Concussions

With Concussions being the new hot topic, I thought I’d try my hand at attempting to explain what a concussion is, why they are such an important topic, and what a PT’s role would be in the management of concussion.

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Gratuitous picture of a concussed Morelli

Concussion was defined at the Third International Conference on Concussion in Sport as “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.” Currently there are over 440,000 emergency department visits per year for concussion, with 65% being children and adolescents and less than 20% of all cases involving loss of consciousness(LOC). On a side note, LOC is actually the least common symptom of concussion, trailing headache, dizziness, light and noise sensitivity, fatigue, and altered sleep, and more (Lau et al – AJSM 2011). In studies throughout the 2000s, football has the highest incidence of concussion, followed by ice hockey, and then women’s soccer.

The seriousness of concussions cannot be overstated. It is the single most common cause of death in sports-related injuries, the majority of which are thought to be the result of second impact syndrome, in which a second concussive incident occurs prior to a full recovery from a previous concussion. The prevelence of returning to play before being ready is staggering. The American Academy of Neurology estimated that between ’05 and ‘08 41% of concussed athletes returned to play too soon, and 16% of HS football players who experienced LOC returned to play the same day. Proper diagnosis and treatment is essential to reducing the deleterious and potentially fatal effects of second impact syndrome.

Another serious side effect of concussions is impaired balance. A study by Van Kampen in AJSM in 2006 showed a person’s 2nd concussion resulted in significant balance deficiency 10 days post concussive incident. Consequences of playing with impaired balance may be as minor as a decrease in athletic performance to as severe as being susceptible to serious injury such as an ACL tear. A quick balance screen can be performed using the BESS test, which has been proven reliable and valid (picture of BESS test assessment shown below).

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Errors during BESS testing:

Hands lifted off the iliac crests

Opening eyes

Step, stumble, or fall

Moving the hip into more than 30° of flexion or extension

Lifting the forefoot or heel

Remaining out of the testing position for more than 5 seconds

Research shows 80-90% of all concussions will have resolved symptoms in 7-10 days. So what symptoms may indicate prolonged recovery times? During sideline assessment, memory dysfunction and dizziness were both associated with prolonged recovery. Interestingly, there was no association of LOC with prolonged symptoms. It also appears that during neuropsych testing (ImPACT testing), NFL players recovered faster than collegiate players, who recovered quicker than high schoolers. This may be due to the incomplete development of high schoolers brains, and also due to the unique academic rigors high schoolers and collegiate athletes have. Studies in rats have shown that exercise within one week of a concussive episode delays recovery of cognitive function, so I don’t think it’s much of a stretch to think that excessive cognitive stimulation (like physical stimulation) could also have deleterious effects on recovery.

So how can we predict who will suffer repeated concussions?  Collins et al showed that high school athletes with 3 or more concussions have an 8x greater risk of LOC during a concussive episode and a 5x greater incidence of amnesia and confusion. Furthermore, once an athlete suffers a concussion, that athlete is at a 3x higher risk of concussion compared to his/her teammates (Guskiewitz et al – AJSM 2000 , JAMA 2003)

For Physical Therapists, what is our role in concussion management? One main role of a PT is an accurate sideline assessment. Knowconcussion.org is a terrific resource to brush up on your sideline management of concussion. Providers MUST be able to identify potential neurosurgical emergencies, and prevent potentially catastrophic injuries caused by cerebral edema. Acute worsening following a stabilization of symptoms may indicate a potentially fatal epidural hematoma.

When determining if the athlete is appropriate for return to play, one should be sure to know state laws to determine if one is allowed to take such measures. If allowed, collaboration with trained Physicians and Athletic Trainers is recommended. A balance assessment should always be done to determine if the athlete is physically ready for return to play.

If a PT is seeing a post-concussed athlete in the clinic, balance retraining may be necessary. The PT should be sure to strike an appropriate balance between working on deficiencies while not overworking the athlete as it can prolong recovery.

Now let’s delve into the long-term effects of concussion. Head injury has been linked (but not proven in quality studies) with Chronic Traumatic Encephalopathy (CTE), a degenerative process that has been linked with reduced cognitive function, dementia, depression, and other negative long-term effects. Regardless of CTE presence, football players with a history of 3 or more concussions have a 5x increase in the incidence of clinical depression, mild cognitive decline, and early onset Alzheimer’s. Regardless it appears clear from research on football players and boxers that concussions are not good for the brain (shocking, I know).

Normal-v-CTE-brain-courtesy-Ann-McKee

The University of Michigan’s Steven Broglio tracked 95 football players over the course of a season, and found lineman hat 868 sub-concussive hits per season. RBs, TEs, and LBs averaged 619, QBs 467, and WRs, CBs, and S averaged 372. These results are useful in combination with a recent study by Boston University showing lineman had the highest incidence of CTE, while receivers had the lowest incidence of CTE upon autopsy.

Concussions are a hot button topic and will continue to be as the NFL becomes more entangled in its lawsuit from former players. I hope that this helped you all understand a few facts about concussion and helps health care providers give improved care when dealing with these serious injuries.

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