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Prospective longitudinal cohort study.Adolescent athletes may be more susceptible to the long-term effects of mild traumatic brain injury (mTBI). A diagnostic and prognostic neuromarker may optimize management and return-to-activity decision-making in athletes who experience mTBI.Measure an event-related potential (ERP) component captured with electroencephalography (EEG), called processing negativity (PN), at baseline and post-injury in adolescents who suffered mTBI and determine their longitudinal response relative to healthy controls.Thirty adolescents had EEG recorded during an auditory oddball task at a pre-mTBI baseline session and subsequent post-mTBI sessions. Longitudinal EEG data from patients and healthy controls (n= 77) were obtained from up to four sessions in total and processed using Brain Network Analysis algorithms.The average PN amplitude in healthy controls significantly decreased over sessions 2 and 3; however, it remained steady in the mTBI group's 2nd (post-mTBI) session and decreased only in sessions 3 and 4. Pre- to post-mTBI amplitude changes correlated with the time interval between sessions.These results demonstrate that PN amplitude changes may be associated with mTBI exposure and subsequent recovery in adolescent athletes. Further study of PN may lead to it becoming a neuromarker for mTBI prognosis and return-to-activity decision-making in adolescents.

Background: The clinical diagnosis and management of patients with sport-related concussion is largely dependent on subjectively reported symptoms, clinical examinations, cognitive, balance, vestibular and oculomotor testing. Consequently, there is an unmet need for objective assessment tools that can identify the injury from a physiological perspective and add an important layer of information to the clinician’s decision-making process. Objective: The goal of the study was to evaluate the clinical utility of the EEG-based tool named Brain Network Activation (BNA) as a longitudinal assessment method of brain function in the management of young athletes with concussion. Methods: Athletes with concussion (n = 86) and age-matched controls (n = 81) were evaluated at four time points with symptom questionnaires and BNA. BNA scores were calculated by comparing functional networks to a previously defined normative reference brain network model to the same cognitive task. Results: Subjects above 16 years of age exhibited a significant decrease in BNA scores immediately following injury, as well as notable changes in functional network activity, relative to the controls. Three representative case studies of the tested population are discussed in detail, to demonstrate the clinical utility of BNA. Conclusion: The data support the utility of BNA to augment clinical examinations, symptoms and additional tests by providing an effective method for evaluating objective electrophysiological changes associated with sport-related concussions.

Despite growing research on concussion, there is minimal evidence comparing the acute presentation of concussion between pediatric and adult patients. This cross-sectional study compares injury characteristics, symptoms, and neurologic examination in sport-related concussion based on age. Patients presenting to an outpatient sports neurology clinic for initial assessment of concussion within 7 days of injury were divided into 2 groups, 18 and older (n = 28) and 17 and younger (n = 107). There were no significant differences between pediatric and adult patients in any score of the Sport Concussion Assessment Tool–3rd Edition symptom scale, neurologic examination category, pertinent elements of past medical history, or characteristics of the concussion. The pediatric group had higher average hours of sleep (8.1 ± 0.3 vs 7.1 ± 0.58; P = .03) and were less likely to wake refreshed (36.3% vs 65%; P = .02). The initial presentation of concussion within 7 days of injury will likely not differ by age, specifically 18 and older versus 17 and younger.

During the past two decades the focus on sport concussion has increased significantly. Young athletes represent the most vulnerable population to sustain a sport concussion yet receive the least amount of attention. Specifically, young athletes who sustain a sport concussion can go unrecognized and continue to participate in sport putting them at an increased risk for a more significant injury. The purpose of this review is to provide a clinical framework for the evaluation and management of sport concussion. In addition, this review provides considerations for health care professionals in regard to clinical measures and follow-up strategies during the acute phase following concussion in young concussed athletes following injury.

To provide the neurologist with a framework for the clinical approach to sports concussion diagnosis and management.As the issue of brain injury in athletes has emerged and developed, shifting the landscape of public concern, neurologists have become more directly involved in the diagnosis and management of sports concussion. Neurologists are now playing an increased role in acute concussion diagnosis, early injury management, return-to-play decisions, and evaluation for potential long-term effects from exposure to biomechanical forces on brain health. Concussion is only one part of this spectrum, but it is no small concern. Sports concussion diagnosis and management require a comprehensive neurologic approach as the return-to-play decision is a medical one covering a spectrum of potential complications and future risks. Understanding the clinical syndrome of concussion as well as the underlying pathophysiologic mechanism is essential to providing care. Employing classic neurologic diagnostic techniques while concurrently respecting the unique nature of caring for athletes is also critical. Without an objective method of measuring the underlying metabolic injury, concussion management is, by necessity, a clinically intense endeavor that requires a broad skill set.Providing recommendations regarding the long-term effects of brain trauma and the need for retirement from contact sports requires an appreciation for both the reason for concern and the lack of data to frame this risk. As science continues to advance in this area, so will our diagnostic approaches and management schema. Neurologists caring for athletes with brain trauma should continue to seek the best possible evidence to help shape their clinical decisions.

Concussions are a major public health issue, and particularly so in the setting of sports. Millions of athletes of all ages may face the risks of concussion and repeat concussion. This article introduces the terminology, epidemiology, and underlying pathophysiology associated with concussion, focused on sports-related injuries.Concussion is a clinical syndrome of symptoms and signs occurring after biomechanical force is imparted to the brain. Because of the subjective nature of symptom reporting, definitions of concussion differ slightly in different guidelines. Concussion nomenclature also includes mild traumatic brain injury, postconcussion symptoms, postconcussion syndrome, chronic neurocognitive impairment, subconcussive injury, and chronic traumatic encephalopathy. Between 1.6 and 3.8 million sports-related concussions are estimated in the United States annually, particularly in youth athletes. Rates of concussion are higher in sports such as football, rugby, ice hockey, and wrestling in males, and soccer and basketball in females. The underlying pathophysiology of concussion centers on membrane leakage, ionic flux, indiscriminate glutamate release, and energy crisis. These initial events then trigger ongoing metabolic impairment, vulnerability to second injury, altered neural activation, and axonal dysfunction. While the linkage between acute neurobiology and chronic deficits remains to be elucidated, activation of cell death pathways, ongoing inflammation, persistent metabolic problems, and accumulation of abnormal or toxic proteins have all been implicated.Concussion is a biomechanically induced syndrome of neural dysfunction. Millions of concussions occur annually, many of them related to sports. Biologically, a complex sequence of events occurs from initial ionic flux, glutamate release, and axonal damage, resulting in vulnerability to second injury and possibly to longer-term neurodegeneration.

The management of patients with sports-related concussion (SRC) is comprehensive and includes preseason planning, education, initial evaluation, postinjury assessment, disposition, return-to-play decisions, and consideration of long-term brain health. Several recent publications have addressed sports concussion management using the best available evidence, and we review them here. The diagnosis and management of sports concussion have evolved over the past several decades, and with a greater understanding of the importance of both short- and long-term sequelae, there has been a clear trend toward recognizing and treating these brain injuries more cautiously and developing a proactive approach to management and return-to-play decision making. Although each of these used different methodologies in their review of the literature, their conclusions are fairly consistent, providing basic guidelines for contemporary approaches to management of SRC. Although many questions remain unanswered, there are several areas of agreement including the importance of education, preseason assessment, the benefit and utility of a standardized multimodal assessment on the sidelines, individualized treatment and return-to-play protocols, and the benefit of a multidisciplinary team in managing complicated injuries. This paper reviews these current sports concussion guidelines and the best available evidence that guides current management of SRC.

AB Purpose: We have developed a reliable and valid clinical test of reaction time (RTclin) that is sensitive to the acute effects of concussion. If RTclin is to be used as a sideline concussion assessment tool then the acute effects of exercise on RTclin may need to be controlled for. The purpose of this study was therefore to determine the effect of exercise on RTclin. Methods: A gender-balanced group of 42 collegiate athletes were assigned to an exercise (n = 28) and a control (n = 14) group using 2:1 block randomization. The exercise group completed a graded four-stage exercise protocol on a stationary bicycle (100 W x 5 min; 150 W x 5 min; 200 W x 5 min; sprint x 2 min), whereas the control group was tested at identical periods without exercising. Mean RTclin was calculated for eight trials as the fall time of a vertically suspended rigid shaft after its release by the examiner before being caught by the athlete. RTclin was measured at baseline and after each of the four stages. Results: As both HR and RPE significantly increased for the four stages in the exercise group (P < 0.001), mean RTclin showed a significant overall decline during repeated test administration (P < 0.008). However, there were no significant group (exercise vs control, P = 0.822) or group-by-stage interaction (P = 0.169) effects on RTclin as assessed by repeated-measures analysis of variance. Conclusions: Exercise did not appear to affect RTclin performance in this study. This suggests that RTclin measured during a sideline concussion assessment does not need to be adjusted to account for the acute effects of exercise

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

Objective The purpose of this review is to examine the evidence for determining the lowest threshold for diagnosing a sport-related concussion. Data Sources MEDLINE, CINAHL, EMBASE, Mosby9s Index, PsycEXTRA, PsycINFO and Scopus. Key words included sports concussion, concussion assessment, diagnosis, concussion symptoms, onfield assessment and sports-related traumatic brain injury. Results The majority of concussions in sport occur without loss of consciousness or frank neurological signs. Some of the hallmark signs of acute concussion include mental confusion, memory and balance disturbance. Over the course of the first 24 h, the most common symptoms include headache, nausea, dizziness and balance problems, blurred vision or other visual disturbance, confusion, memory loss and ‘fatigue’. Symptoms such as tiredness, irritability, nervousness or anxiety, sleep disturbance and sensitivity to light or noise may be noticed in the days after injury. The pathophysiology of sports concussion remains poorly understood. There appears to be a period of vulnerability following concussion in which an overlapping injury might cause magnified pathophysiology. Conclusions Sport-related concussions can be difficult to diagnose. Concussion produces an evolving constellation of somatic, cognitive and neurobehavioral symptoms that are typically most severe during the earliest acute postinjury period (ie, within the first 24–48 h) and diminish over a matter of several days to weeks in the majority of athletes. Athletes suspected of concussion should be removed from play and evaluated thoroughly.

Objective The purpose of this paper was to review the current state of evidence for chronic traumatic encephalopathy (CTE) in retired athletes and to consider the potential differential diagnoses that require consideration when retired athletes present with cognitive and psychiatric problems. Data sources MEDLINE, CINAHL, EMBASE, Mosby’s Index, PsycEXTRA, PsycINFO and Scopus. Key words included CTE, dementia pugilistica, punch drunk syndrome, traumatic encephalopathy, CTE, repetitive head injury, sports concussion, multiple concussions, chronic concussions, subconcussive blow and sportsrelated traumatic brain injury. Results At present, there are no published epidemiological, cross-sectional or prospective studies relating to modern CTE. Owing to the nature of the published studies, being case reports or pathological case series, it is not possible to determine the causality or risk factors with any certainty. As such, the speculation that repeated concussion or subconcussive impacts cause CTE remains unproven. The extent to which age-related changes, psychiatric or mental health illness, alcohol/drug use or coexisting dementing illnesses contribute to this process is largely unaccounted for in the published literature. Conclusions At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. The causal assumptions require further prospective or longitudinal studies on the topic.

Reaction time (RT) is a valuable component of the sport concussion assessment battery. RT is typically measured using computers running specialised software, which limits its applicability in some athletic settings and populations. To address this, we developed a simple clinical test of RT (RTclin) that involves grasping a falling measuring stick.To determine the effect of concussion on RTclin and its sensitivity and specificity for concussion.Concussed athletes (n=28) and non-concussed control team-mates (n=28) completed RTclin assessments at baseline and within 48 h of injury. Repeated measures analysis of variance compared mean baseline and follow-up RTclin values between groups. Sensitivity and specificity were calculated over a range of reliable change confidence levels.RTclin differed significantly between groups (p0.001): there was significant prolongation from baseline to postinjury in the concussed group (p=0.003), with a trend towards improvement in the control group (p=0.058). Sensitivity and specificity were maximised when a critical change value of 0 ms was applied (ie, any increase in RTclin from baseline was interpreted as abnormal), which corresponded to a sensitivity of 75%, specificity of 68% and a 65% reliable change confidence level.RTclin appears sensitive to the effects of concussion and distinguished concussed and non-concussed athletes with similar sensitivity and specificity to other commonly used concussion assessment tools. Given its simplicity, low cost and minimal time requirement, RTclin should be considered a viable component of the sports medicine provider's multifaceted concussion assessment battery.

Discussions surrounding concussion have made their way into the public sphere over the previous decade with media attention and coverage of the injury fueling public debate. These conversations have devolved into discussions on banning contact and collision sports and raised legal questions surrounding injury management. Questions raised about concussion eclipse what science can answer, but the University of Michigan Injury Center (MI, USA) hosted a Concussion Summit in September 2015 as a means to condense, solidify and disseminate what is currently known on the topic. Areas for discussion included concussion incidence and prevention, diagnosis and management, legislation and education, legal and social aspects and future directions. A summary of those presentations are included within.

OBJECTIVE: The purpose of this study was to investigate the association between migraine headache and concussion in athletes. DESIGN: Case-control observational study. SETTING: A university-associated combined sports neurology and orthopedic sports medicine clinic. PARTICIPANTS: A total of 221 male (n = 140) and female (n = 81) athletes aged 12 to 24 years, including 115 concussion cases (52%) and 106 orthopedic controls (48%), were included in this study. INTERVENTIONS: Participants completed a one-page questionnaire that recorded their age, sex, reason for visit (concussion vs any other injury), concussion history, and self/immediate family member migraine headache history. MAIN OUTCOME MEASURES: The odds of having a previous history of migraine headache were compared in the concussion group versus orthopedic controls. RESULTS: Controlling for between-group differences in age and sex, there was a significant positive association between concussion group status and history of migraine headache [adjusted odds ratio (OR), 1.90; 95% confidence interval (CI), 1.03-3.50. P = 0.039]. However, when including a previous concussion history in the statistical model, this relationship failed to reach significance [adjusted OR, 1.68; 95% CI, 0.89-3.16. P = 0.107]. CONCLUSIONS: These results suggest that there is an association between migraine headache and concussion in athletes, but the cause-effect nature of this relationship cannot be determined. Migraine headache should be considered a modifying factor when caring for concussed athletes. Language: en

Importance Chronic traumatic encephalopathy (CTE) refers to pathologic changes that have been found in some individuals with a history of repetitive traumatic impact to the head (hereinafter referred to as head trauma). These changes cannot be assessed during the clinical evaluation of a living patient. Observations The neuropathologic features, taxonomy, history, role of biomarkers in diagnosis, and existing criteria of CTE are reviewed. Previous criteria have been proposed to approach the living patient; however, a unified, specific approach is needed for the practicing clinician. We propose a new diagnostic construct for the clinical syndrome associated with repetitive exposure to head trauma: traumatic encephalopathy syndrome. This clinical paradigm will provide the framework for a diagnosis of probable, possible, and unlikely traumatic encephalopathy syndrome, with included discussion regarding the minimum exposure, nature of the clinical course, and additional clinical features needed for diagnosis. Conclusions and Relevance While prospective longitudinal studies are ongoing to further elucidate the association of exposure to head trauma, clinical features, and the development of pathologic changes, a corresponding clinical construct for diagnosis is necessary.

PURPOSE OF REVIEW: Recent technological advances have allowed the in-vivo measurement of impacts sustained to the head during helmeted sports. These measurements are of interest to researchers and clinicians for their potential to understand both the underlying mechanics of concussive injuries and the potential for real-time injury diagnostics. Following an overview of impact biomechanics, this review will evaluate the following: in-vivo technology being used in American football players; impact frequencies and magnitudes; and the biomechanical threshold for concussion. RECENT FINDINGS: The average high school athlete sustains over 650 impacts in a season, and the level at which concussion occurs is approximately 100 g and 5500 rad/s/s. SUMMARY: High school athletes sustain a significant number of head impacts each year. The impacts are similar in both volume and magnitude when compared with collegiate athletes. The magnitude of impact that results in concussion is also the same at both levels of play, although the collegiate athlete may have a higher injury tolerance. Language: en

Objectives Concussion is common in contact sports such as boxing. Diagnosis of concussion depends on symptom report or recognition of clinical features, and true incidence may be underestimated. Persistent morbidity is a possible risk of repeated or unrecognised concussion. This study aimed to evaluate pre and postbout cognitive performance in motivated amateur boxers in order to detect objective evidence of unrecognised cognitive impairment suggestive of concussive injury. Methods The study employed a prospective and observational design. Participants were amateur boxers who won at least one bout in a single elimination competition. Optimal preparticipation performance using a computerised cognitive assessment tool (CCAT, Axon Sports) and no significant deterioration in cognitive performance within 24 h postbout were required to compete. All boxers were screened for clinical evidence of concussion by a ringside physician. Results Of approximately 200 competing boxers, 96 were eligible having won at least one of the total 160 bouts. Mean age was 21.3 (SD 1.9) years (range 18.5–29.7). Of these, 17 (10.6%) failed their first postbout CCAT, with 12 (71%) passing a repeat test. Of the five remaining boxers, there were two boxers (1.3% of bouts) not suspected of a concussion after their bouts, who showed evolving slowing in cognitive performance typical of a concussion. Conclusions Cognitive impairment, as detected by subtle deterioration in reaction time measures, can occur in amateur boxers postbout that is not recognised at ringside. Although the vast majority of bouts were conducted safely, unrecognised injury may occur and be detectable using objective computerised cognitive assessment.

Concussion is a major public health concern with nearly 4 million injuries occurring each year in the United States. In the acute post-injury stage, concussed individuals demonstrate cognitive function and motor control declines as well as reporting increased symptoms. Researchers have hypothesized that the severity of these impairments is related to impact magnitude. Using the Head Impact Telemetry System (HITS) to record head impact biomechanics, we sought to correlate pre- and post-concussive impact characteristics with declines in cognitive performance and increases in concussion-related symptoms. Over four seasons, 19 high school football athletes wearing instrumented helmets sustained 20 diagnosed concussions. Each athlete completed a baseline computer-based symptom and cognitive assessment during the pre-season and a post-injury assessment within 24 h of injury. Correlational analyses identified no significant relationships between symptoms and cognitive performance change scores and impact biomechanics (i.e., time from session start until injury, time from the previous impact, peak linear acceleration, peak rotational acceleration, and HIT severity profile [HITsp]). Nor were there any significant relationships between change scores and the number of impacts, cumulative linear acceleration, cumulative rotational acceleration, or cumulative HITsp values associated with all impacts prior to or following the injury. This investigation is the first to examine the relationship between concussion impact characteristics, including cumulative impact profiles, and post-morbid outcomes in high school athletes. There appears to be no association between head impact biomechanics and post-concussive outcomes. As such, the use of biomechanical variables to predict injury severity does not appear feasible at this time.

Recent studies using a helmet-based accelerometer system (Head Impact Telemetry System [HITS]) have demonstrated that concussions result from a wide range of head impact magnitudes. Variability in concussion thresholds has been proposed to result from the cumulative effect of non-concussive head impacts prior to injury. We used the HITS to collect biomechanical data representing >100,000 head impacts in 95 high school football players over 4 years. The cumulative impact histories prior to 20 concussive impacts in 19 athletes were compared to the cumulative impact histories prior to the three largest magnitude non-concussive head impacts in the same athletes. No differences were present in any impact history variable between the concussive and non-concussive high magnitude impacts. These analyses included the number of head impacts, cumulative HIT severity profile value, cumulative linear acceleration, and cumulative rotational acceleration during the same practice or game session, as well as over the 30 min and 1 week preceding these impacts. Our data do not support the proposal that impact volume or intensity influence concussion threshold in high school football athletes.

Impacts to the head are common in collision sports such as football. Emerging research has begun to elucidate concussion tolerance levels, but sub-concussive impacts that do not result in clinical signs or symptoms of concussion are much more common, and are speculated to lead to alterations in cerebral structure and function later in life. We investigated the cumulative number of head impacts and their associated acceleration burden in 95 high school football players across four seasons of play using the Head Impact Telemetry System (HITS). The 4-year investigation resulted in 101,994 impacts collected across 190 practice sessions and 50 games. The number of impacts per 14-week season varied by playing position and starting status, with the average player sustaining 652 impacts. Linemen sustained the highest number of impacts per season (868); followed by tight ends, running backs, and linebackers (619); then quarterbacks (467); and receivers, cornerbacks, and safeties (372). Post-impact accelerations of the head also varied by playing position and starting status, with a seasonal linear acceleration burden of 16,746.1g, while the rotational acceleration and HIT severity profile burdens were 1,090,697.7 rad/sec(2) and 10,021, respectively. The adolescent athletes in this study clearly sustained a large number of impacts to the head, with an impressive associated acceleration burden as a direct result of football participation. These findings raise concern about the relationship between sub-concussive head impacts incurred during football participation and late-life cerebral pathogenesis, and justify consideration of ways to best minimize impacts and mitigate cognitive declines.

Context: Reaction time is typically impaired after concussion. A clinical test of reaction time (RTclin) that does not require a computer to administer may be a valuable tool to assist in concussion diagnosis and management. Objective: To determine the test-retest reliability of RTclin measured over successive seasons in competitive collegiate athletes and to compare these results with a computerized measure of reaction time (RTcomp). Design: Case series with repeated measures. Setting: Preparticipation physical examinations for the football, women's soccer, and wrestling teams at a single university. Patients or Other Participants: 102 National Collegiate Athletic Association Division I athletes. Intervention(s): The RTclin was measured using a measuring stick embedded in a weighted rubber disk that was released and caught as quickly as possible. The RTcomp was measured using the simple reaction time component of CogState Sport. Main Outcome Measure(s): Data were collected at 2 time points, 1 season apart, during preparticipation physical examinations. Outcomes were mean simple RTclin and RTcomp. Results: The intraclass correlation coefficient estimates from season 1 to season 2 were 0.645 for RTclin (n = 102, entire sample) and 0.512 for RTcomp (n = 62 athletes who had 2 consecutive valid baseline CogState Sport test sessions). Conclusions: The test-retest reliability of RTclin over consecutive seasons compared favorably with that of a concurrently tested computerized measure of reaction time and with literature-based estimates of computerized reaction time measures. This finding supports the potential use of RTclin as part of a multifaceted concussion assessment battery. Further prospective study is warranted.

Objectives To evaluate the effect of concussion on clinically measured reaction time (RT clin ) and in comparison to a computerized reaction time measure (RT comp ). Design Prospective, repeated measures observational study. Setting Athletic training clinic at a National Collegiate Athletic Association (NCAA) Division I university. Participants Data are reported for 9 collegiate athletes with acute concussion who were part of a larger cohort of 209 athletes recruited from the university's football, women's soccer, and wrestling teams before the start of their respective athletic seasons. Methods Baseline RT clin and RT comp were measured during preparticipation physical examinations. RT clin measured the time required to catch a suspended vertical shaft by hand closure after its release by the examiner. RT comp was derived from the simple RT component of the CogState-Sport computerized neurocognitive test battery. Athletes who subsequently sustained a physician-diagnosed concussion underwent repeated RT clin and RT comp testing within 72 hours of injury. A Wilcoxon signed rank test was used to compare baseline and after-injury RTs. Main Outcome Measurements After-injury changes in RT clin and RT comp were calculated with respect to each athlete's own preseason baseline value. Results After-injury RT clin was prolonged in 8 of the 9 athletes with concussions, whereas RT comp was prolonged in 5 of the 9 athletes with concussions. The mean (standard deviation) RT clin increased from 193 ± 21 ms to 219 ± 31 ms ( P = .050), and mean RT comp increased from 247 ± 75 to 462 ± 120 ms ( P = .214). Conclusions We concluded that RT clin appears to be sensitive to the known prolongation of RT after concussion and compares favorably with an accepted computerized RT measure. This study supports the potential utility of RT clin as part of a multifaceted concussion assessment battery.

Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral development disorder affecting an estimated 6% to 9% of youth in the United States. The typical manifestations of ADHD, attention difficulties and hyperactivity, cause impairment in social and academic functioning, while common comorbid conditions can add significantly to the disease burden. Diagnosing ADHD requires a comprehensive clinical approach. Many medications have been shown to provide benefit for patients with ADHD, and a positive response to medication can be an important factor in clarifying the diagnosis. Medical therapy is of particular interest when treating athletes, as competitive bodies ban many treatment options. This review provides the sports medicine provider with a framework for the treatment of ADHD in the athlete.

Context: Evidence suggests that concussion prolongs reaction time (RT). We have developed a simple, reliable clinical tool for measuring reaction time that may be of value in the assessment of concussion in athletes. Objective: To compare baseline values of clinical RT (RTclin) obtained using the new clinical reaction time apparatus with computerized RT (RTcomp) obtained using a validated computerized neuropsychological test battery. Design: Cross-sectional study. Setting: Data were collected during a National Collegiate Athletic Association Division I collegiate football team's preparticipation physical examination session. Patients or Other Participants: Ninety-four Division I collegiate football players. Main Outcome Measure(s): The RTclin was measured using a 1.3-m measuring stick embedded in a weighted rubber disk that was released and caught as quickly as possible. The RTcomp was measured using the simple RT component of CogState Sport. Results: For the 68 athletes whose CogState Sport tests passed the program's integrity check, RTclin and RTcomp were correlated (r = 0.445, P < .001). Overall, mean RTclin was shorter and less variable than mean RTcomp (203 ± 20 milliseconds versus 268 ± 44 milliseconds; P < .001). When RTclin and RTcomp were compared between those athletes with (n = 68) and those without (n = 26) valid CogState Sport test sessions, mean RTclin was similar (202 ± 19 milliseconds versus 207 ± 23 milliseconds; P = .390), but mean RTcomp was different (258 ± 35 milliseconds versus 290 ± 55 milliseconds; P = .009). Conclusions: The RTclin was positively correlated with RTcomp and yielded more consistent reaction time values during baseline testing. Given that RTclin is easy to measure using simple, inexpensive equipment, further prospective study is warranted to determine its clinical utility in the assessment of concussion in athletes.

Sports-related concussion remains a diagnostic and management challenge for the sports medicine practitioner. Numerous symptom scales and sideline assessment tools are available for team physicians and athletic trainers to objectively assess this difficult injury. The purpose of this article is to update the reader on literature published within the past year relevant to concussion symptom scales and sideline assessment tools. A critical evaluation of pertinent articles is presented. We conclude that multiple symptom scales and assessment tools are available, with no single tool showing clear superiority. Many tools remain based more on expert opinion than rigorous scientific evaluation. A multifaceted approach to sports concussion is advised. The sports medicine practitioner must not rely on any one tool in managing concussion and must be aware of the strengths and limitations of whichever method is chosen to incorporate into a concussion evaluation and management plan.

This paper is a revision and update of the recommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. (1, 2) The Zurich Consensus statement is designed to build on the principles outlined in the original Vienna and Prague documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the "background" section (See Section 11). This document is developed for use by physicians, therapists, certified athletic trainers, health professionals, coaches and other people involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving and therefore management and return to play decisions remain in the realm of clinical judgment on an individualized basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document and / or the Sports Concussion Assessment Tool (SCAT2) card and neither is subject to any copyright restriction. The authors request, however that the document and / or the SCAT2 card be distributed in their full and complete format.

Sports-related concussions are commonplace at all levels of play and across all age groups. The dynamic, evolving nature of this injury coupled with a lack of objective biomarkers creates a challenging management issue for the sports medicine team. Athletes who return to play following a concussion are known to be at higher risk for an additional brain injury, which necessitates a careful, informed return to play (RTP) process.The goal of this paper is to outline historical attempts at developing RTP guidelines and trace their evolution over time, culminating in a discussion of the process and outcomes of the most recent consensus statements/guidelines published by the international Concussion In Sport Group (CISG), the American Academy of Neurology (AAN), the National Athletic Trainers' Association, and the 2013 Team Physician Consensus Statement Update.An evaluation of the pros and cons of these guidelines is presented along with suggestions for future directions. In addition, the Institute of Medicine recently conducted a comprehensive report outlining the current state of evidence regarding youth concussions, which provides specific recommendations for future research.The different methodologies utilized in the development of consensus statements have distinct advantages and disadvantages, and both approaches add value to the everyday management of sports concussions. Importantly, the overall approach for management of sports concussion is remarkably similar using either consensus-based or formal evidence-based methods, which adds confidence to the current guidelines and allows practitioners to focus on accepted standards of clinical care. Moving forward, careful study designs need to be utilized to avoid bias in selection of research subjects, collection of data, and interpretation of results. Although useful, clinicians must venture beyond consensus statements to examine reviews of the literature that are published in much greater frequency than consensus statements.

Background: As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.Objective: To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.Methods: The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.Results: Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke ± SRHP (p < 0.01). Using the median 1999 home health aide wage ($8.20/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from $3,500 to $8,200. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to $6.1 billion for stroke-related informal caregiving in the United States.Conclusions: Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

This paper presents the Sport Concussion Assessment Tool 5th Edition (SCAT5), which is the most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion. The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5–12 years, which is discussed elsewhere.

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.

The Concussion Recognition Tool 5 (CRT5) is the most recent revision of the Pocket Sport Concussion Assessment Tool 2 that was initially introduced by the Concussion in Sport Group in 2005. The CRT5 is designed to assist non-medically trained individuals to recognise the signs and symptoms of possible sport-related concussion and provides guidance for removing an athlete from play/sport and to seek medical attention. This paper presents the development of the CRT5 and highlights the differences between the CRT5 and prior versions of the instrument.

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps. A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …

Background Sideline detection is the first and most significant step in recognising a potential concussion and removing an athlete from harm. This systematic review aims to evaluate the critical elements aiding sideline recognition of potential concussions including screening tools, technologies and integrated assessment protocols. Data sources Bibliographic databases, grey literature repositories and relevant websites were searched from 1 January 2000 to 30 September 2016. A total of 3562 articles were identified. Study selection Original research studies evaluating a sideline tool, technology or protocol for sports-related concussion were eligible, of which 27 studies were included. Data extraction A standardised form was used to record information. The QUADAS-2 and Newcastle-Ottawa tools were used to rate risk of bias. Strength of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group system. Data synthesis Studies assessing symptoms, the King-Devick test and multimodal assessments reported high sensitivity and specificity. Evaluations of balance and cognitive tests described lower sensitivity but higher specificity. However, these studies were at high risk of bias and the overall strength of evidence examining sideline screening tools was very low. A strong body of evidence demonstrated that head impact sensors did not provide useful sideline concussion information. Low-strength evidence suggested a multimodal, multitime-based concussion evaluation process incorporating video review was important in the recognition of significant head impact events and delayed onset concussion. Conclusion In the absence of definitive evidence confirming the diagnostic accuracy of sideline screening tests, consensus-derived multimodal assessment tools, such as the Sports Concussion Assessment Tool, are recommended. Sideline video review may improve recognition and removal from play of athletes who have sustained significant head impact events. Current evidence does not support the use of impact sensor systems for real-time concussion identification.

In 2009, Washington State enacted legislation outlining the medical care of children and adolescents with concussion (ie, the Lystedt Law), with all other states and Washington, DC passing legislation by January 2014.To evaluate the effect of concussion laws on health care utilization rates from January 1, 2006, through June 30, 2012, in states with and without legislation.For commercially insured children aged 12 to 18 years from all 50 states and DC from January 1, 2006, through June 30, 2009, we examined the following: (1) prelegislation trends in concussion-related health care utilization from January 1, 2006, through June 30, 2009, (2) postlegislation trends in states without concussion legislation, and (3) the effect of state concussion laws on trends in states with concussion legislation in effect by means of negative binomial multivariable estimation with state and time fixed effects.Concussion diagnosis.Emergency department and related health care utilization rates for concussion.Between academic school years 2008-2009 and 2011-2012, states with legislation experienced a 92% increase in concussion-related health care utilization, while states without legislation had a 75% overall increase in concussion-related health care utilization during the same period. In the multivariable fixed-effects models, controlling for differences across states, rates of treated concussion in states without legislation were 7% higher in the 2009-2010 school year, 20% higher in the 2010-2011 school year, and 34% higher in the 2011-2012 school year compared with the prelegislation trends (2005-2009) (all P .01). During the same period, states with concussion laws demonstrated a 10% higher concussion-related health care utilization rate compared with states without laws (P .01).Increased health care utilization rates among children with concussion in the United States are both directly and indirectly related to concussion legislation. A portion of the increased rates (60%) in states without legislation is attributable to an ongoing upward trend demonstrated before enactment of the first state law in 2009. The remaining 40% increase in these states is thought to have resulted from elevated awareness brought about by heightened local and national media attention. Concussion legislation has had a seemingly positive effect on health care utilization, but the overall increase can also be attributed to increased injury awareness.

Objective:To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions.Background:An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries.Recommendations:The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations.

Postconcussion syndrome (PCS) is a common condition that follows traumatic brain injury. It can produce symptoms that are physical, cognitive, emotional, or sleep-related. The pathologic mechanism is not well understood but probably includes both physical and psychologic factors. There is no widely accepted unified diagnostic approach to postconcussion syndrome and management is largely symptomatic. Being able to distinguish postconcussion syndrome from a prolonged concussion is paramount to proper management, as rest is an appropriate therapy for concussion but may exacerbate the symptoms of postconcussion syndrome. The presence of other long-term conditions, such as chronic traumatic encephalopathy, should also be carefully considered.

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE e4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Objective The purpose of this critical review is to summarise the evidence for the following technologies/strategies related to diagnosing or managing sports-related concussion: quantitative EEG, functional neuroimaging, head impact sensors, telemedicine and mobile devices. Data sources MEDLINE, PubMed, Cochrane Controlled Trials Registers, SportDiscus, EMBASE, Web of Science and ProQuest databases. Primary search keywords were concussion, sports concussion and mild traumatic brain injury. The keywords used for secondary, topic specific searches were quantitative electroencephalography, qEEG, functionalMRI, magnetoencephalography, near-infrared spectroscopy, positron emission tomography, single photon emissionCT, accelerometer, impact sensor, telemetry, remote monitoring, robotic medicine, telemedicine, mobile device, mobile phone, smart phone and tablet computer. Results The primary search produced 8567 publications. The secondary searches produced nine publications that presented original data, included a comparison group in the study design and involved sports-related concussion. Four studies spoke to the potential of qEEG as a diagnostic or management tool, while five studies addressed the potential of fMRI to be used in the same capacity. Conclusions Emerging technologies and novel approaches that aid in sports concussion diagnosis and management are being introduced at a rapid rate. While some technologies show promise, their clinical utility remains to be established.

PURPOSE OF THE STATEMENT: ▸ To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion. ▸ To establish the level of evidence, knowledge gaps and areas requiring additional research.▸ Sports medicine physicians are frequently involved in the care of patients with sports concussion. ▸ Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions. ▸ The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty. ▸ While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion.▸ Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum.▸ Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell. ▸ Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction.▸ It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported. ▸ Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball. RISK FACTORS FOR SPORT-RELATED CONCUSSION: ▸ A history of concussion is associated with a higher risk of sustaining another concussion. ▸ A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery. ▸ In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes. ▸ Certain sports, positions and individual playing styles have a greater risk of concussion. ▸ Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury. ▸ Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion.▸ Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion. ▸ Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations. ▸ Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available.▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions. ▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination. ▸ While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown. ▸ Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury. ▸ Imaging is reserved for athletes where intracerebral bleeding is suspected. ▸ There is no same day RTP for an athlete diagnosed with a concussion. ▸ Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status.▸ Neuropsychological (NP) tests are an objective measure of brain-behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam. ▸ Most concussions can be managed appropriately without the use of NP testing. ▸ Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates. ▸ Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion. ▸ NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation. ▸ The ideal timing, frequency and type of NP testing have not been determined. ▸ In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery in the management of sports concussions. ▸ It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long-term complications. ▸ Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses.▸ Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion.▸ Concussion symptoms should be resolved before returning to exercise. ▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact. ▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step. ▸ RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions. SHORT-TERM RISKS OF PREMATURE RTP: ▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. LONG-TERM EFFECTS: ▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae. ▸ Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment.▸ There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion. Each case should be carefully deliberated and an individualised approach to determining disqualification taken.▸ Greater efforts are needed to educate involved parties, including athletes, parents, coaches, officials, school administrators and healthcare providers to improve concussion recognition, management and prevention. ▸ Physicians should be prepared to provide counselling regarding potential long-term consequences of a concussion and recurrent concussions.▸ Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play. ▸ Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions. ▸ There is no current evidence that mouth guards can reduce the severity of or prevent concussions. ▸ Secondary prevention may be possible by appropriate RTP management.▸ Legislative efforts provide a uniform standard for scholastic and non-scholastic sports organisations regarding concussion safety and management.▸ Additional research is needed to validate current assessment tools, delineate the role of NP testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications. ▸ Evolving technologies for the diagnosis of concussion, such as newer neuroimaging techniques or biological markers, may provide new insights into the evaluation and management of sports concussion.

Context: Whereas the majority of sports concussions are isolated self-limited events, some patients have more complicated presentations and management needs. This review presents a framework for the management of these complicated concussion patients. Evidence Acquisition A MEDLINE search for the years 1990 to 2009 was performed using the search terms concussion and athletic injuries. Secondary search terms included symptom, incidence, treatment, and risk factor. The Strength of Recommendation Taxonomy grading system was used for all clinical recommendations. Results: Patterns of complicated sports concussion presentations were identified from literature review, anecdote, and personal experience of the author and colleagues. All clinical recommendations carry a grade of C, unless otherwise noted. Conclusion: The sports medicine provider should be aware of certain patterns of complicated sports concussion presentations in order to use a patient-focused approach to management.

Concussion is an injury to the brain occurring as the result of biomechanical forces, generally characterized by the rapid onset of a constellation of symptoms or cognitive impairment, which is typically self-limited and resolves spontaneously. Concussion as the result of playing sports is particularly common, estimated to occur up to 3.8 million times each year in the United States. Although most concussions can be considered benign, the symptoms are often severe enough to interfere with daily function. A small percentage of concussions can be more serious, resulting in a prolonged symptom course, significant morbidity, or even death. The management of concussion in the athlete presents a unique set of challenges for the clinician, requiring not only a detailed neurologic history and examination, but also careful consideration of an athlete's risk of further injury and possible long-term sequelae.