                     wise fashion with gradual
       Loss of intellectual capacity          Fatigue                                 increments in physical exertion and
       Poor recent memory                     Irritability                            risk of contact. After a period of
       Personality changes                    Phono/photophobia                       remaining asymptomatic, the first
       Headaches                              Sleep disturbances                      step is an “exertional challenge” in
       Dizziness                              Sleep disturbances
       Lack of concentration                  Depressed mood                          to 20 minutes in an activity such as
       Poor attention                         Anxiety                                 biking or running in which he/she
54                                                                                    increases his/her heart rate and
breaks a sweat. If he/she does not
experience any symptoms, this can               The NCAA Executive Committee adopted
be followed by a steady increase in             (April 2010) the following policy for
exertion, followed by return-to-
                                                institutions in all three divisions.
sport-specific activities that do not
put the athlete at risk for contact.            “Institutions shall have a concussion management plan on file such
Examples include dribbling a ball               that a student-athlete who exhibits signs, symptoms or behaviors con-
or shooting, stickwork or passing,              sistent with a concussion shall be removed from practice or competi-
or other agilities. This allows the             tion and evaluated by an athletics healthcare provider with experience
athlete to return to the practice               in the evaluation and management of concussions. Student-athletes
setting, albeit in a limited role.              diagnosed with a concussion shall not return to activity for the
Finally, the athlete can be                     remainder of that day. Medical clearance shall be determined by the
progressed to practice activities               team physician or his or her designee according to the concussion
with limited contact and finally full           management plan.
contact. How quickly one moves                  “In addition, student-athletes must sign a statement in which they ac-
through this progression remains                cept the responsibility for reporting their injuries and illnesses to the
controversial.                                  institutional medical staff, including signs and symptoms of concus-
                                                sions. During the review and signing process, student-athletes should
                                                be presented with educational material on concussions.”

1. Cantu RC: Concussion severity should     and Neuropsychological Performance in       13. Makdissi M, Collie A, Maruff P et al:
not be determined until all                 College Football Players. JAMA              Computerized cognitive assessment of
postconcussion symptoms have abated.        282:964-970, 1999.                          concussed Australian Rules footballers.
Lancet 3:437-8, 2004.                       8. Guskiewicz KM, Bruce SL, Cantu R,        Br. J Sports Med 35(5):354-360, 2001.
2. Cantu RC: Recurrent athletic head        Ferrara MS, Kelly JP, McCrea M,             14. McCrea M: Standardized mental
injury: risks and when to retire. Clin      Putukian M, McLeod-Valovich TC;             status assessment of sports concussion.
Sports Med. 22:593-603, 2003.               National Athletic Trainers’ Association     Clin J Sport Med 11(3):176-181, 2001.
3. Cantu RC: Post traumatic (retrograde/    Position Statement: Management of
                                            Sport-related Concussion: Journal of        15. McCrea M, Hammeke T, Olsen G,
anterograde) amnesia: pathophysiology
                                            Athletic Training. 39(3): 280-297, 2004.    Leo , Guskiewicz K: Unreported
and implications in grading and safe
return to play. Journal of Athletic                                                     concussion in high school football
                                            9. Guskiewicz KM: Postural stability        players. Clin J Sport Med 2004;14:13-
Training. 36(3): 244-8, 2001.               assessment following concussion: One
                                            piece of the puzzle. Clin J Sport Med       17.
4. Centers for Disease Control and
Prevention. Sports-related recurrent        2001; 11:182-189.                           16. McCrory P, Meeuwisse W, Johnston
brain injuries: United States. MMWR         10. Hovda DA, Lee SM, Smith ML et al:       K, Dvorak J, Aubry M, Molloy M, Cantu
Morb Mortal Wkly Rep 1997; 46:224-          The Neurochemical and metabolic             R. Concensus Statement on Concussion
227.                                        cascade following brain injury: Moving      in Sport: the Third International
5. Collie A, Darby D, Maruff P:             from animal models to man. J                Conference on Concussion in Sport.
Computerized cognitive assessment of        Neurotrauma 12(5):143-146, 1995.            Zurich, Switzerland, 2008. Br J Sports
athletes with sports related head injury.   11. Johnston K, Aubry M, Cantu R et al:     Med 2009;43:i76-i84.
Br. J Sports Med 35(5):297-302, 2001.       Summary and Agreement Statement of          17. Torg JS: Athletic Injuries to the Head,
6. Collins MW, Iverson GL, Lovell MR,       the First International Conference on       Neck, and Face. St. Louis, Mosby-Year
McKeag DB, Norwig J, Maroon J: On-          Concussion in Sport, Vienna 2001, Phys      Book, 1991.
field predictors of neuropsychological      & Sportsmed 30(2):57-63, 2002.              18. Langlois JA, Rutland-Brown LV, Wald
and symptom deficit following sports-       12. Lovell MR, Iverson GL, Collins MW       MM. The Epidemiology and Impact of
related concussion. Clin J Sport Med        et al: Does loss of consciousness predict   Traumatic Brain Injury. J Head Trauma
2003; 13:222-229.                           neuropsychological decrements after         Rehabil. 2006; 21:375-8.
7. Collins MW, Grindel SH, Lovell MR et     concussion? Clin J Sport Med 9:193-
al: Relationship Between Concussion         198, 1999.                                                                                55
     In Addition to the Executive Committee Policy Requirements,
     Additional Best Practices for a Concussion Management Plan
     Include, but are not Limited to:
     1. Although sports currently have rules in place,                   for each student-athlete before the first practice
        athletics staff, student-athletes and officials should            in the sports of baseball, basketball, diving,
        continue to emphasize that purposeful or flagrant                 equestrian, field hockey, football, gymnastics,
        head or neck contact in any sport should not be per-             ice hockey, lacrosse, pole vaulting, rugby,
        mitted and current rules of play should be strictly              soccer, softball, water polo and wrestling, at
        enforced.                                                        a minimum. The same baseline assessment
                                                                         tools should be used post-injury at appropriate
     2. Institutions should have on file and annually update
                                                                         time intervals. The baseline assessment should
        an emergency action plan for each athletics venue
                                                                         consist of one or more of the following areas of
        to respond to student-athlete catastrophic injuries
        and illnesses, including but not limited to, con-
        cussions, heat illness, spine injury, cardiac arrest,           1) At a minimum, the baseline assessment should
        respiratory distress (e.g., asthma), and sickle cell               consist of the use of a symptoms checklist and
        trait collapses. All athletics healthcare providers                standardized cognitive and balance assess-
        and coaches should review and practice the plan at                 ments [e.g., SAC; SCAT; SCAT II; Balance
        least annually.                                                    Error Scoring System (BESS)].
     3. Institutions should have on file an appropriate                  2) Additionally, neuropsychological testing (e.g.,
        healthcare plan that includes equitable access to                  computerized, standard paper and pencil) has
        athletics healthcare providers for each NCAA sport.                been shown to be effective in the evaluation
                                                                           and management of concussions. The develop-
     4. Athletics healthcare providers should be empowered
                                                                           ment and implementation of a neuropsycho-
        to have the unchallengeable authority to determine
                                                                           logical testing program should be performed
        management and return-to-play of any ill or injured
                                                                           in consultation with a neuropsychologist who
        student-athlete, as the provider deems appropriate.
                                                                           is in the best position to interpret NP tests by
        For example, a countable coach should not serve as
                                                                           virtue of background and training. However,
        the primary supervisor for an athletics healthcare
                                                                           there may be situations in which neuropsy-
        provider, nor should the coach have sole hiring or
                                                                           chologists are not available and a physician ex-
        firing authority over a provider.
                                                                           perienced in the use and interpretation of such
     5. The concussion management plan should outline                      testing in an athletic population may perform
        the roles of athletics healthcare staff (e.g., physician,          or interpret NP screening tests.
        certified athletic trainer, nurse practitioner, physician
                                                                      d. The student-athlete should receive serial
        assistant, neurologist, neuropsychologist). In addi-
                                                                         monitoring for deterioration. Athletes should be
        tion, the following components have been specifi-
                                                                         provided with written instructions upon dis-
        cally identified for the collegiate environment:
                                                                         charge, preferably with a roommate, guardian or
       a. Institutions should ensure that coaches have ac-               someone who can follow the instructions.
          knowledged that they understand the concussion
                                                                       e. The student-athlete should be evaluated by a
          management plan, their role within the plan and
                                                                          team physician as outlined within the concus-
          that they received education about concussions.
                                                                          sion management plan. Once asymptomatic
       b. Athletics healthcare providers should practice                  and post-exertion assessments are within normal
          within the standards as established for their                   baseline limits, return-to-play should follow a
          professional practice (e.g., physician, certified                medically supervised stepwise process.
          athletic trainer, nurse practitioner, physician as-       6. Institutions should document the incident, evalua-
          sistant, neurologist, neuropsychologist).                    tion, continued management and clearance of the
       c. Institutions should record a baseline assessment             student-athlete with a concussion.

       For references, visit www.NCAA.org/health-safety.

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