Special Report

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Summary of the 2015 University of
Michigan Sport Concussion Summit

Discussions surrounding concussion have made their way into the public sphere over Steven P Broglio*,1, Grant
the previous decade with media attention and coverage of the injury fueling public Baldwin2, Rudy J Castellani3,
debate. These conversations have devolved into discussions on banning contact and Sara PD Chrisman4, Stefan
collision sports and raised legal questions surrounding injury management. Questions Duma5, Brian Hainline6,
Joanne C Gerstner7, Kevin
raised about concussion eclipse what science can answer, but the University of Michigan
Guskiewicz8, Jeffrey Kutcher9,
Injury Center (MI, USA) hosted a Concussion Summit in September 2015 as a means
Adria Lamba10, Michael
to condense, solidify and disseminate what is currently known on the topic. Areas for McCrea11, Steven Pachman12,
discussion included concussion incidence and prevention, diagnosis and management, Christopher Randolph13
legislation and education, legal and social aspects and future directions. A summary & Tamara C Valovich McLeod14
of those presentations are included within. 1
NeuroTrauma Research Laboratory,
University of Michigan Injury Center,
University of Michigan, Ann Arbor, MI,
Final draft submitted: 25 April 2016; Accepted for publication: 26 July 2016; Published
USA
online: 23 September 2016 2
Centers for Disease Control
& Prevention, Atlanta, GA, USA
Keywords: chronic traumatic encephalopathy • concussion • impact biomechanics • mild 3
University of Maryland, Baltimore, MD,
traumatic brain injury USA
4
Seattle Children’s Hospital, University of
Washington, Seattle, WA, USA
Background a summary of those presentations that high- 5
School of Biomedical Engineering
Interest in concussions has risen over the lighted relevant works and expert opinion on & Sciences, Virginia Tech, Blacksburg,
previous decade, with a particular focus on each topic. VA, USA
6
National Collegiate Athletic Association,
improving injury identification, diagnosis,
Indianapolis, IN, USA
management and understanding the poten- Concussion incidence & prevention 7
School of Journalism, Michigan State
tial for long-term consequences. As aware- The foundation of injury research lies in University, East Lansing, MI, USA
ness and knowledge in the general popula- understanding true injury incidence. Recent 8
Department of Exercise & Sport Science,
tion has increased, researchers have sought media reports about the dangers of head University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA
to answer many unanswered questions pos- trauma in sport have led the assumption that 9
The Sports Neurology Clinic, CORE
ited in the literature and by the media. The sport concussion incidence has risen dramati- Institute, Brighton, MI, USA
result has been a nearly fivefold increase in cally and there is now a ‘concussion crisis’. In 10
Georgetown University Law Center,
sport concussion research in the previous reality, the increased reported concussion Washington DC, USA
10 years compared with the 10 years prior. incidence can be attributed to both concus-
11
Department of Neurosurgery, Medical
College of Wisconsin, Milwaukee,
With a rapid increase in knowledge fueled by sion legislation in all 50 states and media
WI, USA
research efforts, information dissemination influence  [1] . While the specifics vary from 12
Montgomery McCracken, Philadelphia,
is critical. To better publicize information state to state, each state law generally requires PA, USA
from this rapidly evolving area of research, concussion education and improved concus- 13
Department of Neurology, Loyola
the University of Michigan Injury Center sion diagnosis and management for youth University Chicago, Chicago, IL, USA
14
School of Health Sciences, A.T. Still
(MI, USA) hosted a Sport Concussion Sum- and adolescent athletes. Therefore, increased
University, Mesa, AZ, USA
mit in September 2015. Speakers from across awareness and improved management is most *Author for correspondence:
the country were invited to address five broad likely capturing previously undiagnosed broglio@ umich.edu
topics targeting a wide array of stake hold- concussions in high school athletes. This is
ers (i.e., researchers, clinicians, administra- highlighted at the collegiate level, whereby
tors, athletes, coaches, parents, attorneys and concussion laws do not address intercolle-
media). Although the literature in this area is giate athletics and concussion incidence rates
part of
changing rapidly, within this manuscript is at that level have remained consistent over

10.2217/cnc-2016-0007 © 2016 Steven Broglio Concussion (2016) CNC23 eISSN 2056-3299

. estimation of their future expo- ated with concussion. acceleration sure risk and delineation of potential negative effects data from over two million head impact events have on their overall brain function [12] . helmet design and inform consumers of the relative ing subtle increases during this time [2] . these tools aimed at better understanding brain injury. it odologies demonstrate the same trend: lowering both has become clear that multiple predictors from biologi- linear and rotational accelerations lowers brain injury cal. environmental. cal professionals. Rather. that includes their medical history. Framing concussions in this fashion helps pro- tion of linear or rotational acceleration in isolation of vide a level of clarity to the overall clinical picture and each other. Whether explicitly on evaluating linear and rotational acceleration’s con. Castellani et al. have been used extensively to design safer in a degree of uncertainty and focusing on the con- automobiles. but hel.’ ‘probable’ or ‘possible’ at the time of This research illustrated that brain injury is not a func. reduce concussion risk [8] . injury. A highly attuned skillset is neces- coupled with better assessment tools. pursued a single biomarker that is both diagnostic and tions that can be applied toward designing products to prognostic of clinical outcomes. Injury metrics derived from this generalizing a single best approach to all concussions. Concussion performance of different models [9.10] . work. To develop a rotational loading. Unfortunately. over 60 years ments over the past 30 years. cognitive and neurobehavioral function. been directly recorded from youth. and there. social and psychological risk. In addition. life function and quality). outcomes after concussion. may psychological health. however. sport specific served as the foundation for understanding human tol. Starting in 2003. In the 1990s and early 2000s. is likely leading sary given the ease by which concussion symptoms to increase concussion diagnoses. The Virginia Tech Helmet The combination of predictor and outcome vari- Ratings analyze both linear and rotational acceleration ables creates a complex. These started in the 1950s frequent misuse. middle school. rather than over- erance to head impact. Baldwin. including previous ear and rotational acceleration values are both associ. most research focused overall brain health unaddressed. so too (i. incidence in professional football increased beginning from 2010 to 2012. recovery and ferences in biomechanical performance. neurobiopsychosocial model values for all sports as a mechanism to help improve of mild traumatic brain injury (mTBI) [13] . researchers have performed experiments both the field and clinic. suggest that of research utilizing very different experimental meth.6] . construct. These shifts coincide with the a critical and skillful examination of the human ner- National Football League’s (NFL’s) policy and rule vous system combined with a comprehensive approach changes directed at improving player safety. such as severity index (SI) and head injury crite. This combined research provides the foundation domains operate jointly to affect a range of possible for helmet testing in order to evaluate the relative dif. such a single biomarker does not likely exist. the clear clinical picture. but rather a combined effect of linear and may lead to more efficient management..2217/cnc-2016-0007 Concussion (2016) CNC23 future science group . researchers have have allowed for the development of injury risk func. fore lower both linear and rotational acceleration. cussion alone often leaves a large portion of a patient’s Through the 1970s and 1980s. Interestingly. exposure to contact. but a subtle decrease was observed Concussion diagnosis & management in 2013–2014 with significantly fewer game-related The diagnosis and management of concussion requires concussions reported. stated or not.g. It is thus to patient management by appropriately trained medi- believed that concussion education and legislation. Helmets are outcome can no longer be viewed as a unidimensional not the solution to preventing all concussions. The neu- 10. Scientific advance- reduce concussion risk [7] . For the ments) have been developed to aid the clinician in past 60 years. with only lacrosse and football show. The diagnosis of concussion is quite often steeped rion (HIC). the last 10 years. approaches should be emphasized [11] . Because of the complexity in number of concussions occurring on our playing fields. under the often oversimplify diagnostic schema and nonsport- premise that reducing forces on the human body will specific approaches to injury evaluation. although this does can be hidden by the athlete and the intense scrutiny not necessarily translate to an increase in the true placed on these injuries. ries as ‘definite. motor control and cognitive functioning assess- does research targeted at reducing injury risk. As each sport has a unique set of brain with a small series of tests on human cadavers that injury risks and challenges for clinicians. clinicians may categorize these inju- tribution to brain injury through primate experiments. genetic. These data cussion diagnosis and management. high To supplement the individualized approach to con- school and collegiate football players [5. how concussive injuries present. recovery (e.Special Report  Broglio. but one constituted by multiple vectors of mets that better modulate impact energies.e. military protection and athletic helmets. each patient with a suspected or NFL reconstructed concussive football impacts with diagnosed concussion deserves a thorough evaluation instrumented test dummies [4] and illustrated that lin. resulting in reduce risk of injury [3] . many evaluative tools As awareness of sport concussions grows.

g. treatment). and these same factors may play a role in lapsed and was later found to have a subdural hema- the recovery for some athletes as well [17. from playing with concussive symptoms and thus risk- or exposure to repetitive head trauma in sports. severity. Six years following the passage at autopsy. Zackery Lystedt was a middle school football have theorized that long-lasting ‘post-concussion’ player who was removed from play for a ‘ding’. A progressive toward informing the true natural history of recovery quality to the condition reminiscent of neurodegenera- after concussion in athletes. impulsivity. injury specifics and context suggesting that the accumulation of phosphorylated (e. Research and head impacts [24] . and coaches. but much additional to advance our understanding of neurophysiological research is needed to determine if this unique neuro- effects and recovery after concussion. acute characteristics. Conclusions made to date linking repeated of the first concussion law.18] . neurobiological.g. clinical. geared sive anger and heightened suicidality [24] .g. lar legislation [27. such as depression and known and predict outcome after concussion requires a broad neurodegenerative diseases [21–23] . sis. Our knowl.g. Preliminary studies sug- vary widely and are impossible to separate from other gest increased diagnosis and healthcare utilization future science group www. and intervening life events (e. ing headache. some 2009. lack prevalence data and control specific providers who can clear athletes. Moreover.futuremedicine. pathology is directly associated with clinical features The CARE and similar studies offer the promise downstream of repetitive mild neurotrauma. of informing the lay population and clinicians on the nature and frequency of various short. such as Alzheimer’s disease. given the assumption that athletes have the clinical and basic science of mTBI [15] . In parallel. case–control or cohort studies exist that indicate The law also provides liability coverage to schools that an association between concussion and altered p-tau follow these guidelines. The paradigm for disease pathogenesis. cognitive. passed in Washington State in instances when rapid recovery does not occur. immediate tau occurs in a particular distribution in contact sport post-injury events (e. To date.g. behavioral and psycho. a rich. cussion education required. through experimental models. with some variability regarding and while alluring. has also been allel efforts integrate biomechanical. matrix of predictor domains that incorporate pre. psychological health. diagno. type of con- groups.26] . but symptoms in nonsports settings are due to psychologi. includ- cosponsored by the National Collegiate Athletic Asso. The CARE and other par. then went back in the game.20] is mixed. retired athletes [19. others have shown that phosphory. and ing a similar injury.2217/cnc-2016-0007 .. tive diseases. no prospec. temporal Modern research efforts are leveraging the power and insular cortices and may be one consequence of of the sports concussion research model to advance concussion.28] .. Conversely. In Lystedt Law [25. In addition. toma. to produce a deleterious neuroinflammatory cascade multidimensional approach to outcome measurement which. consensus has been developed on how injury function (e. athlete with suspected concussion must be removed including the existence of a unique clinical syndrome from play. a large-scale effort has been associated with various clinical signs. parents and youth must receive concussion education.and long-term Bringing about change: legislation risks associated with concussion. mechanism). The Lystedt Law was designed to prevent youth edge surrounding the long-term effects of concussion. to identify CTE postmortem. A few states have extended with no adverse consequences. neuroim.com 10. Indeed. sustained another hit. This occurs especially in the sulcal capture the full outcome spectrum. athletes  [20] . gested to involve tau templating and trans-synaptic quality of life.. suggested as the common outcome with the passage aging. all states have enacted simi- head impacts and CTE are based on case studies. Neuroimaging and blood biomarkers are of or subconcussive forces acting on brain parenchyma primary interest in this arena [14] .. research & education findings suggest that the short-term recovery from Concussion legislation originated with the Zackery concussion is typically rapid and complete [16] . Summary of the 2015 University of Michigan Sport Concussion Summit  Special Report robiopsychosocial model suggests that to understand conditions during life. and includes three criteria: any an elevated risk of late-life neurodegenerative disease. has been sug- (e. frequency. inclusion of liability pro- lated tau accumulations occur throughout human life tection and ages covered. memory complaints. genotype). The distribution of tau proteinopathy Education (CARE) Consortium. chronic traumatic encephalopathy [CTE]) in clearance by a healthcare professional. neurobiological and genetic markers of injury of time (as long as decades) [24] . the clinical these laws to mandate decreased full-contact practices features described with chronic repetitive concussion or return to learn protocols. explo- ciation (NCAA) and Department of Defense. col- cal factors. cognition.g.. tive. consists of concussions stressors). with recent literature social function. depths and perivascular areas of the frontal. One such increased exposure to pathophysiologically significant initiative is the Concussion Assessment. vocational/life function) is critical to neurotoxicity  [21] . the athlete cannot return without written (e. life which appears widely accepted.

lawsuits filed 10. from playing with concussive symptoms [30–32] . cussion’ cases. more likely to continue play) after trainer’s best judgment? watching an educational video. tions can be anticipated and often include (but not cussion is important in developing educational tools. schools that the injury is serious enough to warrant disclosure..61] .40] policy adequate? Should preseason neuropsychological that have generated conflicting results. of these actions is attributable not only to the increas- tion of various stakeholders is mandated by law [27. Several video games or social media. the injured athlete – is responsible for that outcome. In some states. Castellani et al. the goal is to series of stories on concussions. concussions that has permeated the US media. ers [54–59] in addition to failure on the part of athletes to That question quickly then becomes who must ulti- report symptoms of concussion [39. Effective high-profile NFL stars committing suicide and the KT includes developing educational pieces specific to ensuing coverage. the first question becomes who – other than coaches [48–50] .42–47] . leading to height- reporting intention and behavior to allow concussions ened national attention and Congressional hearings. it The use of knowledge translation (KT) may assist is now common for the term ‘concussion’ to be heard in in turning knowledge improvements into actionable game reports. KT is defined as “the exchange. athletic trainer have conducted additional testing on More recent concussion knowledge studies seem to indi.41] ing awareness of concussive injuries. Baldwin. Therefore. policy? Did the coach unduly influence the athletic ing behaviors (e. parents and coaches. more and more Concussion education centers on the recognition lawsuits are alleging the failure of schools. of awareness that the injury could be a concussion or In the legal defense of medical professionals.66] . supervision of a physician? Was the school’s concussion These studies have used public health approaches [38. in a frequency not seen before 2006. they participated while symptomatic.39. with sion attitude scores resulting in fewer athletes indicating increasing amounts of daily reporting on the subject.29] . comes. especially the deaths of safety Dave target audiences and measuring the outcomes of inter. studies have highlighted barriers to concussive symp- tom reporting [33–40] .40. to be recognized and managed appropriately. the educa. different stakeholder groups and use different delivery ferent approaches may be necessary to prevent youth methods. and this research may result in Legal & social aspects of sport concussion new recommendations regarding targeted education With increased scrutiny placed on the diagnosis and for youth. parents [51–53] and even medical provid. an injured athlete prior to returning the athlete to cate improved knowledge [62–65] does not always result game play? Was the athletic trainer working under the in altering behavior to increase reporting [37. healthcare of and response to concussion and is important for all providers and athletic associations to meet the appro- stakeholders to ensure appropriate actions are taken to priate standard of care are being filed. for concussion following the passage of concussion est [69] . One study [67] baseline testing have been implemented as part of the noted a significant increase in perceived unsafe report. Lawsuits against medical providers and their strated increased knowledge correlated to increased employers are partly driven by increased awareness of prevalence of concussion reporting and better concus. practice stories and even feature stories items that may better impact concussion management.44.2217/cnc-2016-0007 Concussion (2016) CNC23 future science group . both within and outside the sports sections. the intensity of focus on concussions has cally sound application of knowledge within a com. schools. in-person presentations. The New York plex system of interactions among researchers and Times sports department began an award-winning users”  [68] . While the mately pay the injured athlete or the surviving family reasons for nondisclosure vary. concussion in the sporting context with poor out- ing regarding concussion among athletes [39. today’s reality is that following a that have found a lack of awareness and understand. but continued high rates of youth playing all approach.Special Report  Broglio. and other entities in concussion cases. and ethi. synthesis. education cannot be a one-size-fits- laws  [1. In what is becoming a trend for athletic The inclusion of concussion education into many associations. Duerson and linebacker Junior Seau. Indeed.g. coaches and healthcare providers state laws and association policies results from studies who treat athletes. a litany of ques- While understanding stakeholder knowledge of con. limited to): was the athlete properly educated about educational efforts need to focus on changing attitudes the signs and symptoms of concussions? Should the and ultimately improving reporting behaviors [38. but also because (detailed above) and numerous concussion education plaintiffs’ attorneys are now targeting so-called ‘con- curricula are available for different stakeholder groups. The popularity manage suspected injuries. management of concussive injuries. Notably.60. including internet. The message must be individualized for with concussive symptoms [30–32] . The other [39] demon. This suggests dif. football players strug- determine whether concussion education can modify gling with post-concussive issues. With respect to concussion. they often include lack to compensate for that injury.40] . been keyed by a few factors: in 2007.

the NCAA partnered with the participation for their players. tive effort between the CDC and leading concussion cal professionals. longitudinal within the mainstream media spheres has increased clinical study ever conducted in the history or con- awareness to where it is now a public health concern cussion. Addressing these gaps is the acute competition for audience. a short-term educational challenge and a long-term but these studies were male-dominated and focused on research challenge whose goal is to create a paradigm football and ice hockey. Indeed. B Bushman future science group www. Seminal research in this field has of concussion and neurobiological recovery following provided a foundation for understanding some funda. The purpose of the meeting was to increase knowledge about concussions and change the provide a combination of research and expert opinion culture surrounding concussions. clinicians. related concussions [77] made two focused recommen- dations around these shortcomings. sion and assuring that concussed athletes are not placed these works have begun to better inform medical in an environment in which return-to-play is influenced care and shift the culture of sport concussion at the by stakeholders other than treating clinicians [36. implement and the University of Michigan Injury Center Sport Con- evaluate the effectiveness of large-scale efforts to cussion Summit. The 2013. In addition pendent Medical Care for College Student-Athletes. The science behind sport concussion is rapidly evolv- tion (CDC) to improve the tracking and monitoring ing and this document aims to consolidate and share of youth sports and recreation-related concussions. collegiate level. however. (3) Con- been associated with a cultural shift in reporting concus. the NCAA-Department of Defense Grand Alliance [80] is a Future perspective joint venture that consists of two projects: The CARE The increased discussion of concussions and sports Consortium is the largest prospective. to these barriers. priorities for the next 3–5 years that focuses on address- nels – which now deliver articles and video content. the information disseminated by the invited speakers at Second. cussion Diagnosis and Management. CDC was asked to develop. their policies and procedures to increase the safety of In a similar vein. The Mind Matters Challenge consists of mental aspects of recovery following concussion [16. concussion. CDC Injury Center cussion litigation. A collabora- communication about issues by practicing neurologi. the CDC is developing pediatric be first.74] . Given the many unknowns and the rapid Concussion. partnerships with key not address neurobiological recovery. Substantially more work is needed. Collectively. T Cregeur.2217/cnc-2016-0007 . To address other focus areas. As a result. clinical studies of shift in perceived norms and the culture of concussion concussion focus on clinical return to baseline and do for all stakeholders. Furthermore. Each of these factors has brought experts resulted in a systematic and graded process to concussion into the public domain and placed pressure evaluate the state of the science with publication of the on sports leagues and legislative bodies to examine guidelines scheduled for 2016. which provides a snapshot of current increase in research in this area it is likely that our research on concussion knowledge and awareness and understanding of the topic will be a shifting target. a general lack of understanding of concussion guidelines for the appropriate diagnosis and manage- by mainstream journalists – and a lack of consistent ment of children and teens with mild TBI.75–76] .com 10. This information on the implementation and effectiveness Acknowledgements of the Heads-Up materials will extend the scope of the The authors would like to thank R Cunningham and the Uni- program to help change social norms. three important concussion documents [81] : (1) Inde- robiological recovery following concussion. CDC introduced the Heads-Up initiative and the ers. and concussion guidelines. These same factors also federal government and numerous medical organiza- appear to have led to increased uneasiness among the tions to promote and develop key research initiatives public about sports participation and risk of injury. athletes. behaviors both on and off the playing field [78] .futuremedicine. but how concussion affects young athletes’ attitudes and the general principles outlined here will likely remain. the fracturing of media sources from Research Priorities outlined a set of targeted research traditional sources to website and social media chan. The purpose is to define the natural history in the USA [70–73] . Institute of Medicine report on sports. In addition. among young sport athletes.. Most prominently. Summary of the 2015 University of Michigan Sport Concussion Summit  Special Report against the NFL. coaches and Heads Up: Opportunities to Reshape the Culture around parents. The first was a Conclusion call for the Centers for Disease Control and Preven. current concussion knowledge has not (2) Year-Round Football Practice Contact. versity of Michigan Injury Center staff. ing strategic gaps in the field. there is medical organizations have created and disseminated a paucity of data correlating clinical recovery and neu. leading to the specialty of sports con. administrators. leading to ever critical to reducing the burden of concussions among increasing sensationalism and a rush to publication to youth [79] . More than 10 years to deliver a balanced view of concussion to research- ago.

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