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Classifying Sports-Related Concussion: Precision Classification for Personalized Treatment

By Angela Lumba-Brown, M.D. (Department of Emergency Medicine, Stanford), and Jamshid Ghajar, M.D., Ph.D. (Departent of Neurosurgery, Stanford)

Despite increases in scientific literature on concussion, we still do not know how best to diagnose and treat it.1 United States emergency departments care for 1.7 million cases of concussion each year. This count does not include the 3 million undiagnosed sports-related head injuries that occur each year, which have been reported to be associated with the risk of more severe subsequent head injuries.2,3,4

Concussions are as unique as the individual who sustains them. Some patients present with dizziness, others with persisting headaches and mood disruption, and still others with cognitive impairments. Variations in past medical history and injury produce heterogeneity in clinical presentations, requiring a more personalized approach to concussion management.5,6

The U.S. Department of Defense charged the Stanford Brain Trauma Evidence-Based Consortium with the task of classifying concussion for precision care using best evidence, resulting in the guidelines published in Neurosurgery.7 A work group of concussion experts across the country reviewed more than 3,000 scientific studies and reported that there is significant evidence for concussion to be classified into five common, nonmutually exclusive subtypes with varying symptomatology and targeted treatment approaches:8,9,10

  1. Headache/migraine.
  2. Ocular motor impairment.
  3. Vestibular impairment.
  4. Cognitive impairment.
  5. Anxiety/mood disturbance.

Two subtype-associated conditions, sleep disturbance and cervical strain, can occur across all subtypes. Current concussion tools aid in the clinical assessment of injured athletes but are limited in the comprehensive checklist for concussion subtypes, to assess important post-injury prognostic risk factors.11,12,13,14

Researchers at the Stanford Brain Performance Center recently were awarded funding to prospectively characterize concussion subtypes in all Pac-12 athletes over three years to determine the prevalence of concussion subtypes in sports-related concussion and to identify variations in clustering and recovery trajectories.15 The Pac-12 baseline and concussion evaluations are collected uniformly using the NCAA-Department of Defense Concussion Assessment, Research, and Education Consortium16  assessments and supplemented by objective vestibulo-oculomotor evaluations providing longitudinal data applicable to all five subtypes.17,18 In addition, ongoing work with the Centers for Disease Control and Prevention will develop more robust tools to identify concussion subtypes. Precision care is applied to many aspects of sports injury, and subtype-targeted treatment is the next step in personalized concussion care.

References:

1 Putukian, M., & Kutcher, J. (2014). Current concepts in the treatment of sports concussions. Neurosurgery, 75 Suppl 4, S64-70. doi:10.1227/neu.0000000000000492

2 Langlois, J. A., Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil, 21(5), 375-378.

3 Goldberg LD, Dimeff RJ. Sideline management of sport-related concussions. Sports Med Arthrosc. 2006;14:199-205.

4 Meehan, W. P., 3rd, Mannix, R. C., O’Brien, M. J., & Collins, M. W. (2013). The prevalence of undiagnosed concussions in athletes. Clin J Sport Med, 23(5), 339-342. doi:10.1097/JSM.0b013e318291d3b3

5 Merritt, V. C., & Arnett, P. A. (2014). Premorbid predictors of postconcussion symptoms in collegiate athletes. J Clin Exp Neuropsychol, 36(10), 1098-1111. doi:10.1080/13803395.2014.983463

6 Morgan, C. D., Zuckerman, S. L., Lee, Y. M., King, L., Beaird, S., Sills, A. K., & Solomon, G. S. (2015). Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr, 15(6), 589-598. doi:10.3171/2014.10.Peds14356

7 Lumba-Brown, A., Teramoto, M., Bloom, O. J., Brody, D., Chesnutt, J., Clugston, J. R., . . . Ghajar, J. (2019). Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery. doi:10.1093/neuros/nyz332

8 Maruta, J., Lumba-Brown, A., & Ghajar, J. (2018). Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire. Front Neurol, 9, 1034. doi:10.3389/fneur.2018.01034

9 Collins, M. W., Kontos, A. P., Okonkwo, D. O., Almquist, J., Bailes, J., Barisa, M., . . . Zafonte, R. (2016). Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery, 79(6), 912-929. doi:10.1227/neu.0000000000001447

10 Kontos, A. P., & Collins, M. W. (2018). Concussion: A Clinical Profile Approach to Assessment and Treatment: American Psychological Association.

11 Okonkwo, D. O., Tempel, Z. J., & Maroon, J. (2014). Sideline assessment tools for the evaluation of concussion in athletes: a review. Neurosurgery, 75 Suppl 4, S82-95. doi:10.1227/neu.0000000000000493

12 Carney, N., Ghajar, J., Jagoda, A., Bedrick, S., Davis-O'Reilly, C., du Coudray, H., . . . Riggio, S. (2014). Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery, 75 Suppl 1, S3-15. doi:10.1227/neu.0000000000000433

13 Broglio, S. P., & Guskiewicz, K. M. (2009). Concussion in sports: the sideline assessment. Sports Health, 1(5), 361-369. doi:10.1177/1941738109343158

14 Lumba-Brown, A., Ghajar, J., Cornwell, J., Bloom, O. J., Chesnutt, J., Clugston, J. R., . . . Gioia, G. (2019). Representation of concussion subtypes in common postconcussion symptom-rating scales. Concussion, 4(3), CNC65. doi:10.2217/cnc-2019-0005

15 Pac-12 Student-Athlete Health and Well-being Initiative; Prior Awardees. https://pac-12.com/conference/sahwbgp/prior-grant-awardees

16 Broglio, S. P., McCrea, M., McAllister, T., Harezlak, J., Katz, B., Hack, D., & Hainline, B. (2017). A National Study on the Effects of Concussion in Collegiate Athletes and US Military Service Academy Members: The NCAA–DoD Concussion Assessment, Research and Education (CARE) Consortium Structure and Methods. Sports Medicine, 47(7), 1437-1451. doi:10.1007/s40279-017-0707-1

17 Sundaram, V., Ding, V. Y., Desai, M., Lumba-Brown, A., & Little, J. (2019). Reliable sideline ocular-motor assessment following exercise in healthy student athletes. J Sci Med Sport. doi:10.1016/j.jsams.2019.07.015

18 Maruta, J., Jaw, E., Modera, P., Rajashekar, U., Spielman, L. A., & Ghajar, J. (2017). Frequency Responses to Visual Tracking Stimuli May Be Affected by Concussion. Mil Med, 182(S1), 120-123. doi:10.7205/milmed-d-16-00093