Dr. Jason Mihalik guests on ‘5 questions with CJSM’: concussions and apps

We’re already seeing an uptick in our concussion clinics now that the football (both ‘American Football’ and soccer) seasons have begun.  It promises to be a busy few months.

jason mihalik

Dr. Mihalik and colleagues with their
pre-participation ‘sports drinks’

How fortunate my colleagues and I were, then, to have a special guest visit us a couple weeks ago:  Jason P. Mihalik, Assistant Professor in the Department of Exercise and Sport Science at the University of North Carolina and Co-Director of the Mathew Gfeller Sport-Related Traumatic Brain Injury Research Center.  

I first became aware of Dr. Mihalik from the work he has done regarding what is generally considered the most user-friendly layperson’s app for recognizing a concussion on the field of play.  The app, known as “Concussion Recognition and Response App,” can be downloaded to both iPhone and Android systems, has a version specifically designed for coaches and parents; it is designed to assist the layperson in recognizing when a concussion may have occurred.  Dr. Mihalik himself talks about the app in this YouTube video.

mihalik and pommering

From Left to Right:
Drs. Mihalik, Pommering, and Patrick,
on ‘Pediacast’

Dr. Mihalik ripped through his 24 hours with us with little time to breathe as he dispensed his wisdom concerning sports-related concussions, one of the hottest topics in the world of clinical sports medicine.  The highlights included the taping of a podcast; a lecture to the research staff and faculty; and the requisite beers and lounge experience in an informal setting.

I had to breakaway to cover a FINA open-water swimming event.  In lieu of attending the lecture Dr. Mihalik gave at our hospital, I tracked him down for a quick Q & A session.

—————Five Questions for Dr. Mihalik————–

1) CJSM: What do you think accounts for the dramatic rise in incidence of sports related concussions over the last decade? is it just a matter of recognition bias, or is something more going on?

Dr. Mihalik:  Research has shown a steady increase in the incidence of concussion across many sports. There is always an issue with incidence rates since precisely identifying the denominator (exposure) is always tricky at best. Notwithstanding, I believe this rise can be attributed to the increased hypersensitivity of this injury. More people know about concussions, which I feel biases recognition in more recent publications that highlight increases in concussion rates. I don’t think we should sensationalize these findings to suggest that concussion is now a problem when, in the past, it may not have been. Concussion has always been there, but we are now educating parents, coaches, and athletes to recognize the signs & symptoms.

2) CJSM: What do you think are the biggest new items/newsworthy items that came out of the zurich 2012 consensus conference on concussions?

Dr. Mihalik: For the most part, things remained mostly unchanged in the text of the recent consensus statement.  While subtle, the definition of concussion removes ‘mild’ and now begins simply with “concussion is a brain injury and is defined as…” This is a very important change in my mind to promoting a nomenclature update in our clinical practices. While most concussions do resolve within a couple of weeks of the injury, many result in persistent symptoms that may last weeks, months, or even years. One could hardly argue that a brain injury with such lasting issues be considered ‘mild.’ Some other notable changes are the new SCAT3—which reports individual subcomponent scores instead of the total score we saw in SCAT2—and the new Child-SCAT3. Lastly, all athletes (even professional athletes) are to be removed from participation if they are suspected of having suffered a concussion.

3) CJSM:  You have a 140 character ‘tweet’ to compose about the smartphone app you developed on concussion recognition:  what does the tweet say?

Splash Screen

Concussion? There’s an app for that:
The “Concussion Recognition and Response” App

Dr. Mihalik: Concussion? Everything you need to know is in the Concussion Recognition & Response app…right in the palm of your hand! And now for free! (3 characters to spare!  good job Dr. Mihalik!)

4)CJSM:  From LED therapy to potential biomarkers of concussion to anything else you are aware of, what do you think are the top 2 or 3 ‘things’ coming down the pike that relate to the diagnosis and/or management of concussions?

Dr. Mihalik: There is a lot emerging in the concussion marketplace, with many claims being made. With respect to diagnosis, research using functional imaging techniques (functional magnetic resonance imagines, diffusion tensor imaging, susceptible weighted imaging, resting state blood oxygen level dependent, etc) are all showing promise—at least in research enterprises—of being sensitive to subtle functional deficits in brain function. Biomarkers continue to be an interesting area with conflicting reports in the literature as to their diagnostic and prognostic capabilities with concussion.

5) CJSM: The Zachary Lystedt laws which most states now have are predicated on a concept of secondary prevention:  that holding a young athlete with a recent concussion from playing while symptomatic will reduce the rates of ‘second impact syndrome’.  there is controversy over the very existence of a ‘second impact syndrome.’ what do you see in the medical literature/evidence that supports the existence of this syndrome or would make one skeptical?

Dr. Mihalik: Fortunately, SIS is a very rare condition, with no more than 50 cases for which sufficient medical evidence supports its diagnosis. Because of this rarity, it is hard to arrive at a definitive agreement—and certainly voids us of the ability to study in a randomized fashion—of SIS. However, what we do know is that in all cases of SIS, the [usually young] athlete sustains a blow to the head—often minor—when symptoms related to an initial head injury have yet to fully resolve. In the extreme, death occurs within minutes of this blow to the head. In other situations, we see immediate and permanent brain damage. In milder cases, we see permanent cognitive changes (e.g. A students now struggling to get C’s). It is believe that any of these outcomes can be prevented if the athlete experiencing signs (things you see) and complaining of symptoms (things they tell you they feel) be removed and not permitted to return to participation until properly evaluated by a licensed medical professional. The key here is for quick and rapid response to any potentially catastrophic event. To provide young athletes the best chance of surviving catastrophic events, the Gfeller-Waller Concussion Awareness Act—North Carolina’s ‘concussion law’—also requires that schools have an Emergency Action Plan (EAP) in place for each venue their school uses for sports. This EAP needs to be approved by the school’s athletic trainer. In the event the school does not employ an athletic trainer, the EAPs must be vetted by the North Carolina Athletic Trainers’ Association.


Thanks so much Dr. Mihalik for the time you devoted to putting together your insightful answers.

To the readers:  if you’re looking for more information on the subject of sports-related concussions, by all means check out the collection of ten studies we have made freely available, for a limited time, in the “Collections” section of the CJSM home page.  I’ll be talking about that more in an upcoming blog post.

And, in closing, may I make a plug:  if you haven’t taken the poll on Second-Impact Syndrome (a unique clinical entity, or not?), be sure to go to the recent blog post on the subject to vote and see what your peers think.


About sportingjim
I work at Nationwide Children's Hospital in Columbus, Ohio USA, where I am a specialist in pediatric sports medicine. My academic appointment as an Associate Professor of Pediatrics is through Ohio State University. I am a public health advocate for kids' health and safety. I am also the Deputy Editor for the Clinical Journal of Sport Medicine.

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