SPORTS-RELATED
CONCUSSIONS IN YOUTH
Improving the Science, Changing the Culture
Committee on Sports-Related Concussions in Youth
Board on Children, Youth, and Families
Robert Graham, Frederick P. Rivara, Morgan A. Ford,
and Carol Mason Spicer, Editors
INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by contracts between the National Academy of Sciences and the Centers for Disease Control and Prevention (CDC) (200-2011-38807); the CDC Foundation (Unnumbered Award) with support from the National Football League; the Department of Defense (HT0011-12-C-0023); the Department of Education (ED-OSE-12-P-0049); the Health Resources and Services Administration (HHSH250200976014I); the National Athletic Trainers’ Association Research and Education Foundation (0512SETGRANT); and the National Institutes of Health (HHSN263201200074I). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
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Suggested citation: Institute of Medicine (IOM) and National Research Council (NRC). 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
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COMMITTEE ON SPORTS-RELATED CONCUSSIONS IN YOUTH
ROBERT GRAHAM (Chair), Director, National Program Office, Aligning Forces for Quality, and Research Professor of Health Policy, School of Public Health and Health Services, George Washington University, Washington, DC
FREDERICK P. RIVARA (Vice Chair), Seattle Children’s Guild Endowed Chair in Pediatrics and Professor, Pediatrics, School of Medicine, University of Washington, Seattle
KRISTY B. ARBOGAST, Engineering Core Director, Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, and Associate Professor of Pediatrics, University of Pennsylvania
DAVID A. BRENT, Academic Chief, Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, and Professor of Psychiatry, Pediatrics, and Epidemiology, School of Medicine, University of Pittsburgh
B. J. CASEY, Sackler Professor of Developmental Psychobiology and Director, Sackler Institute for Developmental Psychobiology, Weill Medical College of Cornell University, New York, New York
TRACEY COVASSIN, Associate Professor of Kinesiology and Undergraduate Athletic Training Program Director, Michigan State University, Lansing
JOE DOYLE, former Regional Manager, American Development Model, Rocky Mountain and Pacific Districts, USA Hockey, Colorado Springs, Colorado
ERIC J. HUANG, Professor of Pathology and Neuropathology, Department of Pathology, School of Medicine, University of California, San Francisco
ARTHUR C. MAERLENDER, Director, Pediatric Neuropsychological Services, and Assistant Professor, Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
SUSAN S. MARGULIES, George H. Stephenson Professor in Bioengineering, Department of Bioengineering, University of Pennsylvania, Philadelphia
DENNIS L. MOLFESE, Mildred Francis Thompson Professor and Director, Center for Brain, Biology, and Behavior, Department of Psychology, University of Nebraska, Lincoln
MAYUMI L. PRINS, Associate Professor in Residence and Director, Brain Injury Research Center Education Program, David Geffen School of Medicine, University of California, Los Angeles
NEHA P. RAUKAR, Assistant Professor of Emergency Medicine, and Director, Division of Sports Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
NANCY R. TEMKIN, Professor, Departments of Biostatistics and Neurological Surgery, University of Washington, Seattle
KASISOMAYAJULA VISWANATH, Associate Professor of Social and Behavioral Sciences, Harvard School of Public Health, and Director, Health Communication Core, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
KEVIN D. WALTER, Associate Professor, Departments of Orthopaedic Surgery and Pediatrics, Medical College of Wisconsin, Milwaukee
JOSEPH L. WRIGHT, Senior Vice President, Community Affairs, Children’s National Medical Center, and Professor of Pediatrics (Vice Chair), Emergency Medicine and Health Policy, George Washington University, Washington, DC
Study Staff
MORGAN A. FORD, Study Director
CAROL MASON SPICER, Associate Program Officer
WENDY KEENAN, Program Associate (through April 2013)
SAMANTHA ROBOTHAM, Senior Program Assistant
PAMELLA ATAYI, Administrative Assistant
KIMBER BOGARD, Director, Board on Children, Youth, and Families
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Gordon Bloom, McGill University
R. Dawn Comstock, University of Colorado, Denver
Joseph J. Trey Crisco, Brown University
John DiFiori, University of California, Los Angeles
Corey S. Goodman, venBio LLC
Michael V. Johnston, Johns Hopkins University
Matthew W. Kreuter, Washington University
Brad G. Kurowski, University of Cincinnati
Karen McAvoy, Rocky Mountain Youth Sports Medicine Institute
Tamara C. Valovich McLeod, A.T. Still University
Barclay Morrison, Columbia University
Cara Camiolo Reddy, University of Pittsburgh
Thomas L. Schwenk, University of Nevada
CAPT Jack W. Tsao, Uniformed Services University of the Health Sciences
Keith O. Yeates, Nationwide Children’s Hospital
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Bradford H. Gray, The Urban Institute, and Floyd E. Bloom, The Scripps Research Institute. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Acknowledgments
The Institute of Medicine-National Research Council (IOM-NRC) Committee on Sports-Related Concussions in Youth and its supporting staff thank the colleagues, organizations, and agencies that shared their expertise and information during the committee’s information-gathering meetings (see Appendix A for the names of the speakers). Their contributions informed the committee’s deliberations and enhanced the quality of this report. The study sponsors gladly provided information and responded to questions. The committee also thanks the National Collegiate Athletic Association and the Datalys Center for Sports Injury Research and Prevention, Inc., and Dawn Comstock (University of Colorado, Denver) for responding to questions and providing concussion incidence data for use in the committee’s report. The IOM-NRC staff, including board director Kimber Bogard, study director Morgan Ford, associate program officer Carol Mason Spicer, as well as Wendy Keenan, Samantha Robotham, Pamella Atayi, Colin Fink, and Daniel Bearss, were central in shepherding the report though all its stages. The committee would also like to thank study consultant Stefan Duma (Virginia Tech–Wake Forest University), for preparing a background paper to inform the committee’s deliberations on the effectiveness of helmets to reduce sports-related concussions in youth. The committee and staff extend their gratitude to Laura DeStefano, Nicole Joy, and Abbey Meltzer, IOM Office of Reports and Communications, and Jennifer Walsh, Office of News and Public Information, for their assistance with report release and communication activities. Last but not least, the committee and staff thank Clyde Behney, Interim Leonard D. Schaeffer Executive Officer of the IOM, for the guidance he provided throughout this important study.
4 TREATMENT AND MANAGEMENT OF PROLONGED SYMPTOMS AND POST-CONCUSSION SYNDROME
Short-Term Predictors of a Prolonged Symptomatic Period Post Concussion
Symptomatology in Prolonged Recovery and Post-Concussion Syndrome
Clinical Management of Prolonged Symptoms and Post-Concussion Syndrome
Effects of Prolonged Recovery on Family
Access to Care for Individuals with Prolonged Recovery
5 CONSEQUENCES OF REPETITIVE HEAD IMPACTS AND MULTIPLE CONCUSSIONS
Neuropsychological and Neurophysiological Consequences
Multiple Concussions and Depression and Suicide
Long-Term Neurodegenerative Consequences
6 PROTECTION AND PREVENTION STRATEGIES
7 CONCLUSIONS AND RECOMMENDATIONS
Evidence-Based Guidelines for Concussion Diagnosis and Management
Short- and Long-Term Consequences of Concussions and Repetitive Head Impacts
Boxes, Figures, and Tables
BOXES
S-1 Committee’s Recommendations
2-1 Overview of Commonly Used Experimental Models of Traumatic Brain Injury
FIGURES
1-1 Relationship of concussions to the spectrum of traumatic brain injury
2-2 Neurochemical cascade observed after moderate traumatic brain injuries
3-1 Factors that impact the results of neuropsychological tests
4-3 Postural stability recovery curve
C-1 Standardized assessment of concussion
C-2 Demonstration and test cards for King-Devick (K-D) test
C-3 Page one of the acute concussion evaluation form
C-4 Concussion symptom inventory
TABLES
1-1 Primary Surveillance Systems for Sports-Related Concussion Data
3-1 Signs and Symptoms of Concussions Relevant to Sideline Assessment
3-2 Sideline Concussion Screening Tools
3-3 Concussion Symptoms by Category
3-4 Measures of Post-Concussion Symptomatology
3-5 Common Computerized Neuropsychological Tests
3-6 Reliability Studies on Common Neuropsychological Tests
3-7 Validity Studies on Common Neuropsychological Tests
ACE |
Acute Concussion Evaluation |
AE |
athletic exposure |
AIS |
Abbreviated Injury Scale |
ALS |
amyotrophic lateral sclerosis |
ANAM |
Automated Neuropsychological Assessment Metrics |
APOE |
apolipoprotein E |
APP |
amyloid precursor protein |
ATD |
anthropomorphic test device |
ATP |
adenosine triphosphate |
BESS |
Balance Error Scoring System |
CBF |
cerebral blood flow |
CBT |
cognitive behavioral therapy |
CCAT |
Computerized Cognitive Assessment Tool |
CCI |
controlled cortical impact |
CDC |
Centers for Disease Control and Prevention |
CI |
confidence interval |
CMRglc |
cerebral metabolic rate of glucose consumption |
CNS |
central nervous system |
CPSC |
Consumer Product Safety Commission |
CRI |
Concussion Resolution Index |
CSI |
Concussion Symptom Inventory |
CT |
computed tomography |
CTE |
chronic traumatic encephalopathy |
CTP |
cleaved tau protein |
DNA |
deoxyribonucleic acid |
DTI |
diffusion tensor imaging |
ED |
emergency department |
EE |
enriched environment |
EEG |
electroencephalogram |
ERP |
event-related potential |
FA |
fractional anisotropy |
fMRI |
functional magnetic resonance imaging |
FTLD |
frontotemporal lobar degeneration |
GCS |
Glasgow Coma Scale |
GSC/GSS |
Graded Symptom Checklist/Scale |
HBI |
Health and Behavior Inventory |
HIT |
Head Impact Telemetry |
ICC |
intraclass correlation coefficient |
IEP |
individualized educational plan |
ImPACT |
Immediate Post-Concussion Assessment and Cognitive Testing |
iNOS |
inducible isoform of nitric oxide synthase |
IOM |
Institute of Medicine |
MACE |
Military Acute Concussion Evaluation |
MD |
mean diffusivity |
MRI |
magnetic resonance imaging |
MRS |
magnetic resonance spectroscopy |
mTBI |
mild traumatic brain injury |
MWM |
Morris water maze |
NAA |
N-Acetylaspartic acid |
NC |
non-concussed |
NCAA |
National Collegiate Athletic Association |
NCAA ISS |
National Collegiate Athletic Association Injury Surveillance System |
NEISS-AIP |
National Electronic Injury Surveillance System—All Injury Program |
NFHS |
National Federation of State High School Associations |
NFL |
National Football League |
NFT |
neurofibrillary tangle |
NHIS |
National Health Interview Survey |
NHL |
National Hockey League |
NMDA |
N-methyl-D-aspartate |
NOCSAE |
National Operating Committee on Standards for Athletic Equipment |
NOR |
novel object recognition |
NSE |
neuron-specific enolase |
OR |
odds ratio |
OSSAA |
Oklahoma Secondary School Activities Association |
PARP |
poly-ADP ribose polymerase |
PCS |
post-concussion syndrome |
PCSI |
Post-Concussion Symptom Inventory |
PCSS |
Post-Concussion Symptom Scale |
PET |
positron emission tomography |
PR |
prolonged recovery |
PTSD |
posttraumatic stress disorder |
QEEG |
quantitative EEG |
RCT |
randomized controlled trial |
RIO |
Reporting Information Online |
ROS |
reactive oxygen species |
RPCSQ |
Rivermead Post-Concussion Symptoms Questionnaire |
SAC |
Standardized Assessment of Concussion |
SAT |
Scholastic Aptitude Test |
SCAT |
Sport Concussion Assessment Tool |
SLAM |
Sports as a Laboratory Assessment Model |
SOT |
Sensory Organization Test |
TBI |
traumatic brain injury |
TR |
typical recovery |
VA |
Department of Veterans Affairs |