Designing a Comprehensive Sideline Concussion Evaluation

Many people, including fellow medical/healthcare professionals or parents are not familiar with what an Athletic Trainer is or what we in the profession do. I cannot begin to tell you how many times I have had to give my elevator speech to someone to explain how we are not personal trainers, but actually licensed healthcare professionals that work on injury prevention, injury management, and rehabilitation of injury! Which I think is sort of comprehensive when it comes to a job description for an AT. But, even though we are moving to a Professional-level degree with the Masters it does not change the over all view of our abilities. Fortunately, there is research backing up our capabilities in healthcare professions to effectively and properly diagnose. Lombardi et al (2016) published a study that found over the window of 2010 to 2015 across 5 regional high schools that the Athletic Trainer’s and Physician’s (MD or DO) diagnosis were the same 92% of the time! That’s right, a Bachelors educated healthcare professional’s prognosis was the same as an MD’s or DO’s 92% of the time, and when it wasn’t it was a mismatch between sprain and fracture (cool, I do not know a single AT that has an MRI or Radiograph on the sideline, so I will take that small loss).

Thus, it is safe to say that Athletic Trainers are spot on when it comes to concussion diagnosis. But, this brings us to discussing how then can an AT best design their sideline assessment to accurately capture a concussion diagnosis and potentially save lives… After all, according to the 5th International Consensus Statement on Sports Related Concussions (2017):

“SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. (McCroy et al, 2017)”

Creating the perfect, timely, and most comprehensive sideline assessment of concussions is not easy, by any means. As we are beginning to learn, no single test is perfect and no single test should be used alone to establish a patient’s/athlete’s concussion diagnosis (McCroy et al, 2017; Broglio et al, 2014). Thus, the Athletic Trainer must develop a battery of tests that can be confidently and quickly administered to established the patient’s status on the sideline. After a good deal of review of the items out there, here is what I have come up with and implemented at my clinical setting:

Let’s set the stage with the AT is covering a football game when they see one of the Student-Athletes experience one of the multiple mechanism of injuries (MOIs) consistent with concussion, even better allow me to describe a likely one: The Wide Receiver takes off the line a clears his defender. He gets open about 20 yards off the line and the quarterback launches the football to him. The ball is a little high so he leaps into the air to catch the ball with his upper torso rotated to align with the catch. He receives the ball in the air with his eyes back where the ball was coming from. He does not see the opposing team’s Free Safety coming in who makes the hit before the Wide Receiver makes it back to the ground. The Wide Receiver hits the ground with his shoulders then helmeted-head and does not get up. Or any of these real-life examples:

With this scene set, we have a few of the rotational-translations to the skull MOIs occurring, once on the initial hit to the Wide Receiver, another occurs when his head hits the field and there is potential of a third on rebound. Moral of the story, that is a solid MOI for concussion.

So here goes the sideline eval:

The Athletic Trainer does the AT-Jog out to the patient who is still on the ground and establishes consciousness (Glascow Coma Scale or GCS) and cognitive awareness with some light history questions.

1. Check the patient’s neck in accordance with the SCAT5 procedures in order to rule out any fractures.
2. Ask the patient if they have any numbness or tingling into the hands or feet, ask them to move them if possible in order to rule out neurological damage.
3. At this point if there are no concerns we can move them to the sideline, if there are concerns then we are activating EMS/EAPs respectively.
4. On the Sideline the AT would start by taking vitals for Heart Rate, PulseOx, BP, etc. This will be important for serial testing to know if the patient is getting worse or circling the drain as it were.
5. Once vitals are done, its time for Post Concussion Symptom Scores (PCSS) and Maddox Questions. These are part of the SCAT5 and can be used to established symptom sets.
   1.  If they have no symptoms at this time, then the patient would be exertionally tested for a few minutes to see if the symptoms return. This could include burpees, sprints, change of direction, and other drills that should elicit symptoms in a potentially concussed patient.
      1. If this elicits symptoms they will continue to the sideline battery assessment.
      2. If they have no symptoms after exertional testing, then they are returned to play with no diagnosis of concussion.
   2. If they do have symptoms then we continue along to our sideline battery
6. The sideline battery consists of a Cranial Nerve Assessment to rule out more serious injuries, the remainder of the On-Field SCAT5, and the VOMS Screening.
   1. At my institution, VOMS was chosen over the King-Devick Test only because of the cost associated to the King-Devick Test, in my own personal opinion I must stress that I believe the K-D Test to be very strong and much faster than VOMS, it also produces more objective data than VOMS that can be used to justify diagnosis of concussion.
7. If the patient is no longer demonstrating ANY symptoms or deficits in assessments, they will be exertionally tested as before, if they pass exertional testing without symptoms then they will be returned to play with no diagnosis of concussion.
8. If the patient fails any of the evaluations or the AT feels there is something not right, then they will be moved to Off-Field assessments and serial tested for potential degradation of status.

I personally believe this is an ideal and comprehensive sideline evaluation for concussion. Due to the fact that some sports have limited injury time and the nature of game play, it is important for ATs to be both timely and comprehensive in their evaluation of a patient for concussion. No matter what, the AT should feel confident in their sideline assessment and practicing the routine will always help in making it flow easy and timely.

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Lombardi, N.J., Tucker, B., Freedman, K.B., Austin, L.S., Eck, B., Pepe, M., and Tjoumakaris, F.P. (2016). Accuracy of athletic trainer and physician diagnosis in sports medicine. Orthopedics, 39(5), e944-e949.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

Subtle Difference Between Head-Up and Head-Down Tackling

Allow me to set the scene, I have been working Collegiate Football for a bit now and the other morning, before the sun had risen, I was covering a practice. There I was with my water bottles watching the Defense work on a tackling drill, and I was amazed how subtle a difference it is between the ideal head-up and the horrible head-down tackling style.

The importance of the drill is vital. A head-down tackle, or spear tackling by its more common moniker, lines up everything perfectly for a world of pain and hurt for the athlete and is the leading reason why the sport of Football experienced a major change in tackling rules in 1976 (Heck et al, 2004).  The following excerpt is from the 2004 Position Statement by the National Athletic Trainers’ Association addressing the issue with Head-Down Tackling:

“Axial loading of the cervical spine resulting from head-down contact is the primary cause of spinal cord injuries. Keeping the head up and initiating contact with the shoulder or chest decreases the risk of these injuries.”

But think about the popularity being built around spear tackling through things such as professional wrestling:

Or, what about spear tackling in Rugby?

Well, that also lends itself to the discussion on the issue in American Football. In previous blogs we have discussed just how wearing equipment can give an athlete a false sense of security against injury and how those athletes then tend to adopt dangerous behaviors that predispose them to catastrophic injury. American Football, unlike Rugby or Professional Wrestling, uses equipment designed to prevent the skull and other portions of the body from being damaged. However, the equipment does not and cannot prevent the axial load from a spear style tackle being transmitted down through the spine and leading to many horrible outcomes, such as quadriplegia (Heck, 2004).

One of the major issues brought to light in the 2004 position statement on tackling was that many officials were not enforcing the rule that had gone into effect in 1976. I know your probably thinking to yourself, this research article came out in 2004 and it is now 2017… working on 2018 for that matter. There is no way this is still an issue in the sport. Well, according to College Sports Scholarship (2017), there was a study conducted by Tulane University and the Louisiana Office of Public Health found some shocking results…

“600 football players from 16 southeastern Louisiana high schools and found that 29 percent thought that using the top of their helmets to tackle was legal, 32 percent thought head-butting an opponent was legal and 35 percent thought it was permissible to barrel over an opponent headfirst.”

You would think that a rule created in 1976 for the sport to prevent major injuries would be a little better well known to the athletes playing the game. Oh, but wait… Maybe that is just the athletes, we all know not all athletes know all the rules… Sadly, there is more, the study also addressed the coaches, and here is what they found:

“Of the coaches at those 16 schools, only two said they’d shown a blocking and tackling safety video distributed free by the Louisiana High School Athletic Association, three refused comment, five said they hadn’t had time to show it and six believed showing the tape to their players would curb their aggressiveness.”

That’s right, potentially life-saving sport techniques that have been proven to keep athletes safe and in the game couldn’t be instructed due to a lack of ‘time’ and the fear that it would curb their aggressiveness… 

The moral of the story here is that proper technique is vital! Coaches play an important role in teaching proper technique and helping us, as Athletic Trainers, by not letting their athletes conduct dangerous styles of play.

Let me make this statement here, this is not an attack on coaches, but it needs to be said. No coach should ever use an excuse of a lack of time or a fear of curbing the athletes aggressiveness when it comes to the safety of their athletes. If you are a parent, an athlete, or a healthcare practitioner that deals with student athletes, the question should be posed to the coaching staff. If you are a coach you should put in the due diligence to help keep your athlete in the fight and playing the game! After all, the difference may be subtle, but it is an important one!

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References:

College Sports Scholarships. (2017). Spearing in football. Retrieved from http://www.collegesportsscholarships.com/football-spearing.htm.

Heck, J.F., Clarke, K.S., Peterson, T.R., Torg, J.S., and Weis, M.P. (2004). National athletic trainers’ association position statement: Head-down contact and spearing in tackle football. Journal of Athletic Training, 39(1), 101-111.

 

Does Youth Football Need Tackling?

BLUF: All concussion cannot be prevented, the most effective reduction measure would be to remove tackling from Youth Football until the age of 16, but that would bring about a good deal of social pressure.

Let me preface this article with stating that I want to preserve the integrity of the sport in all of its athleticism and visual appeal. So, bear with me here… Don’t just read the title of this blog post and never come back, because it is my intent to present to you a few different sides of the story, with that ammunition in hand you can come to your own conclusion on tackling in youth football. 

If all youth football tackles looked as textbook as this one ———————–> Then, many of the problems we are about to discuss would not be a major concern. This kid is looking where the the tackle is going to be made and does not use the head as a weapon.

Unfortunately, we end up seeing a few more tackles like this… It’s just brutal to watch.

It is estimated that there are approximately 3,000,000 youth players of football, this number simultaneously dwarfs and puts to shame the 2,000 professional football athletes, 100,000 collegiate football athletes, and of course the 1,300,000 high school football athletes (Kontos et al, 2013). Of the 23,000 annual Emergency Department football related non-fatal TBIs, 90% occur in the adolescent (youth) ages of 5-18 years (Syd & Johnson, 2012). Arguably, the biggest point to discuss is that multiple researchers have found youth athletes with histories of concussion have presented with lingering neurological and cognitive deficits for up to 3 years (Syd & Johnson, 2012)… that’s 36 months, 156 weeks, or 1,095 days.

Many discussion have come down the line to help with what the CDC has labelled as an epidemic of concussion (Kontos et al, 2013). Some of these concepts scientists and researchers have included the dreaded and debated removal of tackling, hit counts for athletes, rotating specialty players, rule changes on starting positions, season length concerns, and a slew of other potential fixes (Syd & Johnson, 2012).  But, why are these considerations of such importance in this population? Let’s dive in a little deeper to the developing brain of the youth athlete and see what research has found…

According to Kontos et al (2013) post concussion, youth athletes demonstrate far worse outcomes then other populations. Referring back to Syd and Johnson (2012), concussions are traumatic disruptions of the brain’s physiology and that children can experience deficits in cognitive function for up to 3 years! They pose this to be due to neuromaturation processes being disturbed due to the injury. We are all ready well versed from previous topics that this same population is in danger of Second Impact Syndrome, and some researchers have even found CTE in a 20 year old’s brain post-mortem  with no history of concussion, just sub-concussive impacts… That’s serious. 

Another point for risk factors in this population that is brought up is the developing brain of the youth athlete. We know that kiddoes grow 2-4 inches per year in puberty, this can lead to under developed muscles that frame and support the spine, neck, and head, the immature nature of the myelin sheaths of both the CNS and PNS can effect nerve transmissions, cranial bones are less protective, and the body is still acquiring cognitive and physical skills (Norton et al, 2013). In this state of development, it is clear that any damage to the brain’s physiology could potentially arrest development down the line, this makes the 3 year cognitive deficits make a little more sense, though sad.

The question becomes, how do we make the sport safe for our kiddoes (youth athletes) yet maintain the integrity of the sport for what it is? Can we truly remove tackling from the sport? Syd and Johnson (2012) suggested that due to the major differences in athlete size up until the age of 16 (see picture below for reference), and considering only 6% of American Football players will go on to play Collegiate ball while only 0.08% will ever make it to pro-level, that we could tentatively remove tackling from youth football. They suggest teaching the skills and drills of tackling sub-16 years old, gradually bringing them to full contact football. This would fall in-line with current best practices recommended by the American Academy of Pediatrics recommendations for ice hockey and body checking. But, would making this change be received well?

I highly doubt it!  I can just feel the mob coming now…

So, what do we do that can make the sport safe but still receive social support for the changes? Syd and Johnson’s (2012) suggestion to remove tackling from youth football was not their only recommendation and they acknowledged that making the posed change would not receive great support.

They also posed other rule changes such as decreasing season games, as most injuries occurred in game and not practice. The reinforcing of head’s up tackling drills in practice in order to build the baseline of skills for tackling was also mentioned. Not permitting the athletes to start in the 3 point stance, rather having them up in the 2 point stance to prevent head-down (spear) tackling, was also mentioned, and of course the ever elusive ‘hit-count’ concept. We use a pitch count on pitchers at all levels for their well being and longevity, why can’t we adapt this to a hit count concept for players?

Could these adaptations be more socially well received? I find this to be far more likely than removing tackling all together. I do think that limiting live-action practice/games for youth will be vital and using these times to expand on proper form to ensure the heads up tackling method is always used will better prepare our youth athletes for moving on to high school athletics, then to collegiate, and if they are lucky… pro ball!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Kontos, A.P., Elbin, R.J., Fazio-Sumrock, V.C., Burkhart, S., Swindell, H., Maroon, J., & Collins, M.W. (2013). Incidence of sports-related concussions among youth football players aged 8-12 years. The Journal of Pediatrics, 163, 717-720.

Norton, C., Feltz, S.J., Brocker, A., & Granitto, M. (2013). Tackling long-term consequences of concussion. Nursing, 50-55.

Syd, L., & Johnson, M. (2012). Return to play guidelines cannot solve the football-related concussion problem. Journal of School Health, 82(4), 180-185.

Helmets Vs Concussion

Bottom Line Up Front (BLUF): Helmets don’t stop concussion!

Working in a Sports Medicine Department for a collegiate athletics program and being a Soldier in the United States Army and Florida Army National Guard, I cannot begin to tell you how many times I have heard an athlete, coach, parent, Soldier, etc. make a statement along the lines of, “My helmet will keep me safe from concussion.” 

The sad part here, is that this bit of misinformation could be lethal…

The National Athletic Trainers’ Association, in their Position Statement on Concussions (2014), has began pushing for Athletic Trainers to support the use of certified helmets. The go-to in the field now is the National Operating Committee on Standards for Athletic Equipment, or NOCSAE, and according to them:

“Serious brain and neck injuries leading to death, permanent brain damage or quadriplegia (extensive paralysis from injury to the spinal cord at the neck level) occur in football. The toll is relatively small but persistent, averaging 1.44 fatal or severe, nonfatal brain or spinal cord injuries annually for every 100,000 players. HELMETS DO NOT PROTECT THE NECK, and none of these injuries can be completely prevented due to the tremendous forces occasionally encountered in football collisions; but they can be minimized by manufacturer, coach and player compliance with published rules of play, proper coaching, and in the case of head and brain injuries, compliance with accepted equipment standards.”

It is safe to take this quote to the bank! NOCSAE takes on certifying athletic headgear for various sports in its ability to protect from skull fracture or other dangers to the external portions of the head, it has no chance of protecting the brain against any of the proposed mechanisms of injury that have been known to cause concussion, the coup-contrecoup, axonal torsion, concussive blast, or even non/sub-concussive cumulative impacts. No matter how much padding you put around the head it wont stop a concussion!

So, where does this lead us? The 5th International Consensus Statement on Sports Related Concussions, held in Berlin (2017), addressed the use of protective equipment in an attempt to stop concussion. When it came to helmets, here is what they had to say:

“The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in many sports because of the nature of mandatory helmet regulations.”

Further, compare this to the National Athletic Trainers Association’s Position Statement on Concussion, and here are their thoughts on helmets:

“…although such helmets help to prevent catastrophic head injuries (eg, skull fractures), they do not significantly reduce the risk of concussions”

Looking at two predominant official statements by major players in concussion research and seeing what they think, It seems clear that super-sizing helmets or the wear of any headgear will not truly stop the frequency of concussions!

Another major concern, is that research suggests that athletes wearing protective headgear may have a false sense of security against injury or even be more prone to use their head as a weapon, a dangerous thing in sport that can put them in danger of far worse injury than a concussion (Swartz et al, 2015). Swartz’s research posed a training concept for tackling in practice only without headgear on, they designed a process of slowly increasing intensity from static training through walking to tackle, to full speed once ready, and their research showed great potential in decreasing head-down tackling in football athletes! The group with the helmet-less tackling training decreased their head impacts by 30%.

Knowing this information, we may start to ask, “Well, if helmets don’t protect against concussions, then why does my son/daughter need to wear one?” That is a valid question, but we must always remember that while helmets don’t protect against concussions, they do keep our children and Warfighters safer from skull fractures!

In the end, helmets are a necessary evil. They may not prevent or reduce concussions, but they do help in decreasing skull fractures and lacerations. It takes proper training in tackling form, concussion education, rule enforcement, and good sportsmanship to limit the rate of concussions. Remember tackle with your head up!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

National Operating Committee on Standards for Athletic Equipment [NOCSAE]. (2011). Statement of shared responsibility. Retrieved from http://nocsae.org/nocsae-standard/statement-on-shared-responsibilities/.

Swartz, E.E., Broglio, S.P., Cook, S.B., Cantu, R.C., Ferrara, M.S., Guskiewicz, K.M., and Myers, J.L. (2015). Early results of a helmetless-tackling intervention to decrease head impacts in football players. Journal of Athletic Training, 50 (12), 1219-1222.

The Q-Collar for Concussion Reduction

BLUF (Bottom Line Up Front): Concussion is an internal problem, not external.

Annual speaking, Sports Related Concussion, or SRC, occurrence rated are approaching endemic levels. With an estimated range of 1.6-3.8 million per year (Broglio et al, 2014) occurring in sport and 300,000 annual visits to the Emergency Department according to the CDC (1997), many researchers and clinicians have started looking at various preventative measures. Let me assure you there are some pretty wild concepts of Concussion Prevention being discussed and not all is legitimately supported by valid, unbiased, and peer-reviewed research. 

The first approach most people think about addresses that often a concussion occurs from a blunt force trauma to the head (though there are other mechanisms of injury for concussion this is the most commonly known). Along this lines of thinking many of the concussion prevention products addressed are typically based on padding the head. An example is an air bag system developed for cyclists that deploys when a fall is sensed by the system.

Another external fix for the concussion endemic is the Full 90 Soccer Headgear. The link leads to YouTube where there is a video of an NBC News on the Full 90 headgear for Soccer. The designer posed the idea and claims that it will decrease concussions by something like 50%… Dr. Cantu (we will cal him the man when it comes to Concussion research), tears the product to pieces. Aside from Dr. Cantu’s expert opinion, just listen to the video and it is ripe with inconsistency on the product preventing concussion. The video highlights  Natasha Helmick, a women’s soccer player that played on the Olympic Development Team before being forced to quit the sport from a high frequency of concussions (5 after starting to wear the Full 90). Worse off… she had to drop out of college due to the long-term effects of her extensive concussion history.

But, why doesn’t this idea of throwing on padding to the head stop or decrease concussions? As I mentioned in the BLUF, concussion are an internal problem, they are caused when the brain either rotates and causes axonal torsion or from a coup-contra coup impact against the inside of the skull. The brain is not snuggly fit in the skull, there is room to move.

 

But, if external padding doesn’t work… then what will? Well, I mentioned in the BLUF once again that concussions are an internal problem. While we cannot go in and screw down the brain we can work externally to address the internal problem. In-fact, Q30 Technology, has developed just such a promising product, the Q-Collar. According to Myer et al (2016), the inspiration for this product came with the realization that there are less concussions occurring at higher altitudes.

“We postulated that acclimatisation to altitude may have influenced an
increased intracranial blood volume, resulting in a tighter fit of the brain within the cranium. The proposed physiological response to decreased relative ambient oxygen (thus increasing intracranial flow and volume) was speculated to have protected the athletes at higher elevations against sports-related TBI. “

The product mimics these natural outcomes by placing pressure over the jugular vein, not the artery, thereby increasing the density and viscosity of the fluids protecting the brain. The effects are less sloshing of the brain back-and-forth during impacts. This is an awesome idea when looking at the levels of G-forces experienced in sport during impacts. According to Broglio et al (2011), over an 8 year period of 4 years of starting high school football and 4 years starting college football, a player is expected to have over 8,000 head impacts, with a mean g-force of 20.9g-22.25g and a cumulative of 183,834g assaulting the brain. That’s a LOT of Gs!!!

The Q-Collar address this concern, and the research by Myer et al (2016) stated that thy found promising outcomes in animal models:

“This approach demonstrated an 83% reduction in amyloid precursor protein positive axons—a widely accepted biomarker of TBI— during a 900 g impact protocol studied in animals.”

When conducted on human models, the study found positive outcomes to decreasing these cumulative loads being placed on the brain. After an intervention of the Q-Collar being placed on 32 athlete for a season of game play, they found that the intervention group of 32 (Q-Collar Football Players), had significantly less brain diffusivity (a marker of brain injury) than the control group (30 Football Players without Q-Collar), this was found to be rather accurate with statistical measurements. They concluded that the Q-Collar may help decrease potential for injury to the brain!

Right now, you cannot get your athlete or self a Q-Collar, they are still in the research phase and have not moved to mass sales and distributions, but go check out their pages to stay abreast in their outcomes: Facebook , LinkedIn, and Website.

Here is a key take-away though, concussion cannot be prevented! What we can work on is reduction of occurrence of the injury through proper concussion education, form training, rule enforcement, rule change to protect the athletes, training on peripheral vision, and items such as the Q-Collar. Internal interventions to internal problems!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Broglio, S.P., Eckner, J.T., Martini, D., Sosnoff, J.J., Kutcher, J.S., & Randolph, C. (2011). Cumulative head impact burden in high school football. Journal of Neurotrauma, 28(10), 2069-2078.

Kelly, J. (1997). Sports-related recurrent brain injuries — United States. CDC Morbidity and Mortality Weekly Report, 46(10), 224-227. Accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/00046702.htm

Myer, G.D., Yuan, W., Foss, K. D. B., Thomas, S., Smith, D., Leach, J., Kiefer, A.W., Chris, …, & Altaye, M. (2016). Analysis of head impact exposure and brain microstructure response in a season-long application of a jugular vein compression collar: a prospective, neuroimaging investigation in American football. British Journal of Sports Medicine, 0, 1-11.

Concussions and the Classroom

The uniqueness of the brain, its developmental process, and its functions are not lost on healthcare providers when it comes to concussion. Concussions are defined as a traumatic brain injury (TBI) which impair neurological and cognitive (mental) functions (McCroy et al, 2017). Youth-athletes that sustain a concussion have been a recent area of focus in concussion research due to the nature of the developing brain at those ages and the unknown long-term consequences that could be associated to sustaining a brain injury at that young age (McAbee, 2015).

Traditional treatment options for concussed student-athletes asked for a 24-48 hour rest period to allow for symptoms to lessen then once the patient had returned to their baseline on neurocognitive tests (ImPACT, ANAM, CRI, etc.) they could initiate a graduated return-to-play (RTP) protocol that over six steps slowly exposed the patient to increasing levels of physical stress to see if symptoms could be elicited to qualify the patient to be fully returned to activity.

However, more recent research has looked at the importance of slowly re-integrating the patient into the classroom. As an example of this, Halstead et al (2013), as part of the American Academy of Neurology, suggested that premature return to the classroom for a concussed student could present with major cognitive difficulties including learning new tasks or remembering old tasks. This is of major concern for any student-athlete or parent of a student-athlete as there is potential for decline in GPA associated to these issues. Decline of GPA can affect acceptance to college/university for a high school student, potentially throw off SAT/ACT scores, and have the ability to disqualify a student for potential grants and scholarships!  For the collegiate student-athlete, a decline in grades and GPA could affect their eligibility to play, standings on the team, and both athletics and academic scholarships. All of these potentially affect the long-term goals of student.

This concern for the student-athlete has become such a major issue in the field that for the first time in 20 years of international consensus statements being published, the fifth consensus statement in Berlin published an example Return-to-School graduated protocol (McCroy et al, 2017). This example protocol, shows potential academic accommodations that can be given to a student-athlete to facilitate the best possible environment for their recovery and long-term health and well-being. However, each concussion is unique, in-fact, research in 2014 suggested that there are actually six different clinical trajectories, of which each have different academic accommodation needs specific to the trajectory (Collins et al, 2014).

I know you may be thinking, “What about 504 Accommodations?” Well, TBI is one of the 13 qualified disabilities for an official 504 academic accommodation to be set into motion. The issue surrounding this is that the symptoms associated to a concussion typically subside after 7-10 days (McCroy et al, 2017), and due to state-variance in the 504 process the student-athlete may already be recovered by the time the official 504 is put into effect to protect their recovery needs. Further, collegiate student-athletes do not fall under the 504 or IEP process, these student-athletes have a separate process at the institution of learning.

Where do we go from here? In the case of the process taking far too long to be beneficial for the student-athlete’s recovery, there can be developed a local policy to abbreviate the process or establish a collegiate level process unique to the student-athletes. Administrators can work together to establish a plan of action, if your high school, college, university, or academy has an Athletic Trainer then they should be involved in the process, along with a Team Physician, Neurologist, Pediatrician, Guidance Counselor, Academic Advisor, School Nurse, Teachers/Professors, intervention specialist, etc. All of these stakeholders can bring a unique approach/intervention to the care of the concussed student-athlete and pre-establishing this group can lead to an effective abbreviated process.

From the Athletic Trainer’s perspective implementation should look like this:

1. Concussion Diagnosis
2. 24-48 Hours of Cognitive and Physical Rest
3. Notify Team of Concussion Players
4. Implement Academic Accommodations
5. Daily Symptom Checks
6. Full Return to School/Learning/Academics
7. Baseline on Computerized Neurocognitive Test
8. Initiate Return to Play Protocol
9. Return Athlete to Sport

As can be seen, the student-athlete must complete their academic accommodations and be fully returned to school prior to initiating the graduated Return to Play Protocol. This is important as the use of academic accommodations should be seen as the patient still being technically symptomatic for concussion. Overall, we must put in the due diligence to take care of this vulnerable population. The research still is unsure of what potential long term effects could come with a history of concussion, particularly when referencing the youth-athlete population. It’s always better to play it safe then to risk the health and well-being of the student-athlete!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

 

References

Collins, M.W., Kontos, A.P., reynolds, E., Murawski, C.D., & Fu, H.H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 22 (2), 235-246.

Halstead, M.E., McAvoy, K., Devore, C.D., Carl, R., Lee, M., & Logan, K. (2013). Returning to learn following a concussion. Pediatrics, 132(5), 948-957.

McAbee, G.N. (2015). Pediatric concussion, cognitive rest and position statements, practice parameters, and clinical practice guidelines. Journal of Child Neurology, 30(10), 1378-1380.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

 

Eenie, Meenie, Miney, Tau

Mike Webster, a celebrated Hall of Fame center for the Pittsburg Steelers, played in 245 NFL games, including his time with the Kansas City Chiefs, and was hit in the head thousands of times. “Iron Mike” died 24 September 2002 at the age of 50. Dr. Bennet Omalu, a neuropathologist, was assigned to perform the autopsy on the body and the brain. Omalu made a groundbreaking discovery, seeing something in Webster’s brain that had never been found in a football player’s brain before and should never have been present in the brain of a 50-year-old man (Breslow, 2013; Concussion Legacy Foundation [CLF], 2017).

 

"When you're faced with a tough opponent who plays dirty and takes cheap shots, buckle on an extra chinstrap and hit him in the snot locker every play until he quits." Mike Webster (PRNewsFoto/Posse Films, LLC.)

 

If you’ve read at all about concussions you’ve probably come across the term Chronic Traumatic Encephalopathy (CTE). CTE is a progressive degenerative disease of the brain found in athletes, military veterans, and others with a history of repetitive brain trauma. The repetitive brain trauma causes a buildup of a protein called tau.  The aggregation of tau is toxic, slowly killing cells of the brain, as also seen in Alzheimer’s disease (CLF, 2017; Lerner, 2016; Mandelkow & Mandelkow, 2012).

The tau protein in itself is not inherently dangerous. Tau is a protein in the brain which helps stabilize brain cell structure and internal transport system (CLF, 2017; Lerner, 2016). Tau links microtubules that run through axons of the brain, two tau proteins in each link; the heads of the tau proteins are each bound to a microtubule, and the tau tails meet in the middle and are bound together, but this bound isn’t permanent (Lerner, 2016). Because of its hydrophilic nature tau does not adopt the typical compact, folded structure of most proteins. Instead, it is “natively unfolded” and “intrinsically disordered”, meaning its highly flexible and mobile, kind of like pipe cleaners you use in arts and crafts  (Mandelkow & Mandelkow, 2012). Motion within the brain easily detaches the tail ends of the tau protein and causes them to reattach to a new tau protein tail. This binding and unbinding allow for easy sliding between microtubules without damage (Lerner, 2016).

However, repeated injury to the brain causes neurons to stretch and tear.  Rapid jolts in concussive episodes do not allow the bound portions of tau tails to untangle and bond with a new tau partner. High-velocity forces of a concussion do not allow to tail ends of the tau proteins to unbind and the forces are exerted on the microtubules instead, causing damage (Lerner, 2016). The tau protein then changes its shape, clumps together with another tau, and spreads while slowly killing neurons. In CTE, clumps of tau tend to first appear around blood vessels within the brain sulci (valleys between brain cortical folds), and then spreads to other areas of the brain (CLF, 2017).

 

The danger of chronic brain injury is the guaranteed risk for memory loss, confusion, impaired judgment, paranoia, impulse control problems, aggression, depression, and eventually progressive dementia (CLF, 2017).

A study by Shahim et al. (2014) looked at blood biomarkers after a concussion in professional ice hockey players and found that the highest concentrations of total tau were measured immediately after injury, tau levels declined after the first 12 hours, and a second peak of tau levels occurred between 12-36 hours post-injury. Most importantly, tau levels 1 hour post-concussion concussion predicted the number of days it took for the concussion symptoms to resolve and the players to have safe return to play. This suggests that total tau levels may potentially be a way to monitor recovery in patients with brain injury (Shahim et al., 2014)Since diagnostic imaging is not able to help health care professionals predict concussion outcomes and recovery, perhaps these findings with help pave the way for more efficient, more informed, and

Since diagnostic imaging is not able to help health care professionals predict concussion outcomes and recovery, perhaps these findings with help pave the way for more efficient, more informed, and better-monitored recovery and return to play.

 

Author: Alyssa Reidy, LAT, ATC, CCTP

References

Breslow, J. (2013). The Autopsy That Changed Football. [online] FRONTLINE. Available at: http://www.pbs.org/wgbh/frontline/article/the-autopsy-that-changed-football/

Concussion Legacy Foundation [CLF] (2017). What is CTE?. [online] Concussion Legacy Foundation. Available at: https://concussionfoundation.org/learning-center/what-is-cte

Lerner, E. (2016). Penn study determines breakaway protein is critical in concussions. [online] Penncurrent.upenn.edu. Available at: https://penncurrent.upenn.edu/2016-01-14/latest-news/penn-study-determines-breakaway-protein-critical-concussions

Mandelkow, E. and Mandelkow, E. (2012). Biochemistry and Cell Biology of Tau Protein in Neurofibrillary Degeneration. Cold Spring Harbor Perspectives in Medicine, 2(7), p.a006247

Shahim, P., Tegner, Y., Wilson, D., Randall, J., Skillbäck, T., Pazooki, D., Kallberg, B., Blennow, K. and Zetterberg, H. (2014). Blood Biomarkers for Brain Injury in Concussed Professional Ice Hockey Players. JAMA Neurology, 71(6), p.684

 

 

The Blue Light Spectrum Concussion

How many times have you stared at your cell phone screen since waking up this morning? How long will you look at after getting in bed tonight?

 

Patients with concussion present with varying symptoms: headaches, dizziness, and vertigo, amnesia, depression, irritability, word-finding difficulty, impulsiveness, difficulty sleeping, difficulty concentrating, sound sensitivity and visual symptoms. These visual symptoms might include photosensitivity and photophobia, wherein “photo-” equates to light. Photophobia translates to “fear of light”, but it is actually a neurological condition affecting how the light receptors in the eye transmit information to the brain. Generally, it refers to exposure to light that exacerbates pain (Digre & Brennan, 2012). Light and sound tolerance decrease in patients with head injuries compared to control subjects (Magone et al., 2013). Light sensitivity after a concussion in the absence of ocular inflammation is a common complaint and effects 40-50% of patients with brain injury.

The increased sensitivity to light occurs in the subacute period (7-21 days) after a head injury, and although most patients/athletes report improved symptoms after 6 months, patients/athletes with post-concussive syndrome continue to report increased photosensitivity (Digre & Brennan, 2012). Research suggests the cause is cortical and subcortical lack of inhibitory control (Magone et al, 2013), as also seen in other brain disorders, such as migraines and epilepsy. These abnormal responses may include non-uniform cortical excitability and cortical hyper-responsiveness, which may interfere with visual perception to cause photophobia. A study of patients using resting state functional magnetic resonance imaging (fMRI) in patients with closed head injuries showed a cluster of increased functional connectivity in the right frontoparietal lobe as compared to and a matched control group (Shumskaya et al., 2012). This increased activity may cause increased awareness of one’s external environment resulting in cognitive fatigue with headache and increased sensitivity to light and sound. Digre and Brennan (2012) provide a more extensive description of the pathophysiology of photophobia. I have included the link below for your reading pleasure.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485070/

Computer Vision Syndrome occurs in 75% of computer workers who view a video display for 6-9 hours per day. Ocular complaints include eye fatigue, burning, redness, blurred vision, and dry eyes, as well as non-ocular symptoms (headache, neck/shoulder pain)(Loh & Redd, 2008; Lynch et al., 2015). Viewing a digital screen is different that reading printed material; the letters on a screen are not as sharply defined, contrast of letters to the background is reduced, and glare and reflection on the screen making it difficult to read, forcing increased visual demand by the reader (AOA, 217; Loh & Redd, 2008).The normal human blink rate of 10-15 times per minute is significantly reduced while using digital screens, causing poor tear film quality, stressing the cornea. Prolonged use of a digital screen (i.e. computers, cell phones, television, tablets, e-readers, etc.) causes transient deviation of phoria (visual alignment), transient myopia (nearsightedness), and diminished accommodation to changing visual stimuli (Loh & Redd, 2008; Lynch et al., 2015).

Digital screens emanate a lot of low wavelength light, what the science world would call blue light. The eyes’ exposure to blue light suppresses the body’s ability to produce melatonin, the hormone produced by the pineal gland when light receptors in the eye detect darkness, helping to regulate the body’s circadian rhythm and make you fall asleep. Ergo, people who are glued to their digital screens, especially in the evening when the body should begin melatonin production, delay this mechanism or even prevent the body from making melatonin the entire night.

Recent research supporting the use of bright light therapy in the morning to help improve sleep, cognition, emotion and brain function in patients with concussion (Stone, 2013).

Add all of that to concussion symptoms and an athlete/patient is guaranteed to hinder the healing process and delay their return to play/work.

Now, in a world that runs on screen time, it’s not realistic to completely cut out all electronics from our daily routines. What we as health care professionals can do it educate our athletes/patients and their parents/guardians on how to modify. First and foremost, limit screen time. The American Optometric Association recommends following the 20-20-20 rule for people without concussions; take a 20-second break to view something 20 feet away every 20 minutes (AOA, 2017).

 

Again, it’s not realistic to micromanage one’s screen time when it’s dark outside, but we’re fortunate enough to live in a time where blue light is able to be eliminated without turning off our screens. Software engineers have created a plethora of apps and settings on our devices that automatically eliminate blue light from our devices at a set time, usually sunset, or a specified time set by the user. Below are just a few of many device applications that can be downloaded to help the concussed patient manage their light exposure.

 

F.Lux (I personally use this for my computer) – this app reduces blue light after the sun sets in your specific location https://justgetflux.com/

 

Twilight – for Android users, this app is similar to f.lux, although it doesn’t have a particular blue light filter, you can control the color temperature and intensity https://play.google.com/store/apps/details?id=com.urbandroid.lux&hl=en

Midnight– you control the black, yellow, blue and red light, you can schedule to start and stop time of the filter, but it doesn’t automatically change based on your location’s sunrise/sunset. However, it can determine ambient light and dims the screen in dark environments.

This list is not exhaustive, all anyone needs is an internet search engine to compare and contrast apps.

 

Author: Alyssa Reidy, LAT, ATC, CCTP

 

 

References

American Optometric Association. (2017). Computer Vision Syndrome. Aoa.org. Retrieved 17 June 2017, from https://www.aoa.org/patients-and-public/caring-for-your-vision/protecting-your-vision/computer-vision-syndrome?sso=y

Digre, K., & Brennan, K. (2012). Shedding Light on Photophobia. Journal Of Neuro-Ophthalmology, 32(1), 68-81. http://dx.doi.org/10.1097/wno.0b013e3182474548

Greenbaum, D. (2017). 5 Best Android Apps that Reduce Eye Strain for Night Reading. Guidingtech.com. Retrieved 17 June 2017, from http://www.guidingtech.com/60491/best-android-night-filters/

Loh, K., & Redd, S. (2008). Understanding and Preventing Computer Vision Syndrome. Malays Fam Physician, 3(3), 128-130.

Lynch, J., Anderson, M., Benton, B., & Green, S. (2015). The Gaming of Concussions: A Unique Intervention in Postconcussion Syndrome. Journal Of Athletic Training, 50(3), 270-276. http://dx.doi.org/10.4085/1062-6050-49.3.78

Magone, M., Cockerham, G., & Shin, S. (2013). Visual Dysfunction in Combat-Related Mild Traumatic Brain Injury: A Review. US Ophthalmic Review, 06(01), 48.

Shumskaya E, Andriessen TM, Norris DG, Vos PE. (Jul 2012). Neurology, 10; 79(2):175-82.

Stone, P. (2013). Bright Light Therapy Relieves TBI Sleep Problems. Neurologic Rehabilitation Institute at Brookhaven Hospital. Retrieved 17 June 2017, from http://www.traumaticbraininjury.net/bright-light-therapy-relieves-tbi-sleep-problems/

Madden Football Vs Concussion

In 2006 NBC ran an article citing that Madden NFL ’07 sold 2,000,000 copies in its opening week, they followed up with a stat that said today, as of September 1, 2006, the franchise had sold 53 million copies of the game (Wong, 2006)! Fast forward 10 years and a Fox Business article stated that EA projected, rather conservatively, that there would be 5.5 million copies of Madden NFL ’17 sold in the year (Barrabi, 2016).

Acknowledging those staggering numbers of the population playing the Madden franchise alone, not taking into account NHL, FIFA, or other sports games on the market, it isn’t hard to see how proper portrayal of concussions in these games could assist in concussion education by creating a cultural framework to build upon.

Concussions were not a potential injury in EA’s Madden franchise until the Madden ’12 edition (Good, 2011), which sold 5 million copies on its own (Zox, 2012). With sales estimates around that same 5 million units mark from that point on, we can make an educated guess that ~25 million Madden fans have been exposed to the video game’s portrayal of concussion!

This level of exposure is an amazing step in the right direction for concussion awareness worldwide. To further show that the NFL isn’t the evil creature that they are portrayed to be, Robinson (2014) in a Sports Illustrated article pointed out that while the NFL and EA decided to remove the fan-favorite and famous Madden Ambulance, the NFL also provided EA with accurate frequency data on concussions so they could properly include them for realism, as well as, using proper verbiage like head injury, over “Bell Ringer” or “Ding”.

These steps in the proper use of terminology of head injury, frequency rates of injury, and return to play time frames being passively exposed to the world’s sports ‘gamers’ and youth, are a key concept in establishing a culture of proper education as to what a concussion is and how it should be treated. We already know that there are major concerns in self-reporting of concussions and concussion-like symptoms, estimated that 40% go unreported (Meier, 2014); thus, this passive education could potentially lead to a world where under-reporting numbers of concussions are significantly lower! The game actually has the sportscasters talk about the injury and the evaluation accurately, check out this video of Madden ’15 portraying a concussion for reference.

Madden is not the only sports game franchise to take on proper portrayal of concussions, FIFA and EA’s NHL games have taken this injury into account as well. This ensures a larger population is learning accurately about concussions and the passive culture change is occurring. All of this is wonderful, but it is important to ensure that accuracy is being taken into account and that there is no improper representation of concussion in these efforts. A mistake of that magnitude could spell disaster.

Overall, wonderful efforts are being made by video game organizations along with their represented sport league partners to ensure concussions are being properly acknowledged, portrayed, and treated to the level that they should be. All of these efforts can truly lead to a well-informed population and hopefully a decreased potential for future concussions!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Barrabi, T. (2016). Is ‘Madden NFL 17’ a touchdown for electronic arts?. Fox Business. Retrieved from http://www.foxbusiness.com/features/2016/08/25/is-madden-nfl-17-touchdown-for-electronic-arts.html.

Good, O. (2011). Madden concussions a teachable moment, says EA sports. Retrieved from http://kotaku.com/5787833/madden-concussions-a-teachable-moment-says-ea-sports.

Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S.F. (2014). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, XX, 1-6.

Robinson, J. (2014). It’s Not In the Game: Eight Features the NFL Made EA Sports Remove from “Madden”. Retrieved from https://www.si.com/extra-mustard/2014/03/12/ea-sports-madden-features-nfl-remove.

Wong, M. (2006). Madden video game post record sales: 17-year-old franchise takes in $100 million in first week. NBC News. Retrieved from http://www.nbcnews.com/id/14621205/ns/technology_and_science-games/t/madden-video-game-posts-record-sales/#.WURaAmjyvIU.

Zox. (2012). FIFA & Madden 12 series sales. Retrieved from http://www.vgstrategy.com/2012/02/15/fifa-madden-12-sales-totals/.

Concussions Kill

At this point most of us have seen either Will Smith’s Concussion movie or the PBS Frontline Special League of Denial on Dr. Omalu’s CTE story. However, CTE is not the only aspect of concussion that can kill, Second Impact Syndrome is another killer associated to concussion and is arguably a much bigger concern in our youth-athlete populations.

Second-Impact Syndrome, or SIS, is defined by Stovitz et al (2017) as follows: “Second-impact syndrome refers to a very rare, but usually fatal diffuse cerebral edema as a consequence of a mild head injury. This term is applied typically when an athlete develops diffuse cerebral edema from a second head injury while still symptomatic from a first concussion.’’

Another issue is that, according to the National Academies Committee on Sports-Related Concussions in Youth (2014), even though a patient may report having no concussive symptoms, they can still show cognitive deficits on a computer administered neurocognitive test (ImPACT, CRI, or ANAM as examples) for up to 3 days from the point of being asymptomatic. This means they patient may think they are no longer concussed but in reality, they still have brain damage from the initial injury. As a result of this finding, a patient may attempt potentially dangerous activities that could expose them to SIS and endanger their lives.  This fact stresses the importance of not only being asymptomatic but also being returned to baseline on neurocognitive testing prior to initiating a graduated return-to-play protocol.

With an estimated annual occurrence of concussions between 1.6 and 3.8 million incidents (Broglio et al, 2014), and when further examining only those aged 10-19 approximately 500,000 are referred to various emergency departments for their concussions (Gilchrist et al, 2011), then to top it off we know there is a major issue in underreporting of concussion and concussion-like symptoms in this population (Meier et al, 2014) we begin to see that there are the makings for a very dangerous situation in the youth-athlete population.

Not every concussion merits referral to the emergency department, Broglio et al (2014) suggests that this in only warranted when there are certain red flags present, such as:

1. Decreasing Levels of Consciousness
2. Increasing confusion
3. Increasing irritability
4. Loss of or fluctuating level of consciousness
5. Numbness in the arms or legs
6. Pupils becoming unequal in size
7. Repeated vomiting
8. Seizures
9. Slurred speech or inability to speak
10. Inability to recognize people or places
11. Worsening headache

The real worry exists in the combined concerns of the underreporting of concussions and the population vulnerable to Second-Impact Syndrome a controversial, infrequent, and potentially fatal outcome of mismanagement of concussion. Most patients that suffer from SIS are under the age of 18 (Cox, 2016), and with an estimated underreporting rate of 40% in concussed student-athletes combined with the 60% of athletes estimated to hide symptoms to return to play sooner (Meier et al, 2014) it can be seen how this has the makings for the perfect storm.

SIS has a 50% mortality rate (Stovitz et al, 2017; Cox, 2016; ), that means of the 20 cases that have been discovered and diagnosed that half of them perished(Dessy et al, 2015) , of the 50% that lived many had significant changes in quality of life. Take for example the Preston Plevretes Story. Horror stories, such as Mr. Plevretes experience with SIS, could have been prevented through proper concussion education and management.

I know what you are thinking, “But, how do we prevent this?” or maybe, “How can I make a difference in this?”. Well, it all starts with education and making subtle cultural changes to protect our youth-athletes from SIS. A great start is to stop referring to concussions as “Bell Ringers”, “Getting his/her bell rung”, or “Dings”. Referring to a concussion, which is actually a mild traumatic brain injury (mTBI), in such a manner as a ding or bell ringer down plays the severity of the injury. Combine that misuse of verbiage for a concussion with the glorification of playing through concussion, such as portrayed by NFL athlete Thomas Jones when he stated he felt playing concussed was when he played his best or that he felt in the zone, and you once more have that perfect storm for SIS.

In the end in order to make culture change we need to ensure we get our Student-Athletes/Youth-Athletes Baseline tested on Neurocognitive tests like ImPACT, ANAM, or CRI and ensure they follow the advice of Medical Professionals such as MD/DO/ATs. If we can shape culture change surrounding concussion, then we could likely prevent SIS from taking or affecting any more lives.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Bey, T. & Ostick, B. (2009). Second impact syndrome. Western Journal of Emergency Medicine, 10(1), 6-10.

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Cox, W.A. (2016). Second impact syndrome. Forensic Science Newsletter, September 15, 2016. http://www.forensicjournals.com/blog/wp-content/uploads/2016/09/Second-Impact-Syndrome.pdf.

Dessy, A.M., Rasouli, J., Yuk, F., & Choudhri, T.F. (2015). Second impact syndrome: A rare, devastating consequence of repetitive concussions. Contemporary Neurosurgery, 37(20), 1-5.

Gilchrist, J., Thomas, K.E., Xu, L., McGuire, L.C., & Coronado, V. (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤ 19 years– United States, 2001-2009. Centers for Disease Control Morbidity and Mortality Weekly Report, 60(39), 1337-1342.

Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S.F. (2014). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, XX, 1-6.

National Academies Committee on Sports-Related Concussions in Youth. (2014). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK185340/.

Stovitz, S.D., Weseman, J.D., Hooks, M.C., Schmidt, R.J., Koffel, J.B., & Patricios, J.S. (2017). What definition is used to describe second impact syndrome in sports? A systematic and critical review. Current Sports Medicine Reports, 16(1), 50-55.

An Athletic Trainer’s view of The Concussion Legacy Foundation and Ambassadorship

It has been estimated that there are as many as 3.8 million reported and unreported concussions every year (Broglio et al, 2014); further, a study comparing 100 high schools and 180 colleges in the United States found that concussions made up 8.9% and 5.8% of the total injuries due to sports (Gessel et al, 2007). With occurrence numbers in those levels it is not a major reach to argue that concussions are approaching an epidemic level in sports. As an Athletic Trainer working in the Collegiate setting, I find these epidemiological findings concerning and disparaging at best.

This information inspired me to seek out advocacy groups for which I could become involved. After a good deal of research I came across the Concussion Legacy Foundation, a non-profit organization co-founded two major players in concussion research Dr. Cantu (MD) and Dr. Nowinski (PhD). This organization, founded in 2007, has taken a three pronged approach to shaping change in regard to the concussion crisis:

1. Education through running Advanced Concussion Training (ACTs) clinics and conducting various conferences and coalitions in concussion education
2. Policy through advocacy for state concussion laws and accurate video game representation of concussions
3. Research through driving multiple published research articles in various journals, involvement in position/consensus statement development, and league driven research.

This organization has been a driving force behind much of the advancement in concussion research and policy. Currently, there is a large push for donations to the VA-BU-CLF Brain Bank this national initiative allows researchers access to brains after the patient has passed away, currently the only way to diagnose CTE or research long-term effects to multiple brain injuries. The Brain Bank currently has been pledged brains from famous athletes the likes of: Brandi Chastain, Dale Earnhardt Jr., and Nancy Hogshead-Makar. As of 2014, they had been donated over 400 brains and of those 400 over 250 had tested positive for CTE!

Another national initiative this organization has taken on to herald takes place at the front lines of concussion in sport, the very athletic team. The Concussion Legacy Foundation advocates for teams and coaches to take the Team Up Speak Up Day Pledge, this annual pledge day is scheduled for September 12, 2017 and the organization is asking for volunteers to pledge that if they notice their teammate and friend is concussed that they will speak up and notify someone to get them help. These pledge drive days are designed to increase reporting of concussion, currently research suggests that only 47.3% of concussed athletes will report their symptoms (Gessel et al, 2007); further, we research has shown that, subject to motor vehicle accidents, sports is the second leading cause of concussion in the 15-24 year old age group (Marar et al, 2012). Knowing that the 15-24 year old age range is also susceptible or vulnerable to Second-Impact Syndrome this disparity in self-reporting could be the makings of the perfect storm… Thus, this advocacy at the front line is a much needed action!

 

A third major action the Concussion Legacy Foundation is taking is their Ambassador program. This is a program that allows interested volunteers to get involved in the efforts and help shape change in the day-to-day concussion fight. Being an Ambassador to the Concussion Legacy Foundation allows mom, dad, sister, brother, cousin, athlete, coach, student, medical professional, or basically anyone with a vested interest to join the efforts in stopping the concussion crisis through raising awareness about concussion or raising funds for the non-profit to bankroll it’s research and education efforts.

I could not be more excited to announce that after much research on the foundation’s efforts and accomplishments to ensure their goals are in line with my own, I have personally taken the pledge to be a Concussion Legacy Foundation Ambassador. If you have a friend, child, or loved one that participates in sports or you care to help make a difference in the world’s concussion crisis then I highly recommend taking the pledge to be an ambassador, Donate your Brain to the Brain Bank, or get your team to take the Team Up Stand Up pledge on the day.  Every effort helps and the numbers don’t lie.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., & Comstock, R.D. (2007). Concussions among United States high school and collegiate athletes. Journal of Athletic Training,42(4), 495-503.

Marar, M., McIlvain, N.M., Fields, S.K., & Comstock, R.D. (2012). Epidemiology of Concussions Among United States High School Athletes in 20 Sports. The American Journal of Sports Medicine, 1-9.

 

 

 

Siri, Alexa, & “Ok, Google” Vs Concussion Education

 

Arguably and anecdotally speaking, a large portion of today’s student-athletes and parents of student-athletes fall under the Millennial generation, being born between 1982 and 2000 (Roberts, Newman, & Schwartzstein, 2012), and other researchers have taken the time to establish that Millennials are a technologically driven population when it comes to education and learning (Desy, Darcy, & Wolanskyj, 2017).

With the recent research focus, hype, discussions, and debates being built around sports related concussion, or SRC as the 5th International Conference on Concussion in Sports Consensus Statement held in Berlin (2017) coined as an abbreviation, thanks to Will Smith’s movie Concussion and the PBS Front Line Special League of Denial it seems that many parents and student-athletes would seek to find education on what a concussion in fact is and the potential long-term effects associated to such an injury.

As mentioned above we know that Millennials are technologically driven and as Desy et al mentioned in their 2017 research article, technology even plays a necessity in this generation’s education. So, it seems a fair and logical conclusion that a Millennial with a question on education would reach for the quickest and closest media to answer their questions. The concern is if the Millennial posing the question is receiving their information from a legitimate resource or are they receiving miss information and is that driving dangerous actions?

This clinical question lead me to think about what available and timely resources Millennials had to answer their questions. That thought process guided me to Personal Assistant Applications and Artificial Intelligence pieces that were commonly available, so here is a list of the available resources I queried as to define what a concussion is:

1. Apple’s Siri Virtual Assistant/AI
2. Amazon’s Alexa/Echo/Tap Virtual Assistant/AI
3. Android’s “Ok, Google” Virtual Assistant/AI

The results from each were vaguely shocking…

Leading off at bat for the Virtual Assistant and AI programs was Apple’s Siri, when asked to define a concussion Siri responded with:

“Temporary unconsciousness caused by a blow to the head. The term is also used loosely of the aftereffects such as confusion or temporary incapacity.” 

I was extremely unimpressed with this definition that Siri provided. Suffice it to say that Siri grounded out at first base. To breakdown the concerns with the misinformation in the definition of a concussion, let’s look at the 5th International Consensus Statement: “The majority of SRCs occur without loss of consciousness or frank neurological signs”; however, Siri’s definition stated that a concussion was a temporary unconsciousness. Referring one more time to the Consensus Statement: “SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.” Once again, Siri’s definition stated that concussion were only caused by a blow to the head. Siri’s definition was riddled with misinformation and this leads to a concern for those using that as a quick resource to know if a concussion has occurred. This Siri does not get the approval of this Sports Medicine professional!

On deck was Amazon’s Alexa Virtual Assistant/AI program, when asked to define a concussion Alexa responded with:

“Concussion has two different meanings. Noun. Injury to the brain caused by a blow usually resulting with loss of consciousness. Two, any violent blow.”

Once again, the virtual assistant/AI program failed to accurately define a concussion. In this case, Alexa hit a pop fly that got her to round first base before being caught for an out. She started off strong with her definition in that according to the 5th International Consensus Statement a concussion is in fact a brain injury, she avoided the common pitfall of referring to the injury as a “Ding” or “Bell Ringer”, which we know we should avoid because it down plays the severity of the brain injury (Broglio et al, 2014). The issue in Alexa’s definition of concussion was once again the statement of usually resulting in a loss of consciousness, which as previously mentioned according to the 5th International Consensus Statement is not a common occurrence in concussion. Thus, Alexa too does not receive approval from this Sports Medicine professional as a valid source or tool for concussion education.

With our team of Virtual Assistants/Artificial Intelligence applications and programs currently sitting with two outs and no one on base, I queried Android’s “Ok, Google” Virtual Assistant/AI to see if we could at least get a base hit in concussion education sources/tools. When asked to define concussion, “Ok, Google” responded with:

“According to Mayo Clinic staff. Print. A concussion is a traumatic brain injury that affects your brain function. Effects are usually temporary but can include headaches and problems with concentration, memory, balance, and coordination. Concussions are usually caused by a blow to the head.”

Finally, a pretty decent swing and a hit. We will call this a definition a ground rule double in Millennial concussion education tools. While “Ok, Google” did a decent job in defining what a concussion is and by far it was the best of the three queried, there was still a shortcoming in the definition. “Ok, Google” hit the nail on the head with stating that a concussion is a traumatic brain injury, in-fact according to the NATA’s Position Statement on Concussion, concussions are a mild TBI or mTBI. So, that jumping off point in the definition was a great start. “Ok, Google” also took the time to reference its source, Mayo Clinic, which neither of the predecessors did. The only concern was once more the inclusion of the usual cause being associated to a blow to the head, while the research suggests that other causes include violent shaking, blows to the body translate movement to the head, or even explosions. Overall, “Ok, Google”‘s response was the strongest of the three Virtual Assistants/AIs, and while it is not the best definition it was a decent one. Thus, Android’s “Ok, Google” receives an acceptable status from this Sports Medicine professional.

The strongest definition to date for concussion can still be found in the 5th International Consensus Statement on Concussion (2017):

“Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
►► SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
►► SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
►► SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
►► SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.”

As far as seeking out great information and concussion education for parents, coaches, or even student-athletes, there is a series of free courses that take approximately 15 minutes to complete that are offered by Sports Safety International, they are called the ConcussionWise course series and can be found at the following links:

1. Athletes
2. Parents
3. Coaches

While there is no way to prevent every concussion from occurring, education on concussion and best practices in prevention can help minimize risk. Always ensure that any resource being used is one of quality and grounded in the proper research, so that you know you are receiving accurate and correct information, especially when concerning mild traumatic brain injuries and student-athletes.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Desy, J.R., Darcy, A.R., and Wolanskyj, A.P. (2017). Milestones and Millennials: A perfect pairing– competency-based medical education and the learning preferences of Generation Y. Mayo Clinic Proceedings, 92(2), 243-250.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

Roberts, D.H., Newman, L.R., and Schwartzstein, R.M. (2012). Twelve tips for facilitating Millennial’s learning. Medical Teacher, 34(4), 274-278.

 

Post Concussion Syndrome

What is PCS?

With the advent of new information and a somewhat better understanding of traumatic brain injuries (TBI), specifically concussions, it seems like the medical community is headed in the right direction. However, there is still a great deal to learn about the true effects of TBI in relation to long term physiological changes. Post-Concussion Syndrome (PCS) is a long-term condition caused by TBI that is still not widely understood, and is often undiagnosed in athletic and non-athletic populations (2015). Whereas most TBI that result in concussion tend to resolve within 1 to 2 weeks, some concussion symptoms can persist for much longer depending on the severity of the original injury, and on how many times the individual has actually suffered a TBI over their lifetime. PCS, specifically, is roughly defined as any TBI related symptoms that persist for more than 3 months beyond the original injury. While there are some discrepancies about how many symptoms must be present for more than 3 months in order for there to be a proper PCS diagnosis, the general opinion is that there must be at least 2 or more persistent symptoms (2015). As with many TBI’s, these symptoms can include headaches, light/sound sensitivity, difficulty concentrating, balance issues, difficulty sleeping, and host of other persistent symptoms. Complications that can come along with such long-term symptoms can include depression, anxiety, and even post-traumatic stress disorder (PTSD) (2015). PCS can last for several months (3 or more), or can even last for several years depending on the factors that caused the original TBI.

Who is most at risk of developing PCS?

·       Athletes who play contact sports and have suffered multiple concussions over their sports career are at highest risk for suffering a TBI. As with many injuries, once an athlete suffers an initial TBI, they are much more likely to have a recurrence at some point in their future (2010). As such, these athletes are also most susceptible to prolonged concussion-type symptoms and potentially PCS as they receive additional concussions.

·       People who have suffered a particularly severe TBI, such as from a motor vehicle accident or falling from an elevated position are also at risk of prolonged, PCS type symptoms (2014).

·       People who are taking certain medications, such as those used to treat ADHD, are at risk of suffering from PCS (2010).

·       Members of the military who have been exposed to concussive blasts as part of their training or deployment to hostile areas have a predisposition to PCS because of their repeated exposure to such conditions (2011).

What are some ways to possibly avoid prolonged concussion symptoms and PCS?

            As with many injuries, the most immediate treatment option for reducing the amount of time that an athlete or patient suffers from concussion type symptoms is rest. While there is a bit of disagreement about how much and what type of rest is truly best for a person suffering from a TBI, it seems that rest immediately following the injury (i.e. 1-2 days) is the standard in most cases (2007). Such rest does not mean that the patient should lock themselves in a dark room and sleep the entire time, but does mean that the patient should reduce their use of electronics and physical activity during this period. Allowing the brain some time to start the healing process has been shown to reduce the period of time that the concussion symptoms will tend to persist. Recent research has shown that sub-symptom, individually controlled aerobic exercise does have some efficacy in reducing and/or eliminating concussion symptoms in both normal TBI populations and those suffering prolonged symptoms or PCS (2014). Such exercise has also been shown to reduce the incidence of depression and anxiety in patients during the recovery phase of a TBI, and in those suffering from PCS.

What are the treatment options for people suffering from PCS?

·       Treating the symptoms of PCS, such as headaches, and sleep issues through drug therapy has been shown to reduce the stress caused by such symptoms. However, drug therapy should not take the place of physical and psychological treatments.

·       Physical therapy that focuses on improving balance through exercise has been shown to be effective in reducing dizziness and balance issues.

·       Physical therapy that slowly introduces sub-symptom aerobic exercise has shown efficacy in reducing and/or eliminating symptoms in PCS patients.

·       Psychological therapy is effective in reducing and/or eliminating the incidence of depression, anxiety, and PTSD in patients suffering from PCS.

By: Hans Smelker, MS, LAT, ATC

Broshek, D. K., De Marco, A. P., & Freeman, J. R. (2015). A review of post-concussion syndrome and psychological factors associated with concussion. Brain Injury, 29(2), 228-237. doi:10.3109/02699052.2014.974674

Grubenhoff, J. A., Deakyne, S. J., Brou, L., Bajaj, L., Comstock, R. D., & Kirkwood, M. W. (2014). Acute concussion symptom severity and delayed symptom resolution. Pediatrics, 134(1), 54-62. doi:10.1542/peds.2013-2988

Leddy, J., Kozlowski, K., Fung, M., Pendergast, D., & Willer, B. (2007). Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: Implications for treatment. Neurorehabilitation, 22(3), 199-205.

Logan, K. (2010). Recognition and management of post-concussion syndrome. Athletic Therapy Today, 15(3), 4-7.

MacGregor, A. J., Dougherty, A. L., Morrison, R. H., Quinn, K. H., & Galarneau, M. R. (2011). Repeated concussion among U.S. military personnel during Operation Iraqi Freedom. Journal Of Rehabilitation Research & Development, 48(10), 1269-1277. doi:10.1682/JRRD.2011.01.0013

Rose, S. C., Fischer, A. N., & Heyer, G. L. (2015). How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Injury, 29(7/8), 798-803. doi:10.3109/02699052.2015.1004756

Swanson, E., Kurowski, B., Hugentobler, J. A., & Quatman-Yates, C. (2014). Feasibility and potential benefits of active rehabilitation for post-concussion syndrome in adolescents. American Journal Of Physical Medicine & Rehabilitation, a94.

Acute Concussion Management: Are We Doing Enough?

Acute Concussion Management: Are We Doing Enough?
As concussion research advances, the management of concussion advances as well. There are many varying factors that contribute to the initial management of concussions. IN this article, I will debunk some myths about concussion management and update you on the current best practice treatments for concussions and concussion symptoms.

We have all been there – athlete gets hurt, concussion is suspected and the inevitable question that follows, “Now what?”. Parents, athletes, coaches, general managers, everyone always wants to know what happens once an athlete sustains a concussion. This article provides you with some answers to that burning question.

 

Medication vs. No Medication

Initial management of concussions and the symptoms associated with them is crucial to the diagnosis of a concussion. Medical emergencies, such as acute subdural hematomas (SDH), manifest within the first 72 hours post initial injury (Subdural, 2017). Intervention of NSAIDs during the acute stages of a concussion increases the severity of the SDH due to thinning of the blood in the brain. However, all medications are not considered back. Over the past 30 years, the mantra has been ‘no medication until they are symptom free.’ That is no longer the case. Acetaminophen administration is a widely accepted treatment option to help provide relief from the headache associated with a concussion, which in turn directly relates to a decrease in other symptoms associated with concussions. Acetaminophen does not increase the risk of SDH and is deemed ‘safe’ for athletes during this subacute phase of a concussion.

 

Complete Rest vs. Returning to Daily Routine

For years the best practice for management of a concussion has been ‘complete and total physical and mental rest.’ Often healthcare professionals refer to this as ‘sitting in a dark room’ during the acute and subacute phases of a concussion to minimize the overload of sensory exposure of a concussed athlete. As research continues to open new avenues of concussion management, healthcare professionals are beginning to questions weather this is still the best practice. According to Jon Almquist, ATC, VATL, Concussion Specialist at Fairfax Family Practice Comprehensive Concussion Clinic, “returning an athlete to a ‘normal daily routine’ facilitates cognitive function and decreases actual recovery time (Almquist, 2017).  Almquist continues to state that returning an athlete to a normal daily routine decreases the potential for associated mood disorders to develop during concussion management and further prolonging the recovery time for an athlete.

 

Is Rest Bad?

No. Rest is still a vital portion of the treatment regime for athletes with concussions, but the amount of rest needed for cognitive repair is a widely debated and researched topic. In order to better care for a concussed athlete, the healthcare provider must find a balance between limited physical and cognitive exertion and rest. ‘Total Rest’ is considered to be the most beneficial during the first 72 hours following a concussion, the subacute . This allows those interacting with the individual to monitor and observe changes in behavior possibly associated with SDH and EDH. As an athlete ventures past the subacute phase and into the recovery phase, the athlete should be subjected to increased loads of mental exertion while being cautious of the amplification of concussion symptoms. A normal daily routine allows the athlete to receive cognitive modifications as well as not missing out on academic responsibilities.

 

Conclusion

Concussion research manifests itself in a variety of avenues. From researched based literature to social media, healthcare professionals are flooded with information regarding concussion management. It is the responsibility of all of us to find the most pertinent information to ensure we are providing the most up-to-date care for our athletes. Research and treatments for all injuries are being updated and the seriousness of head injuries and concussions are driving our profession to evolve and improve.

 

Author: Matt Campbell, LAT, ATC, ITAT, CES

 

Sources:

Subdural Hematoma. (2017, August 28). Retrieved September 19, 2017, from http://emedicine.medscape.com/article/1137207-overview#a3

Almquist, J. (n.d.). Return to Learning. Lecture. Retrieved September 01, 2017, from https://training.impacttest.com/learn/course/223/play/1269/video-return-to-learn;lp=1

 

Concussion Baseline Neurocognitive Test Systems: Who’s the Best???

I know the Football season is already in full swing, but this topic is an important one for parents, athletes, coaches, teachers/professors, and healthcare professionals to be aware of… The Baseline Neurocognitive Test for Concussions. But what is a Neurocognitive Test? The word itself ‘Neurocognitive’ sounds like something those guys and gals with the 1,000 lbs heads would use in daily conversation, not something a parent, coach, or athlete should know.

According to http://www.dictionary.com, ‘Neuro’ means: “pertaining to a nerve or nerves or the nervous system” while ‘cognitive’ means: “of or relating to the mental processes of perception, memory,judgment, and reasoning, as contrasted with emotional and volitional processes.” 

In other words, the naming convention for the test suggests that we are testing the patient’s neurological function and mental processing. Well, when it is broken down like that, it makes sense why this is important. After all, both the International Consensus Statement on Sport Related Concussion and the National Athletic Trainers’ Association (NATA)’s Position Statement on Sport Related Concussion suggest that all athletes should have a Neurocognitive/Neuropsych Baseline test completed prior to their season, in order to use this information as amplifying data in the recovery process of a concussed athlete (McCroy et al, 2017; Broglio et al, 2014). These are some major players in the concussion world that are taking a pretty sturdy stand for the necessity of this sort of testing to help protect athletes from long term brain damage or death.

So, you may ask yourself or a healthcare professional, “why do I need to use a computer-based test for this? If someone has brain damage they should know it and be able to tell someone as such.” Well, interestingly enough researchers have found deficits in neurocognitive function for up to 36 hours beyond a patient reporting they no longer have symptoms on a computer-based neurocognitive test (Broglio et al, 2014), meaning that even though the patient believes they are fine and healthy, they actually have mechanical and metabolic damage to the brain. Thus, the patient may not know they are still technically concussed. Worse yet, there is a major issue with underreporting of concussion symptoms due to fears of losing their place on the team, not thinking its a serious injury, or even simply because the athlete wants to play (Meier et al, 2014). This is why computer-based neurocognitive tests are vital to the health and long-term well being of our athletes.

Now, that I hopefully have your attention, let’s dig into the meat and potatoes of what Neurocognitive Test is best. Though I am credentialed through ImPACT, I will only present factual and unbiased research and data to present the following overview of each system on the market today.

So, on the market today any healthcare professional looking to start using a neurocognitive test will have to chose between some very solid products, these include:

1) Immediate Postconcussion and Cognitive Testing test battery (ImPACT),

2) CogSport

3) Automated Neuropsychological Assessment Metrics (ANAM)

4) HeadMinder Concussion Resolution Index (CRI)

Let’s start with the ImPACT Test. First and foremost, ImPACT is currently the only neurocognitive test to be approved by the FDA (Moran, 2016), that is a very strong start when it comes to establishing a leader. Further, according to Resch et al (2013) ImPACT is the most widely used computer-based neurocognitive test on the market at 93%. Once, again this is not my bias, this information is all cited in the references! But, what about the true stats on the product? Does it do what it is supposed to do? Let’s see… According to Resch’s review of studies they found ImPACT to have a sensitivity (True Positive) of 81.9%-91.4% depending on the study’s population and a specificity (True Negative) of 69.1%-89.4%. Reliability Coefficients (Does it consistently test the same) were listed as ranging from 0.46-0.74 which comes out to be moderate to strong in reliability. Finally, there is validity (true representation of what is being tested), here Resch’s research found the ImPACT test to have a range of 0.31-0.59 which translates to the test being weak to moderate in validity. So, the test is not perfect, there is demonstrated weakness in it’s validity, and it can be moderate in its reliability, but the specificity and sensitivity are very strong scores for the test, at least according to Resch’s research!

Now, let’s chat CogSport. Resch’s research only had one study addressing CogSport and Sensitivity and Specificity, which they stated found that 70.8% of the tested athletes demonstrated deficiencies in their tests. while this is not necessarily as comparable to the research done on the ImPACT, it is valid information to know. With regard to Reliability, there were a few studies done and the ranges were from 0.14 (very weak)-0.94 (strong), this is a good deal of variability in the reliability. However, Resch’s research article does stress that each category did hit the bare minimums, at least, to qualify in the categories of measure. Finally, addressing validity Resch’s review of the literature found a range of 0.23-0.83 depending on the research study, also a huge swing.

Then there is the ANAM. This is a test, I had to take prior to going to Afghanistan with the Army. Resch’s research and review of literature found the ANAM’s specificity and sensitivity to be as follows: Specificity ranged from 86% to 100% and sensitivity was ranged from 1%-15% based on subtest being gauged. When it comes to the reliability of the test, Resch’s research review found that there was range from 0.14-0.86. Another one that is a little wide. This bring s the topic to the validity of the test, here Resch’s group found that of the studies conducted on the test there was a range from -0.01 to 0.65.

The final test to look at is the CRI. Resch et al (2013)’s research looked at the same subset data for this test as the others after reviewing all the pertinent research on this neurocognitive test. With regard to sensitivity and specificity, the two articles reviewed on this test did not use control groups; thus, no specificity is established. However, the sensitivity was rated at a range of 69% to 78.6%. Reliability ranged from 0.03 to 0.66, and the validity for this test was found to be 0.37 to 0.70.

Unless you are a reseacher this may not have made much sense to you. But let’s see if this helps: The Specificity and Sensitivity ranges place the ANAM and ImPACT at the top of the list, the Reliability ratings of the tests placed CogSport and ANAM to be highest overall, but ImPACT had the closest overall range, and the validity ratings placed all tests above the ImPACT, though once again, the ImPACT had a closer overall range. What seems to be paramount to understand here is that ImPACT performed well across all variables, not always the best, but well, and is the only one that is FDA-approved.

Before selecting a neurocognitive test to use, do the research and compare the tests to see what is best in your own eyes!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S.F. (2014). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, XX, 1-6.

Moran, M. (2016). FDA-approved devices assess cognition after possible brain injury in youth. Clinical Research News. Accessed from http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.10b2.

Resch, J.E., McCrea, M.A., and Cullum, M.C. (2013). Computerized neurocognitive testing in the management of sport-related concussions: An update. Neuropsychology Review, 23,335-349.

The Concussive Blast

As a Soldier, this topic is near and dear to my heart! After learning so much about concussions I have began to think back to war movies such as  Saving Private Ryan (click on the link and watch at around 4:30 in to the video), where Tom Hanks character (Captain Miller) is taking the beachhead on D-Day, as he is exciting the water a concussive blast hits and everything slows down, ambient noise goes away, and he is essentially numb to what is going on around him. Reflecting back now, I realize this was a portrayal of a concussion associated to a concussive blast. Just think about how often they showed his shaking hand after this, now it could be associated to some PTSD from the action they saw in Anzio but still it’s a good point to think about. Often in this blog we broach the topic of concussion from the athletics perspective, but rarely do we approach the topic from the military perspective.  So, this week’s topic is sure to take on the challenge!

According to a Congressional Report in 2007 by Wilson, Improvised Explosive Devices, or IEDs, have become the primary weapon of the enemy forces in Operation Enduring Freedom (OEF), Afghanistan and Operation Iraqi Freedom (OIF), Iraq. Wilson (2007) cites that IEDs have been the leading cause of combat casualties in each theater with 70% in Iraq and 50% in Afghanistan. While citing daily uses of this asymmetric threat to our Warfighters would be a violation of Operational Security (OPSEC), I think with such high percentages of casualties associated to this platform of destruction it is fair to say that many of our American Warfighters have been exposed to the threat!

But why is this important when speaking on the subject of concussion? Well, I am glad you asked this ‘head-scratcher’. You see, according to MacDonald et al (2014) concussive blasts have been associated to TBIs in military personnel. Further, we know from Broglio et al (2014) in the National Athletic Trainer’s Association Position Statement, that a concussion is a mild traumatic brain injury, or mTBI. Thus, when we when we take the time to synthesize this data, it becomes far easier to understand, from the healthcare professional’s perspective just what Tom Hank’s character was enduring on D-Day.

Unfortunately, many Warfighters from all branches (Army, Marines, Navy, Air Force, and Coast Guard) have been exposed to this threat. In-fact according to the Defense and Veterans Brain Injury Center (2017), the total TBIs sustained in the Department of Defense (DOD) from the year 2000 through 2016 was 361,092! Further, of the 253,330 TBIs that occured from 1 January 2000 through 20 August 2012, 77% were categorized as mTBIs, the same as the athletic concussion we are more familiar with (Fischer, 2013). Those are some major numbers…

What this author finds truly troubling is that there are common symptoms between both TBI and Post-Traumatic Stress Disorder or PTSD by its more common moniker. This can make diagnosis of the two challenging for healthcare providers, especially as they can have a similar mechanism of injury.

To add just a little more fuel to the fire in this discussion there has been an interesting link drawn between TBI and PTSD, could having one make  a Warfighter more susceptible to contract the other?  Summerall and McAllister (2010) drew a conclusion that a history of TBI could make one more susceptible to PTSD, and there it is…

Many people are familiar, now, with the NFL and CTE research of Dr Omalu as the movie Concussion brought attention to the concern. When I think about the casual link being seen between a history of concussion, a mTBI, and this potentially leading to CTE, I cannot help but draw the conclusion that it must be on a similar spectrum as the link we are seeing between a history of military-related TBI and PTSD. This author and Sports Medicine Professional believes additional research should target this population to see if any findings from either side can assist the other, NFL or military. In the need to do better by not just our athletes but our Service Member and Warfighters; after all, not all wounds are visible!

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References:

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Defense and Veterans Brain Injury Center. (2017). DOD worldwide numbers for TBI. retrieved from http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi.

Fischer, H. (2013). U.S. military casualty statistics: Operation new dawn, operation iraqi freedom, and operation enduring freedom. CRS Report for Congress.

Mac Donald, C.L., Johnson, A.M., Wierzechowski, L., Kassner, E., Stewart, T., Nelson, E.C., Werner, N.J., Zonies, D., Oh, J., Fang, R., and Brody, D.L. (2014). Prospective assessed clinical outcomes in concussive blast vs nonblast traumatic brain injury among evacuated US military personnel. Journal of the American Medical Association, 71(8), 994-1002.  

Summerall, E.L. and McAllister, T.W. (2010). Comorbid posttraumatic stress disorder and traumatic brain injury in the military population. Psychiatric Annals, 40(11), 563-580.

Wilson, C. (2007). Improvised explosive devices (IEDs) in Iraq and Afghanistan: Effects and countermeasures. CRS Report for Congress.

 

Referees Are Friends, Not Food

Be forewarned, this may not be the most “scholarly” article in terms of the use of the scientific method. It will probably consist of opinionated monologues and common sense. Believe me, as an athlete, and even as an Athletic Trainer for my team, I had my fair share of yelling matches and eye rolling with referee calls. But, the more I’ve worked as a PRN ATC as a completely neutral third party, I’ve seen with a clear eye why these “silly” rules are in place. Please be gentle with your opinions as I attempt to play Devil’s Advocate for a moment.

**Note: This post will focus on rules put in place to decrease the risk of head injury.

Like many authority figures, sports officials are targeted with a negative stigma and bad publicity. I think being shark bait is in their job description.

When it’s YOUR team playing, it seems to always be a bad call from the ref, not a poor play by the athlete. Our athletes are good, but you have to admit that there is a point at which some athletes are desperate enough to do anything to win, even if it accidental.

If you really, think about it, referees have to put up with a lot of crap. For instance, getting run over the players, and sometimes even the ATCs (guilty as charged)!

Stumbling, but having to recover immediately because no one cares about their boo boos;

Verbal abuse

And sometimes even physical abuse.

So, instead of thinking “That was a terrible call ref! Just let them play the game!”, maybe we should think, “Okay, yeah I wish he would have just let that go, but he may have saved my kid from breaking his neck and never being able to play again.” Morbid, I know. If referees were not there to judge whether a play/player is safe or not, we’d have athletes doing all sorts of dangerously hooligan things on the field just to get that extra point. As much as I enjoy a good hockey brawl, that’s the player who takes a hit right to the temple and loses consciousness.  Enforcement of rules by officials, coaches, parents, and adherence to rules by athletes will reduce the incidence and severity of sports-related concussions (Committee on Sports-Related Concussions in Youth et al., 2017).

Let’s look at some rules that are in place to save your athletes’ lives:

Rule: Heads Up/Body checking

Sport: Ice Hockey, Football, Men’s Lacrosse

Rationale: Body checking is a tactic by defensive players to separate the carrying player from the object. It is a legal move if it is performed using the trunk (hips and shoulders), but the introduction of helmets and face shields to protect from facial trauma showed an increase in the number of serious head, neck, and spinal injuries related to body checking. Perhaps the helmets created a false send of safety, resulting in rule changes to prohibit head-first contact.  USA Hockey, as well as other hockey leagues, has banned body checking at the Pee Wee level.

(American Academy of Pediatrics, 2000; Peters, 2013)

 

Rule: Targeting/Launching

Sport: Football

Rationale: The  NFL implemented two rule changes to augment player safety. First, an offensive player who is attempting to catch a ball that’s been intercepted will be ruled defenseless and cannot be hit in the head or neck area by the intercepting team as possession changes. Also, the NFL has given certified athletic trainers who are stationed in sky boxes at each game the authority to stop play with the touch of a button if they see a player who is exhibiting notable signs of injury, even if he was hurt in a previous play. How exciting for us!!!!

(National Football League, 2017; Reyes, 2015)

Good news is, the NFL will n linger penalize or fine most post- touchdown celebrations (Patra, 2017)

 

Rule: Head butting

Sport: Soccer

Rationale: A new rule in U.S. soccer limits the amount that youth players are allowed to head butt the soccer ball. For players 10 y.o. and younger, no head butting is allowed. Kids ages 11-13will head butt less during practice; players 14 years and older can head butt as always. “These new rules will resolve a lawsuit brought last year against U.S. soccer and others by a group of parents in California who argued the groups weren’t doing enough to protect kids from head injuries.” More importantly, brains in young children are not as myelinated as an adult’s brain, as they are still developing. When violently shaken, the unmyelinated nerve fibers in a child’s brain are more susceptible to trauma to the nerve fibers and disrupting the neural connections.  Also, the musculature surrounding a young child’s neck and trunk are less developed, meaning there is less support causing a blow to the head to cause more force and motion of the brain in the skull.

(Public Broadcasting Service, 2015)

 

Rule: Lane etiquette

Sport: Swimming

Rationale: When you enter a lane that already has a swimmer in it, you alert that person that you are entering the lane. When 2 swimmers share a lane, each person picks a side to swim laps and sticks to it. With three or more swimmers, everyone “circle swims”, meaning everyone stays to the right. If you must pass, alert the other person and don’t pass anyone who is near the end of the lane. This lane etiquette is important for lifeguards to enforce and for recreational swimmers to follow because the water inhibits out senses. Swimmer’s faces may be in the water, so they cannot see all of their surroundings clearly. Water distorts auditory stimuli. Bright sun may momentarily blind a swimmer. Different strokes cause different blind spots for a swimmer. Fifty percent of Olympic level synchronized swimmers have had a concussion. It is very difficult to control your body in the buoyancy of water, especially with current made by the waves of other team members. However, in competition it is ALL about the points, and teams gain more points the closer they move together and the ore complex their routines are, including throwing teammates into the air.

(Cimons, 2016; Gardner, 2016)

 

Rule: MLB 7.13 Home Plate Collisions- A runner attempting to score may not deviate from his direct pathway to the plate in order to initiate contact with the catcher; unless the catcher is in possession of the ball, the catcher cannot block the pathway of the runner as he is attempting to score

Sport: Baseball

Rationale: Catchers in baseball were beginning to suffer from concussions more than any other position on the field. Collisions at home plate are literally a blind crash between two opposing forces, and they can result in both concussion as well as traumatic fractures.

(Major League Baseball, 2014; Tribou, 2014)

So remember, sports officials are not there for kicks and giggles, they are there to make sure the game is played fairly and safely in order for people to continue to play the games they love. So smile,…..

 

 

and always remember to hug your Ref 🙂

 

References

American Academy of Pediatrics (2000). Safety in Youth Ice Hockey: The Effects of Body Checking. Pediatrics, [online] 105(3). Available at: http://pediatrics.aappublications.org/content/pediatrics/105/3/657.full.pdf [Accessed 4 Aug. 2017].

Cimons, M. (2016). Swimming is supposed to be low-impact, so why the concussions?. [online] Washington Post. Available at: https://www.washingtonpost.com/national/health-science/swimming-is-supposed-to-be-low-impact-so-why-the-concussions/2016/12/09/aff3163e-b0d8-11e6-be1c-8cec35b1ad25_story.html?utm_term=.6dff5f9c8cef [Accessed 4 Aug. 2017].

Committee on Sports-Related Concussions in Youth, Board on Children, Youth, and Families, Institute of Medicine, National Research Council, Graham, R., Rivara, F., Ford, M. and Spicer, C. (2017). Sports-Related Concussions in Youth Improving the Science, Changing the Culture. Washington D.C,: National Academies Press (US), pp.17-19.

Gardner, D. (2016). Synchronized swimming bosses introduce new rules to prevent crashes. [online] Mail Online. Available at: http://www.dailymail.co.uk/news/article-3699412/Synchronized-swimming-bosses-forced-introduce-new-rules-prevent-crashes-emerges-HALF-competitors-suffered-concussion.html [Accessed 4 Aug. 2017].

Major League Baseball (2014). Orbit had one final prank for mortal enemy Chris Archer before the Rays left town. [online] Major League Baseball. Available at: http://m.mlb.com/cutfour/2017/08/04/246386032 [Accessed 4 Aug. 2017].

National Football League (2017). 2017 Rules Changes and Points of Emphasis | NFL Football Operations. [online] Operations.nfl.com. Available at: http://operations.nfl.com/the-rules/2017-rules-changes-and-points-of-emphasis/ [Accessed 4 Aug. 2017].

Patra, K. (2017). NFL relaxing touchdown celebration rules for players. [online] NFL.com. Available at: http://www.nfl.com/news/story/0ap3000000810537/article/nfl-relaxing-touchdown-celebration-rules-for-players [Accessed 4 Aug. 2017].

Peters, C. (2013). Peewee Body-Checking Ban: Why Hockey Canada, USA Hockey are Getting it Right. [online] The United States of Hockey. Available at: https://unitedstatesofhockey.com/2013/05/31/peewee-body-checking-ban-why-hockey-canada-usa-hockey-are-getting-it-right/ [Accessed 4 Aug. 2017].

Public Broadcasting Service (2015). U.S. Soccer rolls out new rules to prevent kids’ concussions. [online] PBS NewsHour. Available at: http://www.pbs.org/newshour/bb/u-s-soccer-rolls-new-rules-prevent-kids-concussions/ [Accessed 4 Aug. 2017].

Reyes, L. (2015). NFL reports reduction in concussions, new measures to protect players. [online] USA TODAY. Available at: https://www.usatoday.com/story/sports/nfl/2015/08/05/concussions-reduced-rule-changes-defenseless-injured-players/31189031/ [Accessed 4 Aug. 2017].

Tribou, D. (2014). New MLB Rule Cuts Home Plate Crashes, But Not Catcher Concussions. [online] NPR.org. Available at: http://www.npr.org/2014/11/09/362459949/new-mlb-rule-cuts-home-plate-crashes-but-not-catcher-concussions [Accessed 4 Aug. 2017].