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+++++++++++++++++++++++++++++++++++++++ + +++ + oRTHoPAEDICS SPECIAL SECTIoN +++ +++++++++++++++++++++++++++++++++++++++ sports-related Concussion: What's the Big Deal? o by Joseph Congeni, mD vER THE PAST decade, there's been a n a la rming 200% increase in reported sportsrelated concussions. Considering that studies show nearly 80% of cases go unidentified, even this number may be underestimated. This epidemic has led to a strong call to action in the medical community about how to improve diagnostic methods to identify athletes who have suffered a concussive episode, and further, what long-term effects to anticipate. Even healthcare professionals well versed in trauma, sports-related and neurologic injuries can find it challenging to identify the signs of concussion. At the onset, symptoms can be subtle. The athlete may appear normal despite acting or feeling differently and may appear ready to return to action. Unlike other traumatic injuries, brain injury may lead to harmful and even fatal problems hours, days, months or years later. When evaluating patients, it's important to understand that symptoms can manifest as physical, cognitive, emotional or sleeprelated. depending on the location of the blow. Concussion symptoms can be common to other conditions such as headache, depression and post-traumatic stress disorder, ma k ing t he dia g nosis even more challenging. Further complicating the matter, there is no single diagnostic tool or clinical test to definitively diag- nose this subtle, evolving condition. Concussion does not show up routinely on MRI or CT scans. However, progression in standardized methods of evaluation has introduced more objectivity in what was typically a clinically subjective process. T he St a nd a rd i zed Conc u ssion Assessment Tool (SCAT) is widely used to evaluate an athlete immediately following a potentially concussive episode. In March 2013, the Consensus Statement on Concussion in Sport updated its guidelines for evaluation of injured athletes known as SCAT3, superseding original versions. Additionally, ChildSCAT3, or C-SCAT3, provides specific guidelines for evaluating children 12 and under and should be used by medical professionals. To achieve best results, diagnosis and management may begin with the implementation of baseline and/or post-injury neurocognitive testing. This eva luation ca n help to objectively assess the athlete's postinjury condition and track recovery. For greater than 85% of patients, full clinical recovery is expected. However, the remaining number of athletes can suffer from long-term conditions including chronic headaches, post-traumatic stress syndrome, depression, learning disabilities and dementia. In the worst cases, concussion sufferers can develop chronic traumatic encephalopathy (CTE), a degenerative brain disease causing memory impairment, emotional instability, erratic behavior, depression or loss of impulse control, before developing into an Alzheimer's-like dementia. In 2009, the National Football League conducted a study of more than 2,500 retired players to better understand the cumulative, long-term effects of concussive episodes. Study results revealed that players with at least three concussions during their careers would have tripled their risk of depression. The study also found that one in three retired players will suffer some cognitive impairment, and many end up suffering a serious degree of dementia in comparison to age-matched controls. To protect athletes and prevent CTE and other devastating long-term effects, it is imperative to increase awareness of symptoms and management principals among medical professionals, coaches, trainers and parents. Along with increased awareness, legislative efforts are taking place. As of April 26, 2013 Ohio implemented the Return-to-Play Law, requiring parents and athletes to receive concussion information annually for each participatory sport. In addition, any athlete believed to have a concussion is to be removed from play immediately and can only return to play or practice after at least 24 hours with clearance from a medical professional. Although great strides have been made to more holistically understand sportsrelated concussive episodes, there is still much progress to be made. Until we solve the mystery of how and when injuries or falls become too much for athletes, we must all work together to better prevent, evaluate, diagnose and aid in the recovery of these traumatic injuries. Dr. Joseph Congeni is Director of Sports Medicine at the Akron Children's Hospital Center for Orthopedics and Sports Medicine. ■