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UNLV Sports Medicine


CONCUSSION MANAGEMENT

The 3rd International Conference on Concussion in Sport was held in Zurich, Switzerland, on October 29+30, 2008. The consensus statement from this conference was used as the outline of the policy adapted by UNLV. Current NCAA Sports Medicine Handbook recommendations were also used to form this policy. Modifications and revisions were made to the outline based on current available resources, new guidelines and the population of student-athletes at UNLV.

1. CONCUSSION

1.1 Definition of Concussion
Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

  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.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
  3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
  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 a small percentage of cases, post-concussive symptoms may be prolonged.
  5. No abnormality on standard structural neuroimaging studies is seen in concussion.

1.2 Classification of Concussion
The majority (80%-90%) of concussions resolve in a short (7-10 days) period, although the recovery time frame may be longer in children and adolescents.

2. CONCUSSION EVALUATION
A student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. Student-athletes that sustain a concussion outside of their sport should be managed in the same manner as those sustained during sport activity.

2.1 Symptoms and Signs of Acute Concussion
The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behavior, balance, sleep and cognition. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the Head Injury Assessment form (Appendix K).

The suspected diagnosis of concussion can include one or more of the following clinical domains:

(a) Symptoms: somatic (eg, headache), cognitive (eg, feeling
like in a fog) and/or emotional symptoms (eg, unstable changes)
(b) Physical signs (eg, loss of consciousness, amnesia)
(c) Behavioral changes (eg, irritability)
(d) Cognitive impairment (eg, slowed reaction times)
(e) Sleep disturbance (eg, drowsiness)

If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted.

A Head Injury Assessment Form will be completed on any student-athlete that is suspected of having a concussion. The student-athlete will be referred to the UNLV Team Physician.

2.2 On-field or Sideline Evaluation of Acute Concussion
When a player shows ANY features of a concussion:

(a) The player should be medically evaluated onsite using standard emergency management principles, and particular attention should be given to excluding a cervical spine injury.
(b) The appropriate disposition of the player must be determined by the treating Certified Athletic Trainer / Team Physician in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
(c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the Head Injury Assessment form.
(d) The player should not be left alone following the injury, and serial monitoring (follow up Head Injury Assessment forms) for deterioration is essential over the initial few hours following injury.
(e) A player with significant symptoms, long duration of symptoms or difficulties with memory function should not be allowed to return to play on the day of injury. (See section 4.5.)
(f) The student-athlete will be given a Take Home Instruction sheet (Appendix K).

Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes.

Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective (Head Injury Assessment form). It is worth noting that standard orientation questions (eg, time, place, and person) have been shown to be unreliable in the sporting situation when compared with memory assessment. It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to be used as a stand-alone tool for the ongoing management of sports concussions. It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode.

2.3 Evaluation in Emergency Room or Office by Medical Personnel
An athlete with concussion may be evaluated in the emergency room or by the UNLV Team Physician as a point of first contact following injury or may have been referred from another care provider.

All suspected concussions will be referred to the UNLV Team Physician for evaluation (next possible day). Contact the UNLV Team Physician or Head Athletic Trainer if there are questions.

In addition to the points outlined above, the key features of this exam should encompass:

(a) A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance.
(b) A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury.
(c) A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

In large part, these points above are included in the Head Injury Assessment form.

3. CONCUSSION INVESTIGATIONS
A range of additional investigations may be recommended by the UNLV Team Physician to assist in the diagnosis and/or exclusion of injury. These include:

3.1 Neuroimaging
Conventional structural neuroimaging is normal in concussive injury. Brain CT (or, where available,MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms. Newer structural MRI modalities including gradient echo, perfusion and diffusion imaging have greater sensitivity for structural abnormalities. However, the lack of published studies, as well as absent pre-injury neuroimaging data, limits the usefulness of this approach in clinical management at the present time. In addition, the predictive value of various MR abnormalities that may be incidentally discovered is not established at the present time.

Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion. Whilst not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting.

3.2 Neuropsychological Assessment
The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation. Although in most case cognitive recovery largely overlaps with the time course of symptom recovery, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution suggesting that the assessment of cognitive function should be an important component in any return to play protocol. It must be emphasized, however, that NP assessment should not be the sole basis of management decisions; rather, it should be seen as an aid to the clinical decision-making process in conjunction with a range of clinical domains and investigational results.

4. CONCUSSION MANAGEMENT
The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies. These are outlined in the section on modifiers below.

As described above, the majority of injuries will recover spontaneously over several days. In these situations, it is expected that an athlete will proceed progressively through a stepwise return to play strategy. During this period of recovery, while symptomatically following an injury, it is important to emphasize to the student-athlete that physical AND cognitive rest is required. Activities that require concentration and attention (eg, classroom work, test taking, reading, working on a computer, computer games, video games, text messaging, watching TV, listening to music, etc.) may exacerbate symptoms and possibly delay recovery. In such cases, apart from limiting relevant physical and cognitive activities (and other risk-taking opportunities for re-injury), while symptomatic, no further intervention is required during the period of recovery, and the athlete typically resumes sport without further problem.

A Head Injury Assessment form (use alternative forms 1-4) will be utilized until student-athlete is symptom free. Results will be recorded daily on the Head Injury / Graded Symptoms Checklist (Appendix K).

4.1 Graduated Return to Play Protocol
Return to play protocol following a concussion follows a stepwise process as outlined in Table 1.

With this stepwise progression, the student-athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that a student- athlete would take approximately one week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed.

A student-athlete can start this progression when given permission by the UNLV Team Physician.

Final authority for Return-to-Play shall reside with the team physician or the physicianÕs designee.

TABLE 1.
Graduated Return to Play Protocol

Rehabilitation StageObjective of Each StageFunctional Exercise at Each Stage of Rehabilitation
Stage 1. No ActivityRecoveryComplete physical and cognitive rest
Stage 2. Light aerobic exercise
Target Heart Rate: 30-40% of maximum exertion
(Max HR - Rest HR X .30) +Resting HR
Recommendations: exercise in quiet area (treatment room recommended); no impact activities, balance and vestibular treatment by specialist (prn); limit head movement / position change; limit concentration activities; 10-15 minutes of light cardio exercise.
*Increase Heart Rate
*Very light aerobic conditioning
*Sub-max isometric strengthening
*ROM / Stretching
*Low level balance activities
*Walking, Swimming, Stationary Bike, Seated
Elliptical, UBE, Treadmill walking (10-15 min).
*Quad sets, Ham sets, SLRÕs.
*No resistance training.
*Cervical ROM exercise, Trap/LS stretching, Pec stretching, Hamstring stretching, Quad stretching, *Calf stretching.
*Romberg exercises (feet together, tandem stance, eyes open-closed), single leg balance.
Stage 3. Sport-specific exercise
Target Heart Rate: 40-60% of maximum exertion
(Max HR - Rest HR X .40) +Rest HR
Recommendations: exercise in gym areas recommended; use various exercise equipment; allow some positional changes and head movement; low level concentration activities (counting repetitions); 20-30 minutes of cardio exercise.
(Stage 2 exercises included, as appropriate)
*Add movement / up + down / side to side
*Light to Moderate aerobic conditioning
*Light weight PREÕs
*Stretching (active stretching initiated)
*Moderate Balance activities; initiate activities with head position changes
*No head impact activities
*Treadmill, Stationary Bike, Elliptical (upright or seated), UBE, (20-25 min).
*Light weight strength exercise (Cybex style equipment), resistive band exercise (UE/LE), wall squats, lunges, step up/downs.
*Any Stage 2 stretching, active stretching as tolerated (Lunge walks, side to side groin stretching, walking hamstring stretch).
*Romberg exercises, VOR exercise (walking with eyes focused with head turns), Swiss ball exercises, single leg balance exercises.
Stage 4. Non-contact training drills
Target Heart Rate: 60-80% of maximum exertion
(Max HR - Rest HR X .65) + Rest HR
Recommendations: any environment ok for exercise (indoor, outdoor); integrate strength, conditioning, and balance / proprioceptive exercise, can incorporate concentration challenges (counting exercises / visual games (Stage 2+3 exercises included, as appropriate)
*Exercise, coordination, and cognitive load
*Moderately aggressive aerobic exercise
*All forms of strength exercise (80% max) under the direction of a Certified Athletic Trainer.
*Active stretching exercise
*Impact activities running, plyometrics (no contact).
*Challenging proprioceptive / dynamic balance (integrated with strength and conditioning), challenging positional changes.
*Treadmill (jogging); Stationary Bike; Elliptical (upright or seated; UBE. (25-30 min)
*Resistive weight training including free weights; Functional Squat, Dynamic Strength activities.
*Active stretching (Lung walks, side to side groin stretching, walking hamstring stretch).
*Initiate agility drills (zig zag runs, side shuffle, etc.), Jumping on tramp / blocks.
*Progression to more complex training drills (eg, passing drills in football).
*Higher level balance activities, ball toss on wobble board, balance discs, trampoline squats and lunges on BOSU ball.
Stage 5. Full practice
Target Heart Rate: 80% of maximum exertion
(Max HR - Rest HR X .80) +Rest HR
Recommendations: continue to avoid contact activity, but resume aggressive training in all environments
*Restore confidence and assess functional skills by coaching staff.
*Non-contact physical training
*Aggressive strength exercise
*Impact activities / plyometrics
*Sport specific Performance Training
*Following medical clearance, participate in normal training activities.
*Limited, controlled return to full-contact practice and monitoring for symptoms.
*Program to be designed by Certified Athletic Trainer.
*Graded Treadmill testing
*Interval training
*Sport Specific drills / training
Stage 6. Return to play
Target Heart Rate: Full exertion
Recommendations: Initiate contact activities as appropriate to sport activity; full exertion activities for sport activities
*Resume full physical training activities with contact
*Continue Aggressive strength / conditioning exercise
*Sport specific activities
*Normal game play
*Program to be designed by Certified Athletic Trainer.
*Practice and game intensity training
*Sport specific activities
HR = heart rate, MPHR = maximum predicted heart rate.

4.2 Psychological Management and Mental Health Issues
In addition, psychological approaches may have potential application in this injury, particularly with the modifiers listed below. Care givers are also encouraged to evaluate the concussed athlete for affective symptoms such as depression, as these symptoms may be common in concussed athletes.

A student-athlete will complete a UNLV Athletic Training / Head Injury Questionnaire daily until signs are normal and responses are symptom free (Appendix K).

4.3 The Role of Pharmacological Therapy
Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific prolonged symptoms (eg, sleep disturbance, anxiety, etc.). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. In broad terms, this approach to management should be only considered by clinicians experienced in concussion management.

An important consideration in RTP is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician.

4.4 The Role of Pre-participation Concussion Evaluation
Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value. Such a history may pre-identify athletes that fit into a high risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions. It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable. The clinical history should also include information about all previous head, face or cervical spine injuries, as these may also have clinical relevance. It is worth emphasizing that, in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history it is advised that details regarding protective equipment employed at time of injury be sought, both for recent and remote injuries. The benefit a comprehensive pre-participation concussion evaluation allows for modification and optimization of protective behavior and is an opportunity for education.

4.5 Same Day RTP
With adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources (eg, access to neuropsychologists, consultants, neuroimaging, etc.), as well as access to immediate (ie, sideline) neuro-cognitive assessment, return to play management may be more rapid. The RTP strategy must still follow the same basic management principles, namely, full clinical and cognitive recovery before consideration of return to play. There is data, however, demonstrating that, at the collegiate and high school level, athletes allowed to RTP on the same day may demonstrate NP deficits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms. It should be emphasized, however, that the young (<18) elite athlete should be treated more conservatively even though the resources may be the same as an older professional athlete. Based on this, student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day.

Any student-athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulties with memory function should not be allowed to return to play during the same day of competition.

It has been further demonstrated that retrograde amnesia, post-traumatic amnesia, and the duration of confusion and mental status changes are more sensitive indications of injury severity, thus a student-athlete with these symptoms should not be allowed to return to play during the same day. These student-athletes should not return to any participation until cleared by the team physician or their designee according to the concussion management plan. The team physician and certified athletic trainers are empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate.

It is essential that no student-athlete be allowed to return to participation when any symptoms-persists, either at rest or exertion. Healthcare professionals should assume a concussion when unsure and waiting for final diagnosis. When in doubt, sit the athlete out.

5. MODIFYING FACTORS IN CONCUSSION MANAGEMENT
The consensus panel agreed that a range of "modifying" factors may influence the investigation and management of concussion and in some cases may predict the potential for prolonged or persistent symptoms. These modifiers would also be important to consider in a detailed concussion history and are outlined in Table 2.

5.1 The Significance of Loss of Consciousness (LOC)
In the overall management of moderate to severe traumatic brain injury, duration of LOC is an acknowledged predictor of outcome. While published findings in concussion describe LOC associated with specific early cognitive deficits, it has not been noted as a measure of injury severity. Consensus discussion determined that prolonged (>1 minute duration) LOC would be considered as a factor that may modify management.

TABLE 2.
Concussion Modifiers

Factors
Modifier
Number
Duration (>10 days)
Severity
SignsProlonged LOC (>1 min), amnesia
Sequelae (aftereffect)Concussive convulsions
TemporalFrequency - repeated concussions over time
Timing - injuries close together in time
''Recency'' - recent concussion or TBI
ThresholdRepeated concussions occurring with progressively less impact force or slower recovery after each successive concussion
AgeChild and adolescent (<18 years old)
Co- and Pre-morbiditiesMigraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD),sleep disorders
MedicationPsychoactive drugs, anticoagulants
BehaviorDangerous style of play
SportHigh-risk activity, contact and collision sport, high sporting level

ADHD = attention deficit hyperactivity disorder
LD = learning disabilities
LOC = loss of consciousness
TBI = traumatic brain injury

5.2 The Significance of Amnesia and Other Symptoms
There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity. Published evidence suggests that the nature, burden and duration of the clinical post-concussive symptoms may be more important than the presence or duration of amnesia alone. Further, it must be noted that retrograde amnesia varies with the time of measurement post-injury and hence is poorly reflective of injury severity.

5.3 Motor and Convulsive Phenomena
A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.

5.4 Depression
Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury including sports related concussion. Neuroimaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression.

5.5 Chronic Traumatic Brain Injury
Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuro-pathological evidence of chronic traumatic encephalopathy was observed in retired football players. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes.

6. INJURY PREVENTION

6.1 Protective Equipment - Mouthguards and Helmets
There is no good clinical evidence that currently available protective equipment will prevent concussion, although mouthguards have a definite role in preventing dental and oral-facial injury. Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence.

6.2 Rule Change
Consideration of rule changes to reduce head injury incidence or severity may be appropriate where a clear-cut mechanism is implicated in a particular sport. An example of this is in soccer where research studies demonstrated that upper limb to head contact in heading contests accounted for approximately 50% of concussions. As noted earlier, rule changes also may be needed in some sports to allow an effective off-field medical assessment to occur without compromising the athleteÕs welfare, affecting the flow of the game or unduly penalizing the playerÕs team. It is important to note that rule enforcement may be a critical aspect of modifying injury risk in these settings, and referees play an important role in this regard.

6.3 Risk Compensation
An important consideration in the use of protective equipment is the concept of risk compensation. This is where the use of protective equipment results in behavioral change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates. This may be a particular concern in child and adolescent athletes where head injury rates are often higher than in adult athletes.

6.4 Aggression vs. Violence in Sport
The competitive/aggressive nature of sport which makes it fun to play and watch should not be discouraged. However, sporting organizations should be encouraged to address violence that may increase concussion risk. Fair play and respect should be supported as key elements of sport.

7. KNOWLEDGE TRANSFER
As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and health care providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe return to play. Methods to improve education including web-based resources, educational videos and international outreach programs are important in delivering the message. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and managers play an important part in ensuring these values are implemented on the field of play.

Structured and documented education of student-athletes and coaches is recommended to improve the success of the recognition and referral components of a consistent concussion management program.

Student-athletes must sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes should be presented with educational material on concussions. (Appendix K).

Coaches must acknowledge they understand the concussion management plan, their role within the plan and that they received education about concussions.

Educational materials on concussions can be found at www.ncaa.org/health-safety.

All athletics healthcare providers and coaches should review and practice the emergency action plan to respond to student-athletes catastrophic injuries and illnesses at least annually.

8. BASELINE TESTING
UNLV will record a baseline assessment for each student-athlete prior to the first practice. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment will consist of the use of a symptoms checklist, standardized cognitive assessment (Standardized Assessment of Concussions - SAC), and balance assessments (Appendix K).

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