Sports Concussion Clinic Research

We conduct leading scientific research to better understand concussions in young people and to develop better approaches to assessment, treatment, and rehabilitation.

Overview

A sport-related concussion is a brain injury. The Centers for Disease Control and Prevention described sport-related concussion as an epidemic1. In an epidemiological study of high school athletes, concussion rates have increased steadily in the past decade2, possibly due to greater awareness among physicians, with recent estimates suggesting as many as 300,000 concussive injuries each year.3 Student athletes who experience a concussion are at statistically increased risk for experiencing a future concussion.

There is tremendous interest and concern about sport-related concussion in youth athletes reflected by thousands of media stories and every state in the United States passing legislation relating to educational efforts, identification, and/or medical management of this injury. Massachusetts law mandates that school athletic personnel and medical professionals be responsible for education about concussion risk, management of injured athletes, and clearance of these athletes in order for them to return to play.

There is considerable concern regarding the long-term effects of this injury, especially in children and adolescents who suffer repetitive injuries. Whether or not there is a long-term effect of multiple concussions in high school athletes is not well understood. There are conflicting results in the medical and scientific literature.

There are some good resources available to health care professionals relating to the assessment, acute medical management, return to school, return to sports, and treatment and rehabilitation services for those who are slow to recover. However, a large amount of research is needed to better inform the medical community on how to manage this injury, and how to provide the most effective treatment and rehabilitation services for student athletes who are slow to recover.

The Accelerate Knowledge/Improve Care Research Program

As one of the top hospitals in the country, Mass General epitomizes what makes an academic medical center special - translating research discoveries into better care for patients. We have a productive, diverse, and internationally recognized research program in sport-related concussion. We collaborate with clinicians and researchers locally, regionally, nationally, and internationally. Our research is designed to enhance knowledge and improve health care for student athletes who have sustained a concussion. We approach our research from a broad biopsychosocial perspective, and we use diverse technologies, biomarkers, and outcome measures such as microstructural neuroimaging (i.e., diffusion tensor imaging), cognitive testing, psychological assessment, and balance testing. We provide research training and experience to graduate students, medical residents, and post-doctoral fellows seeking careers in health service delivery or clinical research. Some of our priority areas of research are listed below.

  1. Understanding the Effects of Multiple Concussions: Athletes, parents, coaches, athletic trainers, physicians, scientists, and society as a whole are concerned about the possible effects of multiple concussions on adolescents and young adults. We are conducting a series of studies designed to address the questions below.

    a. Are high school athletes who have had prior concussions at increased risk for future concussions?
    b. Do athletes with multiple past concussions have worse effects of a future concussion than athletes who have no prior injuries?
    c. Are athletes with developmental problems, such as attention-deficit hyperactivity disorder (ADHD) or a learning disability, at increased risk for (a) sustaining a concussion, or (b) having worse outcome or slower recovery from this injury?
    d. Are multiple past concussions associated with current cognitive difficulties or symptoms (e.g., headaches) in adolescent student athletes?

  2. Improving the Methodology for Assessing Cognitive Impairment Following Concussion. Concussions can have an immediate and large adverse effect on cognitive functioning. This can interfere with an adolescent’s ability to function in daily life and school. We are conducting a series of studies that examine the reliability, accuracy, and clinical usefulness of computerized cognitive testing as a component of a sport concussion management program.

  3. Examining the Usefulness of Baseline, Preseason Testing. Few would doubt that a reliable, valid, and accurate assessment of a person’s pre-injury cognitive functioning would be useful for determining the nature and extent of post-injury cognitive deficits and the rate of recovery. There are multiple challenges and problems, however, associated with baseline testing. First, baseline computerized testing is often conducted in group settings, and one study illustrated that athletes tested in group settings perform more poorly than athletes tested individually10. As such, some authors have recommended individual baseline testing or testing in small, carefully monitored groups (e.g., 3-5 students)11. Second, baseline testing can be fairly expensive and labor intensive, depending on how it is done. Third, some tests used in concussion management programs have modest test-retest reliability12-14. Therefore, it can be difficult to accurately and precisely assess baseline and post-injury change scores. Finally, the value of baseline testing is largely assumed, and baseline testing is often encouraged in consensus15 or agreement16-17 statements – at least with some athletes. Few studies have examined this issue empirically, however.

    We believe that having an accurate measure of baseline cognitive functioning would be helpful for quantifying cognitive deficits following injury and for assessing recovery. This is especially true for athletes who have above average or below average cognitive functioning at baseline. Moreover, it can be helpful for athletes with developmental conditions, such as attention-deficit hyperactivity disorder or a learning disability. Students with self-reported ADHD, learning disabilities, or both perform more poorly on ImPACT® than students who do not have a developmental condition18. At present, however, there is insufficient evidence to conclude that having baseline test results is time- and cost-effective, or clearly superior to not having baseline test results. With our collaborators, we are pursuing studies relating to the advantages, disadvantages, and appropriate use of baseline testing.

  4. Improving Exertional Testing and Return to Play Protocols: Injured athletes are expected to undergo a progressive series of exercises and exertional tests, spanning several days, prior to be cleared to return to contact sports. It is important to understand and document the effects of exertional testing on athletes who are not injured so we have normative reference values to compare to athletes who are injured. We are examining the effects of exertional testing on cardiac physiology, balance, cognition, and subjective symptoms in both uninjured and injured athletes.

  5. Active Rehabilitation for Children and Adolescents Who are Slow to Recover from Concussion. There are no scientifically-established, evidence-based guidelines for providing treatment and rehabilitation services to student athletes who are slow to recover from concussion. An active rehabilitation treatment program for children and adolescents who are slow to recover following concussion has been offered at the Montreal Children’s Hospital Trauma Center since 2007. This group of clinicians and researchers is part of our research network. In addition, we are collaborating with clinicians from GF Strong Rehabilitation Hospital in Vancouver, Canada to do a small clinical trial on active rehabilitation with adolescents who are slow to recover. Through a series of studies conducted locally and with our Canadian collaborators, we will advance knowledge and refine treatment strategies for children and adolescents who have persistent symptoms and problems following their injuries.

References

  1. Injury Prevention and Control: Traumatic Brain Injury. http://www.cdc.gov/concussion/sports/facts.html. Accessed February 26, 2014.
  2. Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. The American journal of sports medicine. 2011;39(5):958-963.
  3. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. The American journal of sports medicine. 2012;40(4):747-755.
  4. Mannix R, Meehan WP, Mandeville J, Grant PE, Gray T, Berglass J, et al. Clinical correlates in an experimental model of repetitive mild brain injury. Annals of neurology. 2013;74(1):65-75.
  5. Meehan WP, 3rd, Zhang J, Mannix R, Whalen MJ. Increasing recovery time between injuries improves cognitive outcome after repetitive mild concussive brain injuries in mice. Neurosurgery. 2012;71(4):885-891.
  6. Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Harding HP, Jr., Matthews A, et al. Recurrent concussion and risk of depression in retired professional football players. Medicine and science in sports and exercise. 2007;39(6):903-909.
  7. Kerr ZY, Marshall SW, Harding HP, Jr., Guskiewicz KM. Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. The American journal of sports medicine. 2012;40(10):2206-2212.
  8. Schwenk TL, Gorenflo DW, Dopp RR, Hipple E. Depression and pain in retired professional football players. Medicine and science in sports and exercise. 2007;39(4):599-605.
  9. Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA: the journal of the American Medical Association. 2003;290(19):2549-2555.
  10. Moser RS, Schatz P, Neidzwski K, Ott SD. Group versus individual administration affects baseline neurocognitive test performance. Am J Sports Med 2011;39:2325-2330.
  11. Echemendia RJ, Iverson GL, McCrea M, Macciocchi SN, Gioia GA, Putukian M, Comper P. Advances in neuropsychological assessment of sport-related concussion. Br J Sports Med 2013;47:294-298.
  12. Mayers LB, Redick TS. Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: psychometric issues. J Clin Exp Neuropsychol 2012;34:235-242.
  13. Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R. Test-retest reliability of computerized concussion assessment programs. J Athl Train 2007;42:509-514.
  14. Resch J, Driscoll A, McCaffrey N, Brown C, Ferrara MS, Macciocchi S, Baumgartner T, Walpert K. ImPact test-retest reliability: reliably unreliable? J Athl Train 2013;48:506-511.
  15. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train 2009;44:434-448.
  16. Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, McLeod TC. Research based recommendations on management of sport related concussion: summary of the National Athletic Trainers' Association position statement. Br J Sports Med 2006;40:6-10.
  17. Moser RS, Iverson GL, Echemendia RJ, Lovell MR, Schatz P, Webbe FM, Ruff RM, Barth JT. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol 2007;22:909-916.
  18. Elbin RJ, Kontos AP, Kegel N, Johnson E, Burkhart S, Schatz P. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin Neuropsychol 2013;28:476-484.

Publications

Day-of-Injury Assessment and Diagnostics

Hänninen, T., Tuominen, M., Parkkari, J., Vartiainen, M., Öhman, J., Iverson, G.L., and Luoto, T.M. (2015). Sport concussion assessment tool - 3rd edition - normative reference values for professional ice hockey players. Journal of Science and Medicine in Sport, S1440-2440(15)00177-2. See in PubMed

Vartiainen, M.V., Holm, A., Peltonen, K., Luoto, T. M., Iverson, G.L., Hokkanen, L. (2015). King-Devick test normative reference values for professional male ice hockey players. Scandinavian Journal of Medicine and Science in Sports. 25 (3):e327-30. See in PubMed

McCrea, M., Iverson, G.L., Echemendia, R., Makdissi, M., & Raftery, M. (2013). Day of injury assessment of sport-related concussion. British Journal of Sports Medicine, 47, 272-284. See in PubMed

McCrory, P., Echemendia, R.J., Meeuwisse, W.H., Iverson, G.L., Dvořák, J., & Kutcher, J.S. (2013). What is the lowest threshold to make a diagnosis of concussion? British Journal of Sports Medicine, 47, 268-271. See in PubMed

Video Analysis of Injuries

Gardner, A.J., Iverson, G.L., Stanwell, P., Moore, T., Ellis, J., Levi, C.R. (2016). A Video
Analysis of Use of the New 'Concussion Interchange Rule' in the National Rugby
League. International Journal of Sports Medicine, 37(4), 267-73. See in PubMed

Gardner A.J., Iverson G.L., Quinn T.N., Makdissi M., Levi C.R., Shultz S.R., Wright D.K., Stanwell P. (2015). A preliminary video analysis of concussion in the National Rugby League. Brain Injury, 29(10), 1182-1185. See in PubMed

Role of Rest and Active Rehabilitation

Silverberg, N.D., Iverson, G.L., McCrea, M., Apps, J.N., Hammeke, T., & Thomas, D.G. (2016). Activity-Related Symptom Exacerbations after Pediatric Concussion. JAMA Pediatrics. See in PubMed

DiFazio, M., Silverberg, N.D., Kirkwood, M.W., Bernier, R., & Iverson, G.L. (2015). Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes? Clinical Pediatrics. See in PubMed

Gagnon, I., Grilli, L., Friedman, D., & Iverson, G. L. (2015). A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scandinavian Journal of Medicine and Science in Sports, 26(3), 299-306. See in PubMed

Iverson, GL (2015). Rest Following Sport-Related Concussion. In R. Echemendia and GL Iverson (Editors), Oxford Handbook of Sport-Related Concussion.

Moser, R. S., Schatz P., Glenn, M., Kollias, K. E., & Iverson, G. L. (2015). Examining Prescribed Rest as Treatment for Adolescents who are Slow to Recover from Concussion. Brain Injury, 29(1):58-63 See in PubMed

Reed, N., Greenspoon, D., Iverson, G.L., DeMatteo, C., Fait, P., Gauvin-Lepage, J., Hunt, A., and Gagnon, I.J. (2015). Management of persistent postconcussion symptoms in youth: a randomised control trial protocol. BMJ Open. 2015 Jul 31;5(7):e008468. See in PubMed

Schneider, K.J., Iverson, G.L., Emery, C.A., McCrory, P., Herring, S.A., & Meeuwisse, W.H. (2013). The effects of rest and treatment following sport-related concussion: A systematic review of the literature. British Journal of Sports Medicine, 47, 304-307. See in PubMed

Multiple Concussions

Brooks, B.L., Mannix, R., Maxwell, B., Zafonte, R., Berkner, P.D., & Iverson, G.L. (2016). Multiple Past Concussions in High School Football Players. American Journal of Sports Medicine. See in PubMed

Wojtowicz, M., Iverson, G.L., Silverberg, N.D., Mannix, R., Zafonte, R.D., Maxwell, B., Berkner, P.D. (2016). Consistency of Self-reported Concussion History in Adolescent Athletes. Journal of Neurotrauma. [Epub ahead of print]. See in PubMed

Iverson, G.L., Wojtowicz, M., Brooks, B.L., Maxwell, B.A., Atkins, J.E., Zafonte, R., & Berkner, P.D. (in press). High School Athletes with Attention-Deficit Hyperactivity Disorder and Learning Difficulties Have a Greater Lifetime Concussion History. Journal of Attention Disorders. [Epub ahead of print].See in PubMed

Iverson, G. L., Atkins, J. E., Zafonte, R. & Berkner, P. D. (2014). Concussion History in Adolescent Athletes with Attention-Deficit Hyperactivity Disorder. Journal of Neurotrauma. Nov 6, 2014 [Epub ahead of print].

Mannix, R., Iverson, G.L., Maxwell, B., Atkins, J.E., Zafonte, R., & Berkner, P.D. (2014). Multiple Prior Concussions are Associated with Symptoms in High School Athletes. Annals of Clinical and Translational Neurology, 1(6), 433-438.

Improving Assessment Methods: Cognition, Symptoms, and Balance

Silverberg, N.D., Berkner, P.D., Atkins, J.E., Zafonte, R., & Iverson, G.L. (2015). Relationship between low sleep quality and preseason concussion testing. Clinical Journal of Sports Medicine, 2015 Aug 4. [Epub ahead of print] See in PubMed

Iverson, G.L., Silverberg, N.D., Mannix, R., Maxwell, B.A., Atkins, J.E., Zafonte, R., & Berkner, P.D. (2015). Factors Associated with Concussion-Like Symptom Reporting in High School Athletes. JAMA Pediatrics, 169(12), 1132-1140. See in PubMed

Brooks B.L., Iverson G.L., Atkins J.E., Zafonte R., Berkner P.D. (2015). Sex Differences and Self-Reported Attention Problems During Baseline Concussion Testing. Applied Neuropsychology- Child, 5(2),119-26. See in PubMed

Iverson G.L., & Schatz, P. (2015). Advanced Topics in Neuropsychological Assessment Following Sport-Related Concussion. Brain Injury, 29 (2), 263-275. See in PubMed

Ritchie, L.J., Mrazik, M., Alfano, D.P., Chase, D., Comper, P., Czarnota, M., Garcia-Barrera, M.A., Iverson, G.L., Maclean, M., Mendella, P., & Williams, T. (2015). The role of neuropsychology in the management of youth concussion in Canada. Current Research: Concussion, 2(1), 8-10. See in PubMed

Echemendia, R.J., Iverson, G.L., McCrea, M., Macciocchi, S.A., Gioia, G.A., Putukian, M., & Comper, P. (2013). Advances in neuropsychological assessment of sport-related concussion. British Journal of Sports Medicine, 47, 294-298. See in PubMed

Brain Imaging and Biomarkers

Gardner A.J., Tan C.O., Ainslie P.N., van Donkelaar P., Stanwell P., Levi C.R., Iverson G.L. (2015). Cerebrovascular reactivity assessed by transcranial Doppler ultrasound in sport-related concussion: a systematic review. British Journal of Sports Medicine, 49(16), 1050-1055. See in PubMed

Marsden, K. R., Strachan, N. C., Monteleone, B. J., Ainslie, P. N., Iverson, G. L., & van Donkelaar, P. (2015). The relationship between exercise-induced increases in cerebral perfusion and headache exacerbation following sport-related concussion: A preliminary study. Current Research: Concussion, 2(1), 17-21.

Gardner, A, Iverson, GL, van Donkelaar, P, & Ainslie, PN (2015). Magnetic Resonance Spectroscopy, Diffusion Tensor Imaging, and Transcranial Doppler Ultrasound Following Sport-Related Concussion. In R. Echemendia and GL Iverson (Editors), Oxford Handbook of Sport-Related Concussion.

Gardner, A., Iverson, G.L., & Stanwell, P. (2014). A Systematic Review of Proton Magnetic Resonance Spectroscopy Findings in Sport-Related Concussion. Journal of Neurotrauma, 31, 1-18. See in PubMed

Tan, C.O., Meehan, W., Iverson, G.L., & Taylor, J.A. (2014). Cerebrovascular Regulation, Exercise, and Mild Traumatic Brain Injury. Neurology, 83(18), 1665-72 See in PubMed

Koerte I.K., Ertl-Wagner B., Reiser M., Zafonte R., & Shenton M.E. (2012). White matter integrity in the brains of professional soccer players without a symptomatic concussion. Journal of the American Medical Association (JAMA), 308(18), 1859-61.See in PubMed

Reviews and Consensus Statements

Iverson, G.L. & Gioia, G. A. (2016). Returning to School Following Sport-Related Concussion. Physical Medicine and Rehabilitation Clinics of North America, 27(2), 429-436. See in PubMed

Gardner, A., Iverson, G.L., Levi, C. R., Schofield, P.W., Kay-Lambkin, F., Kohler, R.M.N., & Stanwell, P. (2015). A systematic review of concussion in Rugby League. British Journal of Sports Medicine, 49(8), 495-498. See in PubMed

Gardner, A., Iverson, G.L., Williams, W. H., Baker, S., & Stanwell, P. (2014). A systematic review and meta-analysis of concussion in Rugby Union. Sports Medicine, 44(12), 1717-31. See in PubMed

Giza C.C., Kutcher J.S., Ashwal S., Barth J., Getchius T.S., Gioia G.A., Gronseth G.S., Guskiewicz K., Mandel S., Manley G., McKeag D.B., Thurman D.J., Zafonte R. (2013). Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 11;80(24):2250-7. See in PubMed

McCrory, P., Meeuwisse, W.H., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R.J., Engebretsen, L., Johnston, K., Kutcher, J.S., Raftery, M., Sills, A., Benson, B.W., Davis, G.A., Ellenbogen, R.G., Guskiewicz, K., Herring, S.A., Iverson, G.L., Jordan, B.D., Kissick, J., McCrea, M., McIntosh, A.S., Maddocks, D., Makdissi, M., Purcell, L., Putukian, M., Schneider, K., Tator, C.H., & Turner, M. (2013). Consensus statement on concussion in sport: The 4th international conference on concussion in sport held in Zurich, November 2012. British Journal of Sports Medicine, 47, 250-258. See in PubMed

Head Impact Exposure & Sensors

Wilcox BJ, Beckwith JG, Greenwald RM, Chu JJ, McAllister TW, Flashman LA, Maerlender AC, Duhaime AC, Crisco JJ (2014). Head impact exposure in male and female collegiate ice hockey players. Journal of Biomechanics, 3;47(1):109-14. Seen on PubMed

Brainard LL, Beckwith JG, Chu JJ, Crisco JJ, McAllister TW, Duhaime AC, Maerlender AC, Greenwald RM (2012). Gender differences in head impacts sustained by collegiate ice hockey players. Medicine and Science in Sports and Exercise, 44(2):297-304. See in PubMed

Crisco JJ, Wilcox BJ, Machan JT, McAllister TW, Duhaime AC, Duma SM, Rowson S, Beckwith JG, Chu JJ, Greenwald RM (2012). Magnitude of head impact exposures in individual collegiate football players. Journal of Applied Biomechanics, 28(2):174-183. See in PubMed

Duhaime AC, Beckwith JG, Maerlender AC, McAllister TW, Crisco JJ, Duma SM, Brolinson PG, Rowson S, Flashman LA, Chu JJ, Greenwald RM (2012). Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets: clinical article. Journal of Neurosurgery, 117(6):1092-1099. See in PubMed

McAllister TW, Flashman LA, Maerlender A, Greenwald RM, Beckwith JG, Tosteson TD, Crisco JJ, Brolinson PG, Duma SM, Duhaime AC, Grove MR, Turco JH (2012). Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology, 78(22):1777-1784. See in PubMed

Rowson S, Duma SM, Beckwith JG, Chu JJ, Greenwald RM, Crisco JJ, Brolinson PG, Duhaime AC, McAllister TW, Maerlender AC (2012). Rotational head kinematics in football impacts: an injury risk function for concussion. Annals of Biomedical Engineering, 40(1):1-13. See in PubMed

Long-Term Effects and Chronic Traumatic Encephalopathy

Webner D. & Iverson, G.L. (in press). Suicide in Professional American Football Players in the Past 95 Years. Brain Injury.

Iverson, G.L., Gardner, A.J., McCrory, P., Zafonte, R., & Castellani, R.J. (2015). A Critical Review of Chronic Traumatic Encephalopathy. Neuroscience & Biobehavioral Reviews, 56, 276-293. See in PubMed

Iverson, G.L. (2015). Suicide and Chronic Traumatic Encephalopathy. Journal of Neuropsychiatry and Clinical Neurosciences, 28(1):9-16. See in PubMed

Castellani R.J., Perry G., Iverson G.L. (2015). Chronic effects of mild neurotrauma: putting the cart before the horse? Journal of Neuropathology and Experimental Neurology, 74 (6), 493-499. See in PubMed

Gardner, A., Iverson, G.L., & McCrory, P. (2014). Chronic traumatic encephalopathy in sport: A systematic review. British Journal of Sports Medicine, 48, 84-90. See in PubMed

Iverson, G.L. (2014). Chronic traumatic encephalopathy and risk of suicide in former athletes. British Journal of Sports Medicine, 48, 162-165. See in PubMed

Contact

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Youth Sports Concussion Program

  • Near Public Transit
  • Accessible
  • Phone: 617-724-YSCC (9722)

Boston:
175 Cambridge Street
Boston, MA 02114

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