Concussion Management Learning Platform

Welcome to the Concussion Management Platform

🎯 Core Clinical Message

"With proper concussion identification and management in outpatient musculoskeletal practice, we can reduce the risk of prolonged symptoms and future injuries while maximizing recovery potential."

📊 The Scope of Concussion

34.4% of concussions occur from motor vehicle accidents
53% from household and leisure-related accidents
18,000 annual ED presentations in Australia
10x that number likely go undiagnosed
1.3-3.8 million annual cases in the USA

🔍 Why This Matters for MSK Practice

A non-trivial portion of your musculoskeletal caseload is already recovering from concussion. By tweaking your existing rehabilitation skills and mastering basic assessments, you can significantly impact this underserved patient population.

Concussion Pathophysiology

🧠 Primary Mechanisms of Injury

Concussions result from two primary mechanisms:

Neuronal Shear Forces: Occur in the midbrain, basal ganglia, and cerebellum when the cortex accelerates on a relatively stationary midbrain
Coup-Contrecoup Injury: Direct impact of the brain on the inside of the skull, commonly affecting frontal cortex and parietal/occipital lobes

⚡ Cellular Cascade

Diffuse Axonal Depolarization: The hallmark of concussion pathophysiology

Widespread depolarization of multiple anatomically neighboring axons
Temporary disruption of neural networks
Large metabolic deficit that persists beyond symptom resolution
Explains why second concussion during recovery is more severe

🔄 Physiological Changes

Observable changes post-concussion include:

Slower conduction rates in neural pathways
Reduced cerebral blood flow, especially in association centers
Secondary ischemic penumbra from acute inflammatory response
Changes persist for months post-injury, often beyond clinical symptom resolution

⚠️ Clinical Implication

Metabolic recovery lags behind symptom resolution. This metabolic vulnerability window explains why premature return to activity increases risk of prolonged recovery or second impact syndrome.

Identifying Concussion

🎯 Mechanisms to Consider

Beyond the obvious head-clash on the sports field, consider concussion in:

Any unexpected rapid deceleration injury
Whiplash mechanisms (even without head impact)
Falls with or without direct head contact
Blast injuries or significant jolting forces

📋 Common Symptoms (SCAT5)

Physical

✓ Headache
✓ Nausea/vomiting
✓ Balance problems
✓ Dizziness
✓ Visual problems
✓ Fatigue
✓ Sensitivity to light/noise

Cognitive

✓ Feeling mentally foggy
✓ Difficulty concentrating
✓ Memory difficulties
✓ Confusion
✓ Slowed thinking

Emotional

✓ Irritability
✓ Sadness
✓ More emotional
✓ Nervousness/anxiety

Sleep

✓ Drowsiness
✓ Sleeping more/less
✓ Trouble falling asleep

💡 Clinical Tip

Don't feel you need to test everything immediately. Let your patient's story and subjective experience guide your clinical reasoning. The phenotypes (COACH CV) help organize your assessment approach.

COACH CV Phenotypes

Understanding concussion phenotypes allows targeted assessment and treatment.

🧠 C - Cognitive

Symptoms: Struggling with work/school tasks, memory issues

Tests: MoCA, memory recall, problem solving

Click for detailed assessment

👁️ O - Oculomotor

Symptoms: Dizziness, blurred vision

Tests: Convergence, saccades, smooth pursuit

Click for detailed assessment

😔 A - Affective

Symptoms: Low mood, anxiety, sleep issues

Tests: PHQ-9, anxiety screening

Click for detailed assessment

🦴 C - Cervical

Symptoms: Neck pain, headaches, muscle tightness

Tests: Joint position error, SPNT test

Click for detailed assessment

🤕 H - Headache

Types: Migraine, cervicogenic, tension, post-traumatic

Tests: Comprehensive headache history

Click for detailed assessment

❤️ C - Cardiovascular

Symptoms: Exercise intolerance, POTS, ANS issues

Tests: Buffalo treadmill test, orthostatic vitals

Click for detailed assessment

🌀 V - Vestibular

Symptoms: Vertigo, balance issues, gait problems

Tests: VOR testing, BESS, Romberg tests

Click for detailed assessment

🔄 Phenotype Overlap

Most patients present with multiple phenotypes. The art of concussion management is identifying the primary drivers and addressing them systematically while monitoring for emergence of other phenotypes during recovery.

SCAT6: Sport Concussion Assessment Tool

🔗 SCAT6 & COACH CV Integration

The SCAT6 provides the foundation for phenotype identification:

Cognitive (C): Orientation, Immediate Memory, Concentration, Delayed Recall scores
Oculomotor (O): Observable signs (blank/vacant look), coordination screening, visual symptoms
Affective (A): Symptom scale items - sadness, irritability, nervousness, emotional changes
Cervical (C): Cervical spine assessment, neck pain symptoms, observable balance difficulties
Headache (H): Symptom scale - headaches, pressure in head, sensitivity to light/noise
Cardiovascular (C): Symptom exacerbation with physical activity, fatigue symptoms
Vestibular (V): mBESS testing, tandem gait, dual-task performance, dizziness/balance symptoms

The SCAT6 isn't just a screening tool—it's your roadmap to phenotype-specific treatment planning.

📋 SCAT6 Overview

The Sport Concussion Assessment Tool 6th Edition (SCAT6) is a standardized tool for evaluating concussions designed for athletes aged 13 years and older.

Key Features:

Administration time: 10-15 minutes minimum
Optimal timing: Within 72 hours (3 days) post-injury, up to 7 days
For use by: Health Care Professionals only
Age range: 13 years and older (use Child SCAT6 for ages 12 and under)
Baseline testing: Helpful but not required for interpretation

⚠️ Critical Understanding

The SCAT6 should NOT be used by itself to make or exclude the diagnosis of concussion. An athlete may have a concussion even if their SCAT6 assessment is within normal limits. Clinical judgment is paramount.

🚨 Step 1: Red Flags - Immediate Medical Attention Required

If ANY of these are present, activate emergency procedures immediately:

Neurological Red Flags

Loss of consciousness
Deteriorating conscious state
Seizure or convulsion
GCS < 15
Weakness or tingling/burning in arms or legs

Spinal Red Flags

Neck pain or tenderness
Visible deformity of skull

Symptom Red Flags

Double vision
Severe or increasing headache
Vomiting
Increasingly restless, agitated or combative

Observable Signs (Document if witnessed or on video):

Lying motionless on playing surface
Falling unprotected to the surface
Balance/gait difficulties, stumbling, slow/laboured movements
Disorientation, confusion, staring, limited responsiveness
Blank or vacant look
Facial injury after head trauma
Impact seizure
High-risk mechanism of injury

🧠 Step 2: Glasgow Coma Scale

Standard measure for consciousness level - can be repeated over time to monitor deterioration.

Best Eye Response (E)

4 - Eyes opening spontaneously
3 - Eye opening to speech
2 - Eye opening to pain
1 - No eye opening

Best Verbal Response (V)

5 - Oriented
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - No verbal response

Best Motor Response (M)

6 - Obeys commands
5 - Localized to pain
4 - Flexion/withdrawal to pain
3 - Abnormal flexion to pain
2 - Extension to pain
1 - No motor response

Total GCS Score = E + V + M

Maximum score: 15 (fully alert and oriented)

Minimum score: 3

🦴 Step 3: Cervical Spine Assessment

In a patient who is not lucid or fully conscious, a cervical spine injury should be assumed and spinal precautions taken.

Assessment Questions:

Does the athlete report neck pain at rest?
Is there tenderness to palpation?
If NO neck pain and NO tenderness, does the athlete have full range of ACTIVE pain-free movement?
Are limb strength and sensation normal?

🔗 COACH CV Link: This assessment directly informs the Cervical (C) phenotype. Positive findings here mandate cervical-focused treatment.

👁️ Step 4: Coordination & Ocular/Motor Screen

Coordination Assessment:

Is finger-to-nose normal for both hands with eyes open and closed?

Ocular/Motor Assessment:

Without moving head or neck, can the patient look side-to-side and up-and-down without double vision?
Are observed extraocular eye movements normal?

🔗 COACH CV Link: Abnormalities here indicate Oculomotor (O) phenotype. Document specific deficits for targeted vision therapy.

🧩 Step 5: Memory Assessment - Maddocks Questions

Say: "I am going to ask you a few questions, please listen carefully and give your best effort. First, tell me what happened?"

Modified Maddocks Questions (Sport-Specific):

What venue are we at today? 0 or 1 point
Which half is it now? 0 or 1 point
Who scored last in this match? 0 or 1 point
What team did you play last week/game? 0 or 1 point
Did your team win the last game? 0 or 1 point

Total: /5 points

Note: Appropriate sport-specific questions may be substituted. The key is assessing immediate and recent memory in the context familiar to the athlete.

🔗 COACH CV Link: Poor performance suggests Cognitive (C) phenotype. This is your first indicator of memory dysfunction.

📊 Off-Field Assessment: Symptom Evaluation

22-item symptom scale rated 0-6 for severity (0 = none, 6 = severe)

Symptom Categories & COACH CV Mapping:

Physical Symptoms

Headaches → H
Pressure in head → H
Neck pain → C (Cervical)
Nausea or vomiting → H/V
Dizziness → V
Blurred vision → O
Balance problems → V
Sensitivity to light → H/O
Sensitivity to noise → H

Cognitive Symptoms

Feeling slowed down → C (Cognitive)
Feeling like "in a fog" → C
"Don't feel right" → C
Difficulty concentrating → C
Difficulty remembering → C
Confusion → C

Emotional/Physical

Fatigue or low energy → C (Cardiovascular)/A
Drowsiness → A
More emotional → A
Irritability → A
Sadness → A
Nervous or anxious → A
Trouble falling asleep → A

Scoring:

Total number of symptoms: ___ of 22
Symptom severity score: ___ of 132 (sum of all ratings)

Critical Follow-up Questions:

Do your symptoms get worse with physical activity? → If YES: Cardiovascular phenotype
Do your symptoms get worse with mental activity? → If YES: Cognitive phenotype
If 100% is feeling perfectly normal, what percent of normal do you feel?

🧠 Cognitive Screening: SAC (Standardized Assessment of Concussion)

Orientation (5 points)

What month is it?
What is the date today?
What is the day of the week?
What year is it?
What time is it right now? (within 1 hour)

Score: ___ of 5

Immediate Memory (30 points)

3 Trials - All must be administered regardless of Trial 1 performance

"I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order."

Word Lists Available:

List A: Jacket, Arrow, Pepper, Cotton, Movie, Dollar, Honey, Mirror, Saddle, Anchor
List B: Finger, Penny, Blanket, Lemon, Insect, Candle, Paper, Sugar, Sandwich, Wagon
List C: Baby, Monkey, Perfume, Sunset, Iron, Elbow, Apple, Carpet, Saddle, Bubble

Administer at rate of one word per second. Score 1 point for each correct word across all 3 trials.

Score: ___ of 30

Concentration (5 points)

A. Digits Backward (4 points)

"I'm going to read a string of numbers and when I am done, you repeat them back to me in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7."

Start with 3 digits, progress to longer strings. Stop after 2 failures at same length.

Score: ___ of 4

B. Months in Reverse Order (1 point)

"Now tell me the months of the year in reverse order as QUICKLY and as accurately as possible."

December → November → October → September → August → July → June → May → April → March → February → January

1 point if no errors and completion under 30 seconds

Score: ___ of 1

🔗 COACH CV Link: These three components (Orientation, Immediate Memory, Concentration) form the core assessment of the Cognitive (C) phenotype. Deficits here drive cognitive rehabilitation strategies.

⚖️ Modified Balance Error Scoring System (mBESS)

Three 20-second balance stances testing proprioception and vestibular function.

Test Conditions:

Test the NON-DOMINANT foot
Hands on hips, eyes closed for all three stances
Document testing surface (hard floor, field, etc.)
Document footwear (shoes, barefoot, braces, tape)

The Three Stances:

1. Double Leg Stance

Feet together, hands on hips, eyes closed

Score: ___ errors out of 10

2. Single Leg Stance

Standing on non-dominant foot, hands on hips, eyes closed

Score: ___ errors out of 10

3. Tandem Stance

Non-dominant foot behind, heel-to-toe, hands on hips, eyes closed

Score: ___ errors out of 10

What Counts as an Error?

Opening eyes
Removing hands from hips
Step, stumble, or fall
Moving hip into more than 30° of flexion or abduction
Lifting forefoot or heel off ground
Remaining out of testing position for >5 seconds

Total mBESS Score: ___ errors out of 30

Optional: Repeat all three stances on medium density foam (50cm × 40cm × 6cm) for additional assessment

🔗 COACH CV Link: High error counts indicate Vestibular (V) phenotype and guide balance rehabilitation programming.

🚶 Timed Tandem Gait

Note: If mBESS reveals abnormal findings or significant difficulties, Tandem Gait is not necessary at this time.

Setup:

3-meter line on floor with athletic tape
Complete 3 trials
Record time for each trial

"Please walk heel-to-toe quickly to the end of the tape, turn around and come back as fast as you can without separating your feet or stepping off the line."

Dual Task Tandem Gait (Optional):

Combines motor task (tandem gait) with cognitive task (counting backwards by 7s)

Practice Phase

"Starting with 93, count backward by sevens until I say 'stop'."

Practice counting only: 93, 86, 79, 72, 65, 58, 51, 44

Test Phase

"Now I will ask you to walk heel-to-toe and count backwards out loud at the same time. The number to start with is 88. Go!"

Trial starting integers: 88, 90, 98 (or alternate double numbers)

Record: Time to complete + Number of subtraction errors

Clinical Significance:

Single task time establishes motor baseline
Dual task reveals cognitive-motor integration deficits
Calculate dual task cost: (Single - Dual) / Single × 100%
Elevated dual task cost persists beyond symptom resolution

🔗 COACH CV Link: This assessment evaluates both Vestibular (V) and Cognitive (C) phenotypes simultaneously, revealing deficits in cognitive-motor integration that increase injury risk.

⏰ Delayed Recall

Timing: Perform at least 5 minutes after Immediate Memory test

"Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order."

Score 1 point for each correct word (use same list as Immediate Memory)

Score: ___ of 10

Total Cognitive Score Summary:

Orientation: ___ of 5
Immediate Memory: ___ of 30
Concentration: ___ of 5
Delayed Recall: ___ of 10
TOTAL: ___ of 50

📈 Interpreting SCAT6 Results

⚠️ Critical Reminder

Scoring on the SCAT6 should NOT be used as a stand-alone method to diagnose concussion, measure recovery, or make decisions about return to sport. An athlete can score within normal limits on the SCAT6 and still have a concussion.

Using SCAT6 to Guide COACH CV Phenotype Treatment:

Step 1: Identify Primary Phenotypes

Review symptom clusters and objective findings to identify 1-3 dominant phenotypes

Step 2: Prioritize Treatment

Address phenotypes in order of symptom severity and functional impact

Step 3: Monitor Progress

Serial SCAT6 assessments track recovery and guide progression decisions

Step 4: Identify Emerging Phenotypes

Watch for new phenotypes that may emerge during recovery phase

✅ SCAT6 Best Practices

Baseline testing helpful but not essential for interpretation
Compare to normative data when baseline unavailable
Consider learning effects on repeat testing
Document all observable signs and red flags
Use alternate word lists for repeat assessments
Integrate findings with clinical judgment and phenotype framework
Remember: Normal SCAT6 does not rule out concussion

Clinical Assessment Tools

SCAT5 Components

The Sport Concussion Assessment Tool 5th Edition provides standardized assessment:

1. Immediate/On-field Assessment

Red flags, observable signs, memory assessment (Maddocks questions)

2. Symptom Evaluation

22-item symptom scale rated 0-6 for severity

3. Cognitive Screening

Orientation, immediate memory, concentration

4. Neurological Screen

Balance (modified BESS), coordination

5. Delayed Recall

Test memory after 5+ minutes

🎯 Buffalo Concussion Treadmill Test (BCTT)

Modified Balke protocol for evaluating exercise intolerance and establishing safe exercise thresholds:

Equipment Required:

Treadmill capable of 15° incline (adaptable for 12°)
Heart rate monitor
Borg RPE scale (6-20)
10-point Likert symptom scale
Recording sheet
Chair, water, towel

Test Protocol:

Starting speed: 3.3 mph / 5.3 km/h (brisk walk) - adjust according to patient height
Progression: Increase incline by 1° every minute
Monitoring: Record HR, RPE, and symptoms each minute
Termination criteria:
- Participant reaches max HR or RPE of 19 (exhaustion), OR
- Symptoms increase by ≥3 points on Likert scale (symptom exacerbation)
Cool down: 2 minutes at 2.5 mph / 4.0 km/h, 0° incline
Record: Symptom-limited heart rate threshold (HRt)

Exercise Prescription Based on Results:

General Patients:

80% of HRt
20 minutes per day after 5-minute warm-up
Once daily

Athletes:

90% of HRt
20 minutes per day
Progress to 2x daily with separation if well tolerated

Progression Protocol:

After one week: Increase exercise HR goal by 5-10%
No need to re-examine immediately
May re-test after 2 weeks on exercise program
Stop exercising if symptoms become exacerbated
Don't exercise if not feeling well

⚠️ Contraindications:

Cardiovascular illness or respiratory dysfunction
Beta blockers (affect HR response)
Serious vestibular/balance problems
Inability to walk safely (orthopedic issues)
Severe dizziness or noticeably poor balance
Patient too symptomatic at baseline

✓ Safety Considerations:

Have second evaluator present
Assess patient risk throughout
Engage in conversation during test
Be aware of postural changes
Emphasize goal is to report symptoms, not push through them

📊 Dual Task Assessment

Critical for identifying persistent deficits and guiding return to play/work:

Dual Task Cost = ((single task - dual task) / single task) × 100%

Motor Tasks (in order of complexity):

Balance (Romberg's test variations)
Gait (TUG, 10m walk, 40-yard dash)
Sport/work specific (typing speed, shooting accuracy)

Cognitive Tasks:

Hold/Short-term memory
Process/Manipulate information
Generate (naming items in categories)
Recall/Long-term memory

📈 Assessment Scales

Borg Rating of Perceived Exertion (RPE) Scale:

6-7

No exertion / Extremely light

8-11

Very light to Light

12-14

Somewhat hard

15-16

Hard

17-18

Very hard

19-20

Extremely hard / Maximal

Symptom Rating Scale (Likert):

😊

0
Feel terrific, no symptoms

🙂

1-2
Some symptoms, tolerable

😐

3-4
Symptoms a little worse

🙁

5-6
Symptoms much worse

😟

7-8
Quite symptomatic

😣

9-10
Feel terrible, worst ever

Examples: Headache, Dizziness, Light/Sound Sensitivity, Feeling "Not Right", Difficulty Concentrating

Evidence-Based Treatment Protocols

🏃 Exercise Prescription

The cornerstone of concussion rehabilitation:

Frequency: 20 minutes, 1-2 times per day
Intensity: 80-90% of symptom-limited HR (from Buffalo test)
Type: Aerobic exercise (walking, cycling, swimming)
Progression: Gradual increase as symptoms allow

Note: Early exercise (within 48 hours) is now recommended over complete rest

🎯 Phenotype-Specific Treatments

Cognitive Phenotype:

Cognitive pacing strategies
Environmental modifications (reduced stimuli)
Gradual cognitive loading

Vestibular/Oculomotor:

VOR exercises
Convergence training
Balance progression
Habituation exercises

Cervical:

Manual therapy
Cervical proprioception exercises
Motor control training
Postural correction

🔄 Dual Task Training

Essential for reducing future injury risk:

Example 1: Rugby Player

Pass ball at target while naming all team players

Example 2: Electrician

Step ladder task while holding object overhead and doing mental arithmetic

Progression: When dual task cost = 0%, upgrade complexity. Complete rehabilitation achieved when patient performs goal task in goal environment with no dual task cost.

Graded Return to Play/Work

📈 Prognosis Factors

Most concussions resolve within 14 days (adults) or 4 weeks (youth)
10-30% progress to prolonged concussion recovery (>3 months)
Second concussion is 1.5x more likely
Third concussion is 3x more likely than second

⚠️ Hidden Risk: Lower Limb Injury

Risk of lower limb injury is significantly elevated in the year post-concussion, with linear increase per subsequent concussion. This is due to persistent dual-task deficits that don't spontaneously resolve.

Return to Play Protocol

Stage 1: Symptom-limited activity

Daily activities that don't provoke symptoms

Stage 2: Light aerobic exercise

Walking, swimming, stationary cycling at <70% max HR

Stage 3: Sport-specific exercise

Running drills, no head impact activities

Stage 4: Non-contact training

Progressive resistance training, complex drills

Stage 5: Full contact practice

Following medical clearance, normal training

Stage 6: Return to play

Normal game play

Progression Rule: Minimum 24 hours per stage. If symptoms return, drop back to previous stage for 24 hours before attempting progression again.

Clinical Case Studies

Case 1: Motor Vehicle Accident

Patient: 35-year-old female, rear-end collision 2 weeks ago

Presentation: Neck pain, headaches, difficulty concentrating at work, dizziness with head turns

Phenotypes Identified: Cervical + Cognitive + Vestibular

Assessment Findings:

SCAT5: 18/132 symptom severity score
Cervical joint position error: 8° (abnormal >4.5°)
Positive SPNT test
MoCA: 24/30 (mild cognitive impairment)

Treatment Plan:

Cervical manual therapy and motor control exercises
Graded aerobic exercise at 80% symptom-limited HR
Cognitive pacing with gradual work re-integration
VOR exercises starting in supported positions

Case 2: Adolescent Athlete

Patient: 16-year-old male soccer player, head collision 3 weeks ago

Presentation: Persistent headaches, exercise intolerance, anxiety about return to sport

Phenotypes Identified: Cardiovascular + Headache + Affective

Assessment Findings:

Buffalo test: Symptoms at 145 bpm (65% max HR)
Post-traumatic headache pattern
PHQ-9: 12/27 (moderate symptoms)
Dual task cost: 35% on gait speed with cognitive task

Treatment Plan:

Sub-symptom threshold aerobic exercise (115-130 bpm)
Headache education and management strategies
Psychology referral for anxiety management
Progressive dual-task training with soccer-specific activities

Case 3: Persistent Post-Concussion Symptoms

Patient: 42-year-old office worker, fall down stairs 4 months ago

Presentation: Ongoing visual disturbances, screen intolerance, fatigue, balance issues

Phenotypes Identified: Oculomotor + Vestibular + Cognitive

Assessment Findings:

Convergence insufficiency: near point 15cm (normal <6cm)
Saccadic dysfunction on testing
BESS: 28 errors (significant impairment)
Reduced processing speed on cognitive testing

Treatment Plan:

Vision therapy program with convergence exercises
Progressive balance training with dual-task components
Workstation ergonomic assessment and modifications
Graduated return to work with cognitive loading management