Clinical Resources and General Information

1. CDC Heads Up: https://www.cdc.gov/headsup/youthsports/index.html
   1. Healthcare Professionals: https://www.train.org/cdctrain/course/1091388/
2. PM&R Now: https://now.aapmr.org/sports-concussion/

General Description

1. Introduction
   1. Consensus statement from the 5th International Conference on Concussion in Sport: 
      1. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 doi: 10.1136/bjsports-2017-097699. 
2. Epidemiology
   1. Incidence/Prevalence
      1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012 Apr;40(4):747-55. doi: 10.1177/0363546511435626. Epub 2012 Jan 27. PMID: 22287642.
      2. Abstract (not open access): Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F; Seattle Sports Concussion Research Collaborative. Sports- and Recreation-Related Concussions in US Youth. Pediatrics. 2016 Jul;138(1):e20154635. doi: 10.1542/peds.2015-4635. Epub 2016 Jun 20. PMID: 27325635.
   2. Risk Factors
      1. Prior Concussions
      2. Sex
      3. Participation in sports
         1. Level of contact
      4. Risk Taking Behavior
      5. Occupation
      6. Mental Health, Mood and Learning Disorder
3. Pathophysiology of Concussion
   1. Neurobiologic cascade/metabolic crisis
      1. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train. 2001;36(3):228-235.
4. Hallmark signs and symptoms
   1. Affective/ emotional function (requires free Elsevier acct): Doroszkiewicz, C., Gold, D., Green, R., Tartaglia, M.C., Ma, J. and Tator, C.H., 2021. Anxiety, depression, and quality of life: a long-term follow-up study of patients with persisting concussion symptoms. Journal of neurotrauma, 38(4), pp.493-505.
   2. Cognitive changes
   3. Somatic/ Physical signs and symptoms
      1. Headache
      2. Dizziness
      3. Decrease balance, unsteady gait
      4. Visual changes
      5. Neck pain
      6. Fatigue
      7. Vomiting
   4. Change in sleep pattern (requires free Elsevier acct): Wickwire, E.M., Williams, S.G., Roth, T., Capaldi, V.F., Jaffe, M., Moline, M., Motamedi, G.K., Morgan, G.W., Mysliwiec, V., Germain, A. and Pazdan, R.M., 2016. Sleep, sleep disorders, and mild traumatic brain injury. What we know and what we need to know: findings from a national working group. Neurotherapeutics, 13(2), pp.403-417.
5. Concussion Clinical Profiles or Phenotypes
   1. Acute vs Prolonged post-concussive symptoms (PPCS)
   2. Physiological, Vestibular, Ocular, Cognitive/emotional, migraine
   3. Cervical issues Sutton, M., Chan, V., Escobar, M., Mollayeva, T., Hu, Z. and Colantonio, A., 2019. Neck injury comorbidity in concussion-related emergency department visits: a population-based study of sex differences across the life span. Journal of Women’s Health, 28(4), pp.473-482.
   4. Sport-related vs non-sport related 

Diagnosis

1. On Field Assessment 
   1. SCAT 5: SCAT5_Adult.pdf (d2cx26qpfwuhvu.cloudfront.net)
   2. Child SCAT 5: SCAT5_Child.pdf (d2cx26qpfwuhvu.cloudfront.net)
   3. King-Devick: King-Devick technologies | Concussion, Reading Solutions, Neurological Function (kingdevick.com)
   4. VOMs:
      1. Vestibular Ocular Motor Screening (VOMS) | Concussion Diagnosis (upmc.com)
      2. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions (nih.gov)
      3. Microsoft Word – VOMS[3].docx (ufl.edu)
   5. SAC: 
   6. Modified Balance Error Scoring System (mBESS) 
      1. Modified Balance Error Scoring System (M-BESS) test scores in athletes wearing protective equipment and cleats (bmj.com)
   7. Red flag signs and symptoms
2. Clinic Assessments 
   1. Buffalo Concussion Physical Exam (video)
      1. Along with a thorough medical history, it is always recommended that a concussion examination include orthostatic vital signs, head/cervical examination, ocular/ oculomotor examinations and vestibular testing. The BCPE is a tool that incorporates all of the aforementioned elements into a single exam. 
      2. Video: https://www.youtube.com/watch?v=yzVWK8juHQk&feature=emb_logo
      3. Form: https://ubortho.com/wp-content/uploads/2020/10/Buffalo-Concussion-PE-Assessment-Form.pdf
   2. Indications and contraindication for assessments
   3. Common Questionnaires
   4. Post-Concussion Symptom Scale (PCSS)
      1. https://hawaiiconcussion.com/downloads/Post-Concussion-Symptom-Scale.pdf
   5. Post-Concussion Symptom Inventory (PCSI) (include blank forms)
      1. https://www.nhmi.net/media/pdf-files/Parent-Symptom-Scale.pdf (This is the parent form)
   6. Buffalo Concussion Risk-of-Delayed-Recovery (RDR) Score (prognosis).
      1. Haider, M. N., Cunningham, A., Darling, S., Suffoletto, H. N., Freitas, M. S., Jain, R. K., Willer, B., & Leddy, J. J. (2021). Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms. British journal of sports medicine, 55(24), 1427–1433. 
   7. Neuropsychological tests
      1. Randolph, C., McCrea, M., & Barr, W. B. (2005). Is neuropsychological testing useful in the management of sport-related concussion?. Journal of athletic training, 40(3), 139–152.
      2. ImPACT
      3. ANAM
      4. CogSport
      5. HeadMinder CRI (online)
      6. Pencil/ Paper Hopkins
      7. Brief Visuospatial
      8. WAIS-3
      9. Symbol Digit Modalities Test
      10. Trail Making Test
      11. Controlled Oral Word Association
      12. Stroop Color Word Test
      13. Paced Auditory Serial Addition Test
      14. Repeatable Bater for the Assessment of Neuropsychological Status
   8. Others: https://www.ncbi.nlm.nih.gov/books/NBK185341/#:~:text=The%20Post%2DConcussion%20Symptom%20Inventory,%2C%20sleep%2C%20and%20physical%20domains.
3. Exercise Tolerance Testing
   1. Indications and contraindications for assessment
   2. Buffalo Concussion Treadmill Test (BCTT) (video)
      1. Form: https://cdn-links.lww.com/permalink/jsm/a/jsm_2020_01_28_haider_19-313_sdc1.pdf
      2. Video: https://www.youtube.com/watch?v=N_zdwERSQrc
   3. Pediatric BCTT
   4. Buffalo Concussion Bike Test
      1. Form: https://cdn-links.lww.com/permalink/jsm/a/jsm_2020_01_28_haider_19-313_sdc2.pdf
   5. Buffalo Concussion March Test
   6. Utilizing results to prescribe exercise

Treatment

1. Acute Concussion
   1. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
   2. Leddy JJ, Hinds AL, Miecznikowski J, Darling S, Matuszak J, Baker JG, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med. 2018;28(1):13–20. doi: 10.1097/JSM.0000000000000431.
   3. Baker, J.G., Freitas, M.S., Leddy, J.J., Kozlowski, K.F., Willer, B.S., 2012. Return to Full Functioning after Graded Exercise Assessment and Progressive Exercise Treatment of Postconcussion Syndrome. Rehabilitation Research and Practice 2012, 1–7.. doi:10.1155/2012/705309
2. PPCS
   1. Morgan CD, Zuckerman SL, Lee YM, King L, Beaird S, Sills AK, Solomon GS. Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 2015 Jun;15(6):589-98. doi: 10.3171/2014.10.PEDS14356. Epub 2015 Mar 6. PMID: 25745949.
   2. Kozlowski KF, Graham J, Leddy JJ, Devinney-Boymel L, Willer BS. Exercise intolerance in individuals with postconcussion syndrome. J Athl Train. 2013;48(5):627–35. doi: 10.4085/1062-6050-48.5.02. Epub 2013/08/21.
   3. Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May-Jun;43(3):265-74. doi: 10.4085/1062-6050-43.3.265. PMID: 18523563; PMCID: PMC2386420.
3. Preventative Measures

Prognosis

1. Typical
2. Risk of Delayed Recovery

Special Population Differences 

1. Pediatric and adolescent population 
   1. Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr. 2013;167(2):156–61. doi: 10.1001/jamapediatrics.2013.434.
   2. Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children with Acute Concussion in the ED. JAMA. 2016;315(10):1014–25. doi: 10.1001/jama.2016.1203.
2. Adults
3. Military
4. Pregnancy
5. Gender
   1. Bretzin, A.C., Covassin, T., Wiebe, D.J. and Stewart, W., 2021. Association of sex with adolescent soccer concussion incidence and characteristics. JAMA network open, 4(4), pp.e218191-e218191.

Educational Material