This document provides an overview of Sac State's concussion protocol. It discusses the classic definition of concussion, symptoms, concerns like second impact syndrome, and the importance of preventing early return to play. Grading systems and the definition from the 2008 Zurich statement are presented. ImPACT testing, treatment guidelines, and a graduated return to play protocol emphasizing full resolution of symptoms are summarized.

1. Sac State
Concussion Protocol
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. Concussion: Classic Definition
• Immediate transient impairment of neural function
– A mild Traumatic Brain Injury (TBI)
– Loss of Consciousness (LOC) not required

3. Concussion
• Symptoms are variable for each individual in terms of
type, intensity and duration
• Symptoms are classified:
– Somatic (i.e. headache, dizziness)
– Neuropsych (i.e. agitation, quiet, depression)
– Cognitive (i.e. memory, processing)

4. Concerns with Concussions
• Bleeding
• Associated neck injury
• Second Impact Syndrome
• Cumulative effects of repeated concussions

5. Second Impact Syndrome
• 2nd head injury before sx’s • Loss of autoregulation of the
from 1st injury have cleared brain’s blood supply
– Can be remarkably minor – Vascular engorgement
– ↑ ICP -> Brain herniation
– Brain stem failure rapid (2-5
• Next 15 seconds to minutes
min)
– Conscious but stunned
– Collapses, semi-comatose
• 50% Mortality!
– Pupils dilate, respiratory failure
Prevention is the key!
Do not return to play too early!!!

6. Long term effects of Concussion
• Dementia pugilistica
– Severe form of chronic TBI commonly manifests as declining
mental & physical abilities such as dementia & parkinsonism
• Many recent studies show an increased risk:
– Dementia
– Alzheimer's disease
– Depression
Guo, Neurology, 2000
Guskiewicz, Neurosurgery, 2005
Guskiewicz, Medicine & Science in Sports, 2007

7. Not just Football!
• Injury rate in HS per 1000 exposures
– Football = 0.44
– Girls soccer = 0.35
– Girls basketball = 0.24
– Boys soccer = 0.23
• Most injuries occur in football players due to the large
number of participants

8. Year Gym WBB MBB MSOC WSOC SB FB Total
2004-5 0 1 2 2 1 1 7
2005-6 0 0 2 0 2 1 5
2006-7 1 0 1 1 3 0 6
2007-8 0 2 1 1 0 0 7 11
2008-9 2 2 0 1 5 1 8 19

9. Grading Systems
Grade Colorado AAN Cantu
No LOC No LOC No LOC
Grade I
Confusion Confusion PTA < 30 min or
Mild No Amnesia PCSS < 15 min PCSS < 30 min
No LOC LOC < 5 min and
Grade II No LOC
Confusion PTA > 30 min or
Moderate PCSS > 15 min
Amnesia PCSS > 30 min < 24 h
LOC > 5 min or
Grade III
LOC LOC PTA > 24 min or
Severe PCSS > 7 days
LOC = Loss of Consciousness
PTA = Post-Traumatic Amnesia
PCSS = Post-Concussion Signs or Symptoms

10. Concussion: New Science
• HS athletes with < 15 min on-field symptoms exhibit deficits on
formal neuropsychologic testing
– Re-emergence of active symptoms one week post-injury
– Symptoms often return with exertion
• Suggests we are returning athletes too early

11. International Symposiums on
Concussion in Sport
• 2001 – Vienna
• 2004 – Prague
• 2008 - Zurich

12. New Definition
• 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:
– 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.
– Typically results in the rapid onset of short-lived impairment of neurologic function that resolves
spontaneously.
– May result in neuropathological changes but the acute clinical symptoms largely reflect a
functional disturbance rather than a structural injury.
– 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 however, post-concussive symptoms may
be prolonged.
– No abnormality on standard structural neuroimaging studies is seen.

13. Zurich 2008 Statement
No Grading System!!!

14. Diagnosis of Concussion
• Symptoms
– Somatic - headache
– Cognitive - feels like in a fog
– Emotional – lability
• Physical signs – LOC, amnesia
– Gait & balance evaluation (BESS)
• Behavioral changes – irritability
• Sleep disturbance - drowsiness
• Cognitive impairment – slowed reaction times
– Neuropsych testing

15. Diagnosis of Concussion
• Concussion injury severity correlates with:
– Number & duration of acute signs and symptoms
– Degree of impairment on neuropsychological testing
• Determination of severity can only be made after:
– All symptoms have cleared
– Normal neurologic examination
– Baseline cognitive function has returned

16. ImPACT Testing
• Computerized neuropsychological testing
– Memory, attention, processing speed
– Documents subtle impairments
– Key in management of complex concussions
• Used extensively in professional, collegiate, and high school
athletes
• “Baseline” testing prior to entrance to university

17. Professional Sports
• NFL – ImPACT testing, League guidelines established
– 1993 – 1994 Steeler’s Project
– 1994 – 1995 NFL Neuropsychology Pilot Program
– 1996 – 2000 Non-computer based testing
– 2001 – 2007 Adoption of computer based testing
– Adopted by NHL, MLB, MLS, Indy Racing, US Ski Team
– Hundreds of colleges & thousands of high schools
• MLB – ImPACT testing, Protocol team dependent

18. Collegiate Sports
• Most schools using Neuropsych testing
• Pac 10 Conference – All use neuropsych testing &
symptoms for RTP
• Mayo Clinic, Syracuse University, Indiana
University, University of Utah, Pittsburgh, Indiana
University, Washington University
– Montana, N Arizona, N Colorado, Portland St.

19. Neuroimaging
• Standard CT, MRI usually do not reveal significant structural lesions
• Not needed for most concussions
• Recommended to patients
– Decompensate
– Concern for structural lesion
– Prolonged disturbance of conscious state
– Focal neurological deficit
– Seizure activity
– Persistent clinical or cognitive symptoms

20. Concussion - Concensus
• 80 – 90% of concussions resolve without
complication within 7 – 10 days

21. Treatment - Acute
• Physical AND Cognitive rest
– Cognitive activities may worsen sx’s & delay recovery
– Minimize driving, school work, computer, gaming, etc.
• No alcohol or meds
• Supervision – 24-48 hours
• Serial evaluation & follow-up
• Appropriate communication/education
• Rule out concomitant injuries

22. Concussion Modifiers
Factors Modifier
Number
Symptoms Duration (> 10 days)
Severity
Signs Prolonged LOC (> 1 min), Amnesia
Sequelae Concussive convulsions
Frequency – repeated concussions over time
Temporal Timing – injuries close together in time
“Recency” – recent concussion or TBI
Repeated concussions occurring with progressively less impact force or
Threshold
slower recovery after each successive concussion
Age Child & adolescent (< 18 years old)
Migraine, depression or other mental health disorders, ADHD, learning
Co & Pre-morbidities
disabilities, sleep disorders
Medication Psychoactive drugs, anticoagulants
Behavior Dangerous style of play
Sport High risk activity, contact & collision sport, high sporting level

23. Return to Play – Day of Injury
• NO RTP - Day of injury
– Collegiate & HS players may demonstrate NP deficits post-injury that
may not be evident on sidelines & more likely to have delayed onset
of symptoms
– Adult NFL players may be returned to same day play with team
physicians experienced in concussion management & sufficient
resources (access to
neuropsychologists, consultants, neuroimaging, etc) &
immediate, complete neuro-cognitive assessment

24. New Guidelines: RTP
• No Same Day Return to Play
• Return to Play Recommendations
– Approximately one week out
• Symptoms fully resolved
– -and-
• Completed a structured, graded exertion protocol over
approximately 5-7 days without symptoms

25. Graduated Return to Play Protocol
Functional exercise at each
Rehabilitation stage Objective of each stage
stage
1. No activity Complete physical & cognitive rest Recovery
Walking, swimming, or stationary
2. Light aerobic exercise cycling keeping intensity < 70% MPHR. Increase HR
No resistance training
Skating drills in hockey, running drills in
3. Sport-specific exercise soccer. No head impact activities
Add movement
Progression to more complex training
4. Non-contact training Exercise, coordination, & cognitive
drills (e.g. passing drills in football) May
drills load
start progressive resistance training
Following medical clearance, Restore confidence & assess
5. Full contact practice participate in normal training activities functional skills by coaching staff
6. Return to play Normal game play

26. Graduated RTP Protocol
• Each stage is about 24 hours or longer
• Advance to next level only if asymptomatic for 24 hrs
• No symptom modifying medications
• If symptoms occur,
– Drop back to previous asymptomatic level
– Try to progress again in 24 hours
• Neurocognitive score may normalize before or after symptoms
resolve

27. Concussion: Final Thoughts
• Be alert for subtle symptoms
• Physical / cognitive rest and limit contact for a minimum of one
week & transition back to play
• Neuropsych testing
– Document baseline, deficits and improvement
• Be aware of cumulative trauma & risk for permanent damage

28. Thank You!