Sport Related Concussion

Hallie Labrador, MD MSMSPrimary Care Sports Medicine

NorthShore Medical Group

Clinical Educator Family Medicine

University of Chicago, Pritzker School of Medicine

No Disclosures

Overview

• Sport related concussion incidence and risk

• Concussion definition

• New Guidelines

• Treatment of acute injury

• Post-concussive syndrome

• Chronic traumatic encephalopathy

Concussion is a Problem

• CDC estimates 1.6-3.8

million sports-related

concussions annually in

USA

• Increased rates over last

decade

• Underreporting is a

problem

McDonald T. Burghart MA, Nazir N. J Trauma Nurs. 2016: Sept-Oct;23(5): 241-6

Zhang A, et al. The Orthopaedic Journal of Sports Medicine. 2016 Aug; 4(8)

Concussion Underreporting

• 2018 Survey of Former NFL Players

– 50.3% report nondisclosure

– Higher in non-white/ Hispanic players

– Higher post spear-rule change

• 2018 Survey of NCAA D1 Athletes

– Understood concussion risks

– No change in attitudes towards hiding symptoms

• 2017 Survey of High School Athletes

– Athletes at schools with ATCs had more knowledge of concussion

– No change in reporting ratesKerr ZY, et al. Am J Sports Med. 2018 Jan;46(1):22-29

Conway FN, et al. Clin J Sports med. 2018 Jan 11

Wallace J, et al. J Athl Train. 2017 March 52(3): 228-235

Concussion Exists in All Sports

• Sports with majority of

concussions: Football,

Wrestling, Boys’ and Girls’

Soccer, Girls’ Basketball

• Depends how you calculate

Marar M, et al. Am J Sports Med. 2012 Apr;40(4):745-55

Ken ZY, et al. J Athl Train. 2016 Jun 22.

Concussion Incidence

• Incidence (frequency)

– Difficult to compare sports

– Information depends on reporting

– Calculate per year, per team, per AE

• 2013-2014 HS Athletes

– Concussion/ 100,000 AE

– Football, boys’ LAX, girls’ soccer

• 2014-2015 HS School year

– Girls’ soccer

O’Connor KL, et al. J Athl Train. 2017 March 52(3): 175-185

Schallmo S, et al. JBJS. 2017 Aug 2;99(15)1314-1320

Concussion Incidence

• Increased Incidence

– May be more likely to

report symptoms

» More concern about

future impact

» Cultural tendencies

– May be related to

anatomic differences

» Smaller/ weaker muscles

» ↓head mass ↑velocity

Up to 2.5 x more

likely to sustain a

concussion

GIRLS

BOYS

Concussion Guidelines

Expert Consensus Based

• 1st International Conference on concussion in Sport: Vienna – 2001

• 2nd: Prague – 2004

• 3rd: Zurich – 2008

• 4th: Zurich – 2012

• 5th: Berlin – 2016 (published April 26, 2017)

The 11 “R’s” of Concussion

• Recognize

• Remove

• Re-evaluate

• Rest

• Recovery

• Rehabilitation

• Refer

• Return to Sport

• Reconsider

• Residual Effects

• Risk Reduction

Recognize

Definition of Concussion

• A complex pathophysiological process affecting the brain, induced

by biomechanical forces, that may include:

– Direct blow to head/body with force transmitted to head

– Rapid onset of short-lived impairment of neurological function

– Neuropathological changes - functional disturbance

– Graded set of clinical symptoms that may involve loss of consciousness

– Symptoms not explained by drug, alcohol or medication use, other injuries

or other comorbidities

Pathophysiology

• Forces to the brain are linear and/or rotational Causes

cellular damage

Pathophysiology

Skull AcceleratesRelative Motion at

the Skull/ Brain

Interface

Brain Lags

• Linear motion –

pressure gradient

change

• Rotational motion –

sheering force

Pathophysiology

“Metabolic Mismatch”

• Thought to be metabolic dysfunction

• Cells exposed to dramatic changes in intracellular and extracellular environment

• Accompanied by decreased cerebral blood flow = neurovascular constriction

Metabolic Mismatch

• Brain has to work harder to meet the same

demands

• Brain has increased vulnerability in the

post-concussion state

• 2nd injury before brain is recovered may

result in worse cellular changes and

cognitive deficits

• Excessive cognitive or physical activity

before complete recovery may result in

prolonged dysfunction

Second Impact Syndrome

• Second head injury in close succession to initial injury

– Increased brain edema -> brain herniation

– Severe neurocognitive dysfunction/ death

– ? Distinct entity or edema from single traumatic impact

• Incidence is unknown, but rare

– Almost all cases in the literature are athletes <20 years old

• More commonly – prolonged symptoms/ delayed recovery

• Lysted Law

– First law signed to provide guidelines around concussion/ RTP 2009

– Prevents same day return to play Foris LA, Donnally CJ. Second Impact Syndrome. Stat Pearls. 2017 October.

Illinois Concussion Law

• Youth Sports Concussion Safety Act – 2015

– Each school board is required to adopt a student athlete

concussion policy in accordance with those developed by the IHSA

– Each school district must educate coaches, athletes, parent/

guardians

– All public, private or charter schools must convene a Concussion

Oversight Team to develop RTP and RTL protocols

– All coaches and licensed officials required to complete 2 hour

training program every 2 years

Illinois Concussion Law

• IHSA Protocol

– “Any athlete who exhibits signs, symptoms or behavior consistent

with a concussion shall be removed from the contest and shall not

return to play until cleared by an appropriate health care professional”

» Physician

» ATC

» PA

» APN

Research is Challenging

• Most concussion pathophysiology research is done in mouse models

• Imaging used in concussion research: fMRI, PET scan, SPECT, Diffusion tension imaging, MR spectroscopy

• Biomarker research looks at blood proteins from axons, glial cells and neurons

Sports Medicine and Arthroscopy Review. Vol 24(3): September 2016.

Research is Challenging

• Blood test helps detect brain

protein in the blood

• Can help determine if a CT

scan is needed with history of

head trauma

• Might help rule in/ out

structural brain damage

• Does NOT diagnose

concussion

Concussion Diagnosis can be Difficult

• Diagnosis is clinical

– Based on history – mechanism

– Based on symptoms constellation

• Probably results in both over and under diagnosis of concussion

• In any suspected case of concussion, the individual should be removed from the playing field and further evaluated

Signs and Symptoms

Physical

Cognitive

Emotional

Sleep

Signs and Symptoms

Physical

• Headache

• Nausea

• Vomiting

• Balance problems

• Dizziness

• Visual Problems

• Fatigue

• Sensitivity to light

• Sensitivity to noise

• Numbness/tingling

• Dazed

• Stunned

Signs and Symptoms

Cognitive

• Feeling mentally “foggy” – feels like standard

TV, instead of HD TV

• Feeling slowed down

• Difficulty concentrating

• Difficulty remembering

• Forgetful of recent information

• Confused about recent events

• Answers questions slowly

• Repeats questions

Signs and Symptoms

Emotional

• Irritable

• Sadness

• More emotional

• Nervousness

Sleep

• Drowsiness

• Sleeping more or less than usual

• Difficulty falling asleep

Concussion Diagnosis – Validated Tools

• Several tests have been

developed to help clinically

diagnose and manage

concussion

• No single test can reliably

and quickly diagnose

concussion in all cases

• Validated tools may be

helpful

Validated Concussion Tools – PCSSSymptoms None Mild Moderate Severe

Headache 0 1 2 3 4 5 6

Pressure in Head 0 1 2 3 4 5 6

Neck Pain 0 1 2 3 4 5 6

Nausea or Vomiting 0 1 2 3 4 5 6

Sensitivity to Light 0 1 2 3 4 5 6

Sensitivity to Noise 0 1 2 3 4 5 6

Balance Problems 0 1 2 3 4 5 6

Dizziness 0 1 2 3 4 5 6

Blurred Vision 0 1 2 3 4 5 6

More Emotional 0 1 2 3 4 5 6

Irritable 0 1 2 3 4 5 6

Sadness 0 1 2 3 4 5 6

Nervous or Anxious 0 1 2 3 4 5 6

Confusion 0 1 2 3 4 5 6

Feeling “in a fog” 0 1 2 3 4 5 6

Difficulty Concentrating 0 1 2 3 4 5 6

Difficulty Remembering 0 1 2 3 4 5 6

“Don’t Feel Right” 0 1 2 3 4 5 6

Feeling Slowed Down 0 1 2 3 4 5 6

Drowsiness 0 1 2 3 4 5 6

Fatigue or Low Energy 0 1 2 3 4 5 6

Difficulty Falling Asleep 0 1 2 3 4 5 6

He

ad

ach

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estibu

lar

Em

otion

al

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gn

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leep

• Objective tool to asses/

monitor symptoms

• Sensitivity of 40.81%

• Specificity of 79.31%

• PPV of 61.33%

• Limitations: wide range of

variability, self reported

• Should not be used in

isolation

Dessy AM, et al. Cureus. December 07, 9(12): e1922

Validated Concussion Tools - SAC

• Should take 5-10 minutes

• Neuropsych test designed for

sideline use

• Sensitivity 80-94%

• Specificity 76-91%

• Can be used to supplement

other tests

Dessy AM, et al. Cureus. December 07, 9(12): e1922

Validated Concussion Tools - SCAT

• Most recent – SCAT5, also child SCAT

• Combines several concussion tools

– PCSS

– SAC

– GCS

– Maddocks Score (Immediate Memory)

– BESS (balance)

– Cervical spine, neurologic/ coordination screen

Validated Concussion Tools - ImPACT

• 20-25 minute computer-based

assessment -> 4 output scores

– Verbal memory

– Reaction time

– Visual-motor speed (most reliable)

– Neuropsych test

– PCSS

• Most widely used test in North America

(NFL, MLB NBA)

• Sensitivity: 81.9-91.4% Specificity: 69.1-

89.4 %

– Increases in asymptomatic athletes attempting

to hide symptomsDessy AM, et al. Cureus. December 07, 9(12): e1922

Validated Concussion Tools

• Concussion Resolution Index (CRI)

– Online neurocognitive and neurobehavioral assessment

» 88% sensitivity; however, this may decline over time

• CogSport

– Series of seven card tasks measuring five composite cognitive

domains

» High correlations with conventional neuropsych testing

» Variability in sensitivity and specificity of composite scores

• King-Devick (KD) Oculomotor Test

– Oculomotor dysfunction is present in 65-90% of patients with TBI

– Athletes read numbers from three cards – done quickly

– Sensitivity: 86%, Specificity: 90% Dessy AM, et al. Cureus. December 07, 9(12): e1922

Galetta KM, et al. Concussion. (2016) 1(2), CNC8

Remove

• When a player shows any signs/ symptoms of concussion:– On-site evaluation – emergency

management

– Assess concussive injury using sideline assessment tool

– Serial monitoring for deterioration during initial few hours after injury

– Player diagnosed with concussion should not be allowed to return to play

Differential Diagnosis

• Concussion symptoms are non-specific. Other problems may

mimic concussion

– Post-traumatic migraine

– Dehydration/ heat exhaustion

– Whiplash

– Depression/ Anxiety

Break Time

Re-evaluate

Who Treats Concussion?Athletic Trainers

ER PhysiciansNeurologists

Neurosurgeons

Primary Care

ProvidersPhysical

Therapists

Neuropsychologists

Primary Care Sports MedicineOrthopedic Surgeons

Re-evaluate

• Follow-up examination should encompass

– Comprehensive history» detailed neurological exam

» cognitive functioning

» sleep/ wake disturbance

» ocular function

» vestibular function

» gait and balance

– Clinical status, including whether there has been improvement or deterioration

» May need additional information from parents, coaches, teammates

– Determination of the need for emergent neuroimaging to exclude more severe brain injury

Neuroimaging – Typically Not Needed

• Imaging is typically normal in concussed athlete

• Head CT

– Used to evaluate for:

»Intracranial bleeding

»Skull fracture

• MRI Brain

– May obtain if prolonged symptoms

Rest

Acute Concussion Management

• Physical rest

– But don’t sit in dark room entire time

– After 24-48 hours, patients encouraged to become gradually and progressively more active

– Early light aerobic activity

• Cognitive rest

– Stay below symptom threshold

– May need school accommodations

• Sleep: 7-9 hours, no naps

• Regular diet and hydration

Return to School is Important

Halstead ME et al. Returning to Learning Following a

Concussion. Pediatrics. 2013 Nov; Vol 132-5: 948-

957.

Headache

Dizziness

Occular Symptoms

(photophobia, blurry vision,

double vision)

• Frequent breaks

• Avoid triggers

• Planned rest breaks

• Allow head down rest

• More time to move through

hallways

• Hat/ sunglasses

• Reduce use of screens/

brightness

• Sit near the center of the room

• Eye patch

Manage symptoms to promote attendance

Phonophobia

Difficulty concentrating/

remembering

Sleep Disturbance

• Limit noisy classes

• Earplugs

• Time to move through hallways

• Avoid major tests/ projects

• Delay standardized tests

•Consider notetaker/ oral exams

• Allow for late start/ shortened

school day

Halstead ME et al. Returning to Learning Following a

Concussion. Pediatrics. 2013 Nov; Vol 132-5: 948-

957.

Recovery

Concussion Recovery

• Majority of concussions resolve in 7-10 days: 80-90%

– May be longer in adolescents/ pediatrics

• Collins et al. Neurosurgery 2006

– 134 High school football players

»40% at week 1

»60% at week 2

»80% at week 3

• Each concussion is unique, even with the same athlete

Pediatric Pathophysiology

• Studies suggest physiologic differences in our younger

athletes

• More prolonged and diffuse cerebral swelling after traumatic

brain injuries

• Immature brain up to 60x more sensitive to glutamate

– Neurotransmitter involved in metabolic cascade following concussion

– Results in longer recovery times

Field M, Collins MW,Lovell MR, Maroon JC. J Pediatr 2003: 142:546-53.

Risk Factors for Prolonged Recovery

• Multiple symptoms at presentation SOR=B

• Memory dysfunction SOR=B

• Migraine symptoms SOR=B

• Longer duration of headache SOR=B

• Age SOR=C

• Also possibly related

– Prior history of concussion with prolonged recovery

– Personal or family history of depression

– Prior history of headache/ migraine

– History of ADHD

Rehabilitation

• Literature has not evaluated early interventions

– Most patients recover in 10-14 days

• A variety of treatments may be required for persistent symptoms

following injury

– Psychological, cervical, ocular and vestibular rehabilitation may be helpful

• Submaximal exercise may help facilitate recovery

Refer

Post-Concussive Syndrome

• Definition

– Neurocognitive disorder which occurs

immediately after the occurrence of a

traumatic brain injury and persists

past the acute post-injury period

• Pathophysiology is unclear

• Depression/ deconditioning may mimic

post-concussive syndrome

Post-Concussive Syndrome

Physiological

Persistent alterations in neuron

depolarization, cell metabolism and

cerebrovascular physiology

Vestibulo-ocular

Isolated dysfunction of central and

peripheral components of the

vestibulo-ocular neurological sub-

system

Cervicogenic

Isolated mechanoceptive, nocioceptive

and proprioceptive dysfunction

within the cervical spine

neurological sub-system

Ellis MJ, Leddy J, Willer B. Frontiers in Neurology.

August 2016;7(136)

Post-Concussive Syndrome

• Physiological

– Global pounding headache at rest

– Dizziness, nausea, fatigue, drowsiness, photophobia/phonophobia

• Vestibulo-ocular

– Headache and eye strain

– Intermittent blurred vision, diplopia, dizziness, fogginess, motion sensitivity, difficulty

focusing or concentrating

– Intermittent vertigo during certain head positions

• Cevicogenic

– Headache elicited/exacerbated by activities with prolonged neck stabilization or

movement

– Neck pain, stiffness, decreased range of motion, dizziness, fogginess and postural

imbalanceEllis MJ, Leddy J, Willer B. Frontiers in Neurology. August 2016;7(136)

Post-Concussive Syndrome Treatment

Guided by

Symptoms

Ocular

Dysfunction● Ocular Rehab

● Glasses

Headache● Analgesics

Cervical Pain● cervical Rehab

Cognitive

Impairment● Stimulants

Sleep

Disturbance● Sedatives

Vestibular

Dysfunction● Vestibular Rehab

Emotional

Dysfunction● Antidepressants

Research on Medication Use in Concussion is Limited

• Medications are used often in acute and

post-concussive syndrome management

– Treatments are extrapolated from

headache research

Medication recommendations for

sport-related concussion treatment

among pediatricians

– 62% - Tylenol

– 54% - NSAIDs

– 20% - Melatonin

– 20% - Tricyclic Antidepressants

– 10% - Amantadine

– 8% - Stimulants

Medication recommendations for

concussion treatment among pediatric

EM physicians

78% - Tylenol

77% - NSAIDs

54% - Ondansetron

7% - Narcotics Halstead, ME. Sports Health. 2016 Jan-Feb; 8(1) 50-52

Graded Aerobic Treadmill Testing

• Can be use to classify PCS sub-types

• Can be used to verify recovery

• Can be used to guide treatment

• Patients perform a standardized incremental

aerobic treadmill test (Buffalo Concussion

Treadmill Test)

• Patients with persistent concussion symptoms not

exacerbated by treadmill test – vestibulo-ocular or

cervicogenic PCD

• Rapid and visible onset of symptom exacerbation

in those not fully recovered

Submaximal Exercise Prescription

• Exercise can be used to treat physiological PCD

– Animal studies: in therapeutic window, aerobic exercise can enhance

neurolgical and neurocognitive recovery

– Clinical studies: both pediatric and adult concussion patients show

high rate of symptom improvement with submaximal exercise

prescription

– Submaximal aerobic exercise programs

• Patients with worsening symptoms may need additional treatment on an

individual basis

Submaximal Exercise Prescription: J Neurosurg

106 Patients with SRC

141 Treadmill Tests

138 (97.9%) Well Tolerated/

Contributed Valuable

Information

65 Patients Tested to Verify

Recovery

63 (96.9%) Recovered

61 Patients Tested to

Classify PCS

58 Physiologic PCS 1 Cervicogenic PCS

2 Indeterminate

41 Patients with Physiologic

PCS Treated with Submax

Exercise Prescription

37 (90.2%) Improved

33 (80.5%)

Return to Sport

7 Migraine Headaches

1 Post-injury Psych D/OCordingley D, et al. J Neurosurg Pediatr. 2016 Dec; 18:693-702

Return to Sport

When Can They Return To Play?

• Improved symptoms

• Normal physical exam

• If NP testing done: Returned to baseline or

normative data

• Off all medications: Symptoms cannot be

masked

• Then athlete can start return to play

protocol: Usually guided by ATC

Graduated RTP Protocol

REHABILITATION STAGEFUNCTIONAL EXERCISE AT EACH STAGE OF

REHABILITATIONOBJECTIVE OF EACH STAGE

1. No activity Symptom limited physical and cognitive rest. Recovery

2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70%

MPHR

No resistance training.

Increase HR

3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact

activities.

Add movement

4.Non-contact training drills Progression to more complex training drills e.g. passing drills in

football and ice hockey.

May start progressive resistance training

Exercise, coordination, and cognitive load

5.Full contact practice Following medical clearance participate in normal training

activities

Restore confidence and assess functional

skills by coaching staff

6.Return to play Normal game play

Reconsider – Special Populations

• Elite athletes – should be

treated the same

• Pediatric – research is needed

– Child: age 5-12

– Adolescent: age 13-18

Residual Effects and Sequelae

Chronic Traumatic Encephalopathy

• Neurodegenerative disorder occurs

as a latent consequence of

cumulative repetitive head impacts

• Accumulation of perivascular tau

protein in the brain

• Only diagnosed post-mortem

• Symptoms include behavioral and

mood changes, and progressive

cognitive impairment

McKee, A, Alosco M, Huber, B. Neurosurgery Clinics of North America. 27 (2016) 529-

535.

Healthy brain, age 65: Former NFL player: Former boxer

Chronic Traumatic Encephalopathy

• First described in boxers “punch

drunk” in 1928

• Symptoms are heterogeneous

and overlap with other

neurodegenerative disorders

• Pathology can overlap with other

disorders

• Proposed 4 stages which

correlate to symptoms and

pathology (unclear if longitudinal)

85 Athlete Autopsies

20% “Pure”

CTE

52% CTE +

Another

Neuropathology

5% No

CTE

24% No

Neuropathology

Chronic Traumatic Encephalopathy

Clinical Presentation

(at least one of 3 domains)

Cognition

• Impaired concentration,

language, memory

• Executive dysfunction

• Visuospatial difficulties

• Dementia

Behavior/ Mood

• Apathy

• Aggression

• Impulsivity

• Depression

• Delusions

• Suicidality

Motor Function

• Dysarthria

• Spasticity

• Ataxia

• Tremors

• Gait disturbance

Chronic Traumatic Encephalopathy

• Heterogeneous symptom presentation

– Dependent on case reports

– Dependent on retrospective next-of-kin interviews

• Limitations

– Biased population

– No review of the medical record

» ? Family h/o mental disorders

» ? Socioeconomic background (retirement)

» ? h/o substance use/ PED

Gardner et al. British Journal of Sports Medicine. Jan 2014;48(2):84-90.

Chronic Traumatic Encephalopathy – Does

Everyone Get It??

Denominator Problem

153 pathology-proven cases

• 69 (45.1%) former boxers

• 63 (41.2%) former amateur/ professional football players

• 5 (3.3%) former hockey players

• 3 (2%) former professional wrestlers

• 7 (4.6%) miscellaneous

Incidence in NFL Players

who commit suicide or

show signs of aggression

?

Incidence in NFL Players

Estimated <4%

Incidence in all At Risk

Athletes

Estimated < 0.01%

Gardner et al. British Journal of Sports Medicine. Jan 2014;48(2):84-90.

Each year….

• 3 million kids play youth football

• 1 million play in HS

• ~70,000 play at collegiate level

• ~2,500 professional players

• “Of the ~44 MILLION PLAYERS, only 63 cases (111) of FB players have

been diagnosed with CTE in the last 10 years”

• Recent study of former High School football players from 1956-1970 did

not show increased risk of dementia

Weighing the childhood risks of contact sports; J Maroon, J Bailes. 1/29/15 The Washington Times

Janssen, PH, et al. Mayo Clinic Proc. 2017 Jan(92)1: 66-71

CTE: Take Home Points

• Mechanism behind the neuropathology and clinical

presentation is unclear

• No prospective or longitudinal studies exist

• CTE may be more than one entity given histopathology and

presentation variation

• Relation between CTE and quality/ quantity of head trauma is

unclear

– Selection bias

– Denominator problem

– Incomplete medical records/ other variables

Risk Reduction

Prevention?

• No evidence that special helmets or mouth guards protect against concussions

• Delaying/ eliminating contact practice is debatable

• Proper technique in their sport/ rule changes

– Football

– Hockey

• Neck strengthening is being researched

• Educate athletes, parents, coaches, administrators, ATCs

• Neck collars to reduce cerebral venous return

Prevention

• Helmets are effective at

reducing skull fractures, scalp

lacerations and intracranial

bleeds

• May help lessen forces and

reduce concussion severity

• Does not reduce concussion

incidence

• May encourage head use

Prevention

• Decreasing contact practices

– There are more concussions during games than practices

– There are many more practices than games during a season

– Reducing the number of contact practices should reduce concussion

incidence

• But:

– Decreasing practice in tackling/ body checking technique could

increase concussion incidence and severity during games

– Decreasing contact practice and teaching technique can be done

simultaneously

Prevention

• Rule Changes

– Football: Spear tackling

– Hockey: Checking from behind

– Soccer: Elbow to the head

• Must be enforced and may require culture change

– Unclear effect of concussion incidence so far

– Zero tolerance for illegal hits

Cervical Collar

Smith, et al. 2013 Orthopedic

Journal of Sports Medicine

High school sports played at

higher altitude – 31%

reduction in concussion

incidence

Slosh Mitigation

Theory

Adjustment to altitude

may increase

intracranial blood

volume – “tighter fit” of

the brain in the cranium

Jugular vein compression –

Increased volume of the

venous capacitance vessels of

the cranium

Gregory D Myer et al. Br J Sports Med doi:10.1136/bjsports-

2016-096134

Summary

– Recognize – concussions are common, occur in all sports

– Remove – a player with concussion should not be allowed back in the game until evaluated

– Re-evaluate – several tools are available to assess and monitor concussion

– Rest – Initial rest is often needed, but return to school/ work is important

– Recovery – most concussions resolve in 1-4 weeks, younger patients may take longer

– Rehabilitation – Vestibular, ocular and cervical rehab can be helpful for post-concussive symptoms depending on the subtype

– Refer – Concussion specialists should be consulted if concussion symptoms persist past the expected recovery period

– Return to Sport – Done in a 6 step, graded fashion, symptom-dependent

Summary

• Reconsider – Special populations such as elite athletes and

pediatric patients

• Residual Effects/ Sequelae – More research is needed to

evaluate the relationship between CTE and head trauma

• Risk Reduction – No known equipment, therapy or devices

can prevent concussion. Rule changes at the youth and

professional level may help

Questions?