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Concussion: Identification, Management, and Testing

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with Tim Takahashi M.Kin, CAT(C), CEP, CSCS, CK | February 08, 19

Concussion: Identification, Management, and Testing

Tim Takahashi M.Kin, CAT(C), CEP, CSCS, CK

For most people that are familiar with concussions, it is easy to recognize if someone is experiencing a concussion. Past that point, however, they are not sure exactly when it happened, or the best way to recover. In this blog, I will review what a concussion is, how to recognize exactly when it happens, and the next steps to have a successful recovery.

Here are a few steps I will cover that happen after a concussion:

  1. The Sideline Evaluation
  2. Developing Signs and Symptoms to Recognize
  3. Removal from Activity and Assessment
  4. Transitioning from Complete Rest to Relative Rest
  5. Re-Evaluation and return to work/school, followed by return to play/sport

Quick Facts about Concussions:

- Approximately 80% of concussions resolve in less than 21 days.

- Concussion is a disturbance in the brain’s regular functioning, rather than structural injury...

- This is why no abnormalities are seen on standard imaging for concussions!

- There is no loss of consciousness required, or direct hit to the skull or head for a concussion to happen.

As of the latest consensus statement on concussion in sport (5th International Conference on Concussion in Sport, Berlin, October 2016) concussion is defined as “representing the immediate and transient symptoms of traumatic brain injury.” The mechanism of injury for a concussion usually features a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Concussion can include a rapid onset of short--lived impairment of cognitive function that resolves spontaneously.


1. Sideline Evaluation:

    Athletic Therapists like myself, also known as AT’s, frequently work with sport teams and individual athletes during practices and competitions to aid with injuries, including concussions. Usually right after an incident, you might see an AT guiding an athlete through a SCAT5 assessment on the sideline.

    The SCAT 5 (Sport Concussion Assessment Tool, version 5) is a tool to aid healthcare professionals in assessment of a concussion. To clarify, it is not a standalone test to diagnose concussion. Currently, the SCAT5 represents the most well-established and rigorously developed instrument available for sideline assessment.

    This test needs to be used within the first 72 hours of the mechanism of injury in order to deem the assessment effective. This is also why it is important to recognize a mechanism of injury quickly, remove the person from the incident, and get them to someone who can assess them right away. Again, note that symptoms onset at different times, and will not appear the same in each person.

    2. Signs and Symptoms:

    It is true that no two concussions will present the same--whether a separate person, or separate incident for the same person. Symptoms can present immediately, or be delayed up to 3 days later. This is why recognizing the initial incident and removing from activity is crucial, in order to avoid “Second-Impact Syndrome,” which can be life-threatening. I will explain more about this in the next section.

    Each set of symptoms, and response to treatment can be different for a concussion. I have listed some below.

    - Somatic (e.g. headache)

    - Cognitive (e.g. amnesia, fogginess, difficulty concentrating, slowed reaction time)

    - Emotional/behavioural (e.g. lability)

    - Physical (e.g. mechanical neck pain, loss of consciousness, nausea, vomiting, fencing response, poor coordination)

    “Fencing Response” after severe head trauma

    - Inner Ear Impairment (e.g. balance or gait unsteadiness, dizziness)

    -Visual Impairment (e.g. eye tracking, double vision)

    - Sleep Impairment (e.g. drowsiness)

    3. Removal from Activity:

    It is important to recognize a concussion, or a suspected concussion immediately. Immediate evaluation from on-site medical personnel is recommended, if possible. Remember, if concussion symptoms can be delayed up to 72 hours, it is best to wait out that duration rather than returning to play.

    “When in doubt, sit them out.”

    Follow this link for an example of how Athletic Therapists work with teams and coaches to make the best possible transitions for players to get back to competition safely.

    Second Impact Syndrome is a condition occurring in individuals who have not completely recovered from a previous concussion, and receive a second impact. This second injury, however, can cause a large brain bleed that can become fatal very quickly, often altering mental status. A force larger than the initial impact is not necessary to cause Second Impact Syndrome. Read more about Rowan’s Law, which was passed in Ontario legislature in memory of Rowan’s passing after a Second Impact Syndrome injury during Rugby.

    Rowan Stringer

    In summation, all players that are suspected to have a concussion should immediately be removed from play. No player with suspected concussion should return to play within 24 hours, especially without clearance from a qualified healthcare provider.

    4. Re-evaluation:

    Currently there is no available imaging technology, blood test or biomarker that can diagnose a concussion.

    Medical assessment will usually include a detailed history of the client’s case. A detailed neurological exam will follow, reviewing cognitive function, sleep, ocular function, vestibular function, gait and balance, and neck.

    Check out this link to learn more about how a quality concussion clinic operates. If you are seeking out a clinic for treatment for a clinic, this link reveals some of the boxes it should check.

    5. Rest:

    For the first 24-48 hours, complete rest is recommended. This includes cognitive and physical activity, as described below. It is suggested to focus on getting good meals and hydration.

    After those first 48 hours or more, relative rest is recommended. Gradual return to work or school is next, and lastly return to play or sport follows.

    Brittany Mercier, BKin, CAT(C), MSc

    Southern Alberta Concussion Clinic

    Sport Medicine Centre

    4401 University Drive W

    Lethbridge, AB

    T1K 3M4

    Dr. Martina Frostad B.Sc., MD CCFP(SEM), FCFP, DipSportMed

    Dr. Ron Garnett MD CCFP(EM), FCFP, DipSportMed, ARCT

    Dr. Kami Makar B.Sc., MD CCFP(EM)

    Dr. Joel Weaver, MD CCFP, FCFP(COE)(SEM) DipSportMed

    Rest:

    Gradually and progressively increase your normal daily activity while staying below cognitive and physical symptom-exacerbation thresholds (do what you can without making symptoms worse).

    Rehabilitation:

    This needs to be specific to the individual based on clinical findings (e.g. cervical, vestibular, visual, physiologic)

    Recovery:

    Return to full school or work before return to sport.

    Return to sport should be performed in steps that are individualized to a player’s sport. Each step takes a minimum of 24 hours (may remain longer at any step). A minimum of 1 week to return to full sport from the date of concussion.

    Baseline Testing:

    - No one specific test has been validated for use as an effective baseline test for concussions - Based on current evidence the use of baseline computerized neuropsychological testing is not required

    Recommended in children and adolescents - Best practice is a detailed history including: concussion history, previous head, face or cervical spine injuries, and comorbidities (e.g. visual tracking dysfunction, migraines, effectors of balance). Tools to assist (e.g. SCAT5, VOMS)

    Prevention:

    - Rule changes (e.g. ice hockey body checking age increase)

    - Hit training: teaching players how to properly hit and be hit (e.g. helmetless football practices)

    - Possibility of vision training and cervical strengthening (more research needed)

    - Helmets do not prevent concussions, but do prevent other head injuries like skull fractures, pressure wounds, or scalp and face lacerations.

    - Mouth guards do not prevent concussions, but do prevent or mitigate dental injuries

    5 Quick Tips for Coaches and Parents

    Concussions can be from “direct” or “indirect” forces

    The impulsive force can cause trauma to the brain through another body part (ex: falling on your bum and the force going up inside your skull to the brain) OR from a direct blow to the face, neck, or skull (ex: car accident trauma to the steering wheel.

    There is so special requirement for a concussion to occur

    There is no specific amount of force required to sustain a concussion, nor a loss of consciousness.

    “When in doubt sit them out”

    No player with a suspected concussion can return to play within 24 hours, especially without clearance from a medical professional.

    Start with complete rest for 24-48 hours, followed by relative rest thereafter.

    Daily activities should be completed as tolerated without exacerbation of symptoms.

    Complete rest = mental (no reading, writing, screen use, bright/noisy locations) and physical (any activity raising blood pressure or heart rate).

    Those baseline tests are not validated

    Baseline testing = assessing and recording cognitive function before a concussion has been sustained.

    This type of testing has not been validated or recommended for youth athletes. Having a baseline test does not change assessment or treatment even if a concussion does occur.

    The top 5 key messages from the 5th International Consensus Statement on Concussion in Sport

    Judo Canada Concussion document

    Parachute Canada - What to do if you have a concussion

    Reasons Why Baseline Concussion Testing is Changing for our Athletes - Statement from Parachute Canada

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