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 Quick Questions in Sports Medicine
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Series Editor, Eric L. Sauers, PhD, ATC, FNATA

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Quick questions in sport-related concussion : expert advice in sports medicine / editor, Tamara C. Valovich McLeod.
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Includes bibliographical references and index.
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I. Valovich McLeod, Tamara C., editor.
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 Dedication
To Ian, Allister, and Kalyn for your unwavering love and support.
 Contents
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

Section I Concussion Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Question 1 What Is Currently the Most Commonly Accepted Definition of a
Sport-Related Concussion, and How Does This Definition Impact
Clinical Management? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Michelle L. Weber, MS, AT, ATC and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 2 How Common Are Sport-Related Concussions? . . . . . . . . . . . . . . . . . . . . . . . 7
Laura Decoster, ATC
Question 3 What Are the Best Educational Materials Available to Help a Coach,
Parent, or Athlete Learn About Concussions? . . . . . . . . . . . . . . . . . . . . . . . . 11
Johna K. Register-Mihalik, PhD, LAT, ATC
Section II Preseason Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Question 4 What Pertinent Questions Should Be Asked During a Preparticipation
Physical Examination to Accurately Determine Prior Concussion
History? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Ian A. McLeod, PA-C, ATC
Question 5 Are There Risk Factors or Behaviors That Can Make Athletes
Prone to Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Scott C. Livingston, PhD, PT, ATC, SCS
Question 6 Are There Differences Between the Sexes Regarding Concussion
Incidence, Outcomes, and Treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Tracey Covassin, PhD, ATC and Erica L. Beidler, MEd, ATC
Question 7 Is It Imperative to Perform Baseline Testing? . . . . . . . . . . . . . . . . . . . . . . . . . 33
Jason P. Mihalik, PhD, CAT(C), ATC and Ashley C. Littleton, MA, ATC
Question 8 Which Medical Professionals Should Be Part of My Concussion
Management Team? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Richelle M. Williams, MS, ATC and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 9 What Are the Most Important Regulations and Policies to Consider
Regarding the Management of Sport-Related Concussion? . . . . . . . . . . . . . . 43
John T. Parsons, PhD, ATC
Question 10 What Factors Aid in the Prevention of Recurrent Concussion? . . . . . . . . . . . 49
Johna K. Register-Mihalik, PhD, LAT, ATC
Question 11 Can Protective Equipment or Strengthening the Neck Decrease
the Risk of Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Jason P. Mihalik, PhD, CAT(C), ATC and Julianne D. Schmidt, PhD, ATC
Section III Concussion Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Question 12 What Should Be Included in the On-Field or Sideline Examination to
Diagnose a Suspected Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Roger McCoy, MD and Matthew Anastasi, MD
Question 13 What Are the Red Flags During a Sideline Assessment for
Immediate Referral to the Emergency Department? . . . . . . . . . . . . . . . . . . . . 65
Kristina Wilson, MD, MPH, CAQSM, FAAP
Question 14 What Constitutes a “Failed” Postconcussion Test for Athletes
With Baseline Neurocognitive or Balance Tests? . . . . . . . . . . . . . . . . . . . . . . 69
Christina B. Kunec, PsyD; Sheri Fedor, PT, DPT; and Michael W. Collins, PhD
Question 15 Which Self-Report Symptom Scales Are the Best
for Concussion Assessment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Lindsey Shepherd, MS, ATC, AT, CSCS and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 16 Are Ocular Movements Related to Concussion Assessment,
and if so, How Do I Measure This? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Steven Erickson, MD, FACP and Shelly Massingale, PT, MPT
Question 17 How Common Are Vestibular Deficits Following Sport-Related Concussion,
and What Tools Are Best Used to Assess Vestibular Dysfunction? . . . . . . . . 85
Shelly Massingale, PT, MPT
Question 18 How Frequently and When Should Postconcussion Assessments
Be Administered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
R.J. Elbin, PhD; Michael W. Collins, PhD; and Anthony P. Kontos, PhD
Question 19 Does Recovery on Clinical Tests Represent True Recovery of the Brain? . . . 97
Steven P. Broglio, PhD, ATC and Douglas Martini, MS
Question 20 Is Imaging Useful to Determine the Severity of, or the Time to
Recovery From, a Concussion?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Max Zeiger, BS; Meeryo C. Choe, MD; and Christopher C. Giza, MD
Section IV Concussion Management Considerations . . . . . . . . . . . . . . . . .105
Question 21 Should Concussions in Children and Adolescents Be Managed
Differently From Those in Adults? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Richelle M. Williams, MS, ATC and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 22 How Many Concussions Are Too Many Before an Athlete Should Retire? . . 113
Amaal J. Starling, MD; Meeryo C. Choe, MD; and Christopher C. Giza, MD
Question 23 What Are the Long-Term Concerns With Concussion?. . . . . . . . . . . . . . . . 119
Steven P. Broglio, PhD, ATC and Douglas Martini, MS
Question 24 How Can We Predict if a Patient Will Have a Protracted Recovery
Following Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Ian A. McLeod, PA-C, ATC
Question 25 Do Subconcussive Blows Place Athletes at Just as Much Risk for
Future Negative Sequelae as Athletes With Diagnosed Concussions? . . . . . 129
Steven P. Broglio, PhD, ATC and Douglas Martini, MS
Question 26 How Should I Manage Concussion in Athletes With
Learning Disabilities, Epilepsy, Depression, or Anxiety? . . . . . . . . . . . . . . 133
Javier Cárdenas, MD and Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 27 Are There Any Medications That May Be Useful in the
Management of Concussions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Javier Cárdenas, MD and Tamara C. Valovich McLeod, PhD, ATC, FNATA
Question 28 Are There Any Rehabilitation Exercises That Help a
Concussed Athlete Heal Faster? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Johna K. Register-Mihalik, PhD, LAT, ATC and
Jason P. Mihalik, PhD, CAT(C), ATC
Question 29 Which Patient Self-Report Measures Are Best for Assessing the Impact
of Concussion on a Patient’s Quality of Life? . . . . . . . . . . . . . . . . . . . . . . . . 145
Michelle L. Weber, MS, AT, ATC and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Section V Return to Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153
Question 30 Why Can’t an Athlete Return to Play on the Same Day
as the Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Scott C. Livingston, PhD, PT, ATC, SCS
Question 31 Does Recovery Following Concussion Follow a Typical Time Course,
and Does This Really Correspond to Resolution of
Self-Reported Symptoms? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Steven P. Broglio, PhD, ATC
Question 32 How Long Should Patients Be Free of Symptoms Prior to Beginning a
Gradual Return to Activity?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Laura Decoster, ATC
Question 33 What Is the Role of the Graded Exertion Protocols for Making
Return-to-Play Decisions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Tracey Covassin, PhD, ATC and Jessica Wallace, MA, ATC, AT
Question 34 How Should Return to Play Be Managed in Athletes With
Comorbid Factors, Such as Attention Deficit Hyperactivity Disorder or
Prior History of Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Christopher G. Vaughan, PsyD and Valerie Needham, MS
Question 35 How Do Head Impact Indicators Work, and Is There Value in
Recommending That Patients Purchase Them? . . . . . . . . . . . . . . . . . . . . . . 177
Jason P. Mihalik, PhD, CAT(C), ATC and Robert C. Lynall, MS, ATC
Section VI Return to School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Question 36 What Is Cognitive Rest, and Can It Help Recovery
Following Concussion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Christopher G. Vaughan, PsyD and Valerie Needham, MS
Question 37 How Can Concussion Negatively Affect School Functioning? . . . . . . . . . . . 189
Danielle M.E. Ransom, PsyD and Christopher G. Vaughan, PsyD
Question 38 What School Policies/Procedures Apply to Concussed Student-Athletes
Who Are Attempting to Return to the Classroom? . . . . . . . . . . . . . . . . . . . 195
John T. Parsons, PhD, ATC and Richelle M. Williams, MS, ATC
Question 39 How Are Educational Accommodations Determined, and
Who Should Be Part of the Decision-Making Process? . . . . . . . . . . . . . . . . 199
Richelle M. Williams, MS, ATC and
Tamara C. Valovich McLeod, PhD, ATC, FNATA
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
 Acknowledgments
I would like to thank all of the contributing authors for their excitement about and effort
toward this project and extend a special thanks to Richelle M. Williams, Lindsey Shepherd,
and Michelle L. Weber for their assistance in soliciting clinical questions and editorial assistance
throughout the project.
 About the Editor
Tamara C. Valovich McLeod, PhD, ATC, FNATA, is the Athletic Training Program Director,
Professor of Athletic Training, and the John P. Wood, DO, Endowed Chair for Sports Medicine
at A.T. Still University in Mesa, Arizona. Dr. McLeod completed her doctor of philosophy degree
in education with an emphasis in sports medicine from the University of Virginia. She is the
director of the Athletic Training Practice-Based Research Network, and her research has focused
on the pediatric athlete with respect to sport-related concussion. Her current work is investigat-
ing the short- and long-term effects of pediatric sports concussion as well as recovery following
concussion on traditional concussion assessments and health-related quality of life. Dr. McLeod
also has research interests regarding gender differences in lower extremity function, specifically
neuromuscular control and postural stability, and studies these areas through an injury prevention
approach in younger athletes.
Dr. McLeod was a contributing author for the National Athletic Trainers’ Association (NATA)
Position Statement on the Management of Sport-Related Concussion, the lead author on the
NATA Position Statement on the Prevention of Pediatric Overuse Injuries, and a consultant and
contributing author on the Appropriate Medical Coverage for Secondary School-Aged Athletes.
Dr. McLeod serves on numerous editorial boards, publishes frequently in athletic training and
sports medicine journals, and is an NATA Fellow.
 Contributing Authors
Matthew Anastasi, MD (Question 12) Tracey Covassin, PhD, ATC (Questions 6, 33)
Assistant Team Physician Associate Professor
Arizona State University Undergraduate Athletic Training Program
Arizona Diamondbacks and Arizona Rattlers Director
Phoenix, Arizona Michigan State University
East Lansing, Michigan
Erica L. Beidler, MEd, ATC (Question 6)
Michigan State University Laura Decoster, ATC (Questions 2, 32)
East Lansing, Michigan Executive Director
New Hampshire Musculoskeletal Institute/
Steven P. Broglio, PhD, ATC (Questions 19, 23, Safe Sports Network
25, 31) Manchester, New Hampshire
Associate Professor
Director, NeuroSport Research Laboratory R.J. Elbin, PhD (Question 18)
School of Kinesiology Assistant Professor
University of Michigan Director, Office for Sport Concussion Research
Ann Arbor, Michigan Department of Health, Human Performance
and Recreation
Javier Cárdenas, MD (Questions 26, 27) University of Arkansas
Director, Barrow Concussion and Brain Injury Fayetteville, Arkansas
Center
Director, Barrow Concussion Network Steven Erickson, MD, FACP (Question 16)
Barrow Neurological Institute Medical Director
St. Joseph’s Hospital and Medical Center Banner Concussion Center
Phoenix, Arizona Phoenix, Arizona

Meeryo C. Choe, MD (Questions 20, 22) Sheri Fedor, PT, DPT (Question 14)
Health Sciences Clinical Instructor Outpatient Neurologic/Vestibular Program
Division of Pediatric Neurology UPMC Centers for Rehabilitation Services
UCLA Steve Tisch BrainSPORT Program Pittsburgh, Pennsylvania
UCLA Mattel Children’s Hospital
Los Angeles, California Christopher C. Giza, MD (Questions 20, 22)
Professor of Pediatric Neurology and
Michael W. Collins, PhD (Questions 14, 18) Neurosurgery
Director UPMC Sports Medicine Concussion UCLA Brain Injury Research Center
Program Mattel Children’s Hospital UCLA
Associate Professor David Geffen School of Medicine at UCLA
Department of Orthopaedic Surgery Los Angeles, California
University of Pittsburgh
Pittsburgh, Pennsylvania
Anthony P. Kontos, PhD (Question 18) Shelly Massingale, PT, MPT (Questions 16, 17)
Assistant Research Director Senior Clinical Manager
UPMC Sports Medicine Concussion Program Banner Concussion Center
Associate Professor Phoenix, Arizona
Department of Orthopaedic Surgery
University of Pittsburgh Roger McCoy, MD (Question 12)
Pittsburgh, Pennsylvania Head Team Physician
Arizona State University
Christina B. Kunec, PsyD (Question 14) Assistant Team Physician
Neuropsychologist Arizona Diamondbacks and Arizona Rattlers
Stamford Hospital Concussion Center Phoenix, Arizona
Orthopedic and Spine Institute
Stamford, Connecticut Ian A. McLeod, PA-C, ATC (Questions 4, 24)
Assistant Professor, Department of Physician
Ashley C. Littleton, MA, ATC (Question 7) Studies
Department of Allied Health Science Director of Didactic Education
Interdisciplinary Curriculum in Human A.T. Still University
Movement Science Mesa, Arizona
University of North Carolina at Chapel Hill
Matthew A. Gfeller Sport-Related Traumatic Jason P. Mihalik, PhD, CAT(C), ATC (Questions
Brain Injury Research Center 7, 11, 28, 35)
Chapel Hill, North Carolina Assistant Professor, Department of Exercise
and Sport Science
Scott C. Livingston, PhD, PT, ATC, SCS University of North Carolina at Chapel Hill
(Questions 5, 30) Co-Director, Matthew A. Gfeller Sport-Related
Program Manager, Warrior Athlete Traumatic Brain Injury Research Center
Reconditioning Program Chapel Hill, North Carolina
Wounded Warrior Battalion East
United States Marine Corps Wounded Warrior Valerie Needham, MS (Questions 34, 36)
Regiment Doctoral Candidate
Camp Lejeune, North Carolina American School of Professional Psychology
Argosy University
Robert C. Lynall, MS, ATC (Question 35) Washington, DC
Doctoral Candidate
Department of Allied Health Science John T. Parsons, PhD, ATC (Questions 9, 38)
Interdisciplinary Curriculum in Human Director, Sport Science Institute
Movement Science NCAA
University of North Carolina at Chapel Hill Indianapolis, Indiana
Chapel Hill, North Carolina
Danielle M.E. Ransom, PsyD (Question 37)
Douglas Martini, MS (Questions 19, 23, 25) Postdoctoral Fellow
Graduate Research Assistant Division of Pediatric Neuropsychology
NeuroSport Research Laboratory Children’s National Health System
School of Kinesiology Rockville, Maryland
University of Michigan
Ann Arbor, Michigan
Johna K. Register-Mihalik, PhD, LAT, ATC Jessica Wallace, MA, ATC, AT (Question 33)
(Questions 3, 10, 28) Michigan State University
Assistant Professor, Exercise and Sport Science East Lansing, Michigan
Research Scientist, Injury Prevention Research
Center Michelle L. Weber, MS, AT, ATC (Questions 1, 29)
Faculty, Matthew Gfeller Sport-Related TBI Co-Head Athletic Trainer
Research Center Desert Edge High School
The University of North Carolina at Chapel Hill Goodyear, Arizona
Chapel Hill, North Carolina
Richelle M. Williams, MS, ATC (Questions 8,
Julianne D. Schmidt, PhD, ATC (Question 11) 21, 38, 39)
Assistant Professor Graduate Research Assistant
Department of Kinesiology School of Kinesiology
University of Georgia University of Michigan
Athens, Georgia Ann Arbor, Michigan

Lindsey Shepherd, MS, ATC, AT, CSCS (Question Kristina Wilson, MD, MPH, CAQSM, FAAP
15) (Question 13)
Charleston, Illinois Director, Primary Care Sports Medicine
Center for Pediatric Orthopaedics, Phoenix
Amaal J. Starling, MD (Question 22) Children’s Hospital
Assistant Professor of Neurology Co-Director, Neurotrauma/Concussion Program
Division of Concussion Barrow Neurologic Institute at Phoenix
Division of Headache Children’s Hospital
Department of Neurology Assistant Clinical Professor, Department of
Mayo Clinic Child Health
Phoenix, Arizona University of Arizona School of Medicine–
Phoenix
Christopher G. Vaughan, PsyD (Questions 34,
36, 37) Max Zeiger, BS (Question 20)
Pediatric Neuropsychologist Clinic and Research Coordinator
Division of Pediatric Neuropsychology UCLA Steve Tisch BrainSPORT Program
Children’s National Health System Division of Pediatric Neurology
Assistant Professor, Departments of Pediatrics UCLA Mattel Children’s Hospital
& Psychiatry and Behavioral Sciences Los Angeles, California
George Washington University School of
Medicine
Rockville, Maryland
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