Program
Assessment
Cognitive assessment is not enough
Experts agree that cognition is an important component of a comprehensive concussion program. Experts also agree, however, that no tool should be used in isolation. More recent guidelines have recognized the importance of assessing symptoms, cognition, balance and vision as part of a comprehensive concussion evaluation at baseline, time of injury and throughout the recovery process.
- Symptoms – There are a number of clinical symptoms associated with an acute concussion, which are frequently categorized into somatic, cognitive and/or emotional. The table below summarizes the more commonly recognized symptoms as well as behavior changes related to concussions. If any of the below symptoms/behavioral changes are present then a concussion should be expected and appropriate management provided.
| Somatic | Cognitive | Emotional |
|---|---|---|
| Vision Changes | Disoriented | Depression |
| Dizziness | Foggy Headedness | Moodiness |
| Unsteadiness | Confusion | Irritability |
| Headache | Concentration Problems | Changes in Personality |
| Nausea | Memory Loss (before and after injury) | |
| Tinnitus (ringing in the ears) | ||
| Light Sensitivity | ||
| Noise Sensitivity |
- Cognition – Cognitive testing has been one of the more recognizable tools for concussion assessment. A number of studies show that cognitive function is sensitive to recovery of a concussion and should be part of any return to play guideline. Cognitive testing can be performed without technology (e.g., Pen and Paper test) although computerized cognitive testing is the preferred method and, as with any tool, should be used in conjuction with other clinical tests.
- Balance – Balance testing can be a reliable and valid tool for assessing a concussion. There have been a number of published studies identifying balance impairments following a concussion, including postural stability changes 3-5 days post-injury. Such impairments can be detected in standard clinical balance tests and/or with more sophisticated force plate technology.
- Vision – Vision testing is often not recognized as part of a comprehensive program although reported visual changes are commonly associated with a concussion. More recently, there has been more attention to the importance of visual testing – both by the National Football League (NFL) as well as the National (NCAA). Visual testing should also be performed baseline and post-injury. Visual assessment would ideally include static visual acuity, dynamic visual acuity and motor control of eye movements.
Post-injury assessment is not enough
- Baseline – Baseline testing is the cornerstone for any comprehensive concussion program – not only for comparative data but to identify impairments before the season begins that could be considered “at risk” indicators. If an athlete does not achieve acceptable baseline testing in any of the above components then repeat, emphasizing the importance that participation depends on testing within acceptable limits. Pre-existing findings warrant consideration of further evaluation. We also recommend annual baseline testing to account for maturational changes, additional inter-season injury/injuries that may or may not have been reported and/or cumulative/persistent effects of previous injuries.
- Time of injury – First and foremost, the athlete should undergo standard emergency care to rule out more serious injuries (e.g., brain/spinal cord). Once the athlete has been safely removed from the sideline and allowed a minimum of 5 minutes to rest then a sideline assessment can be performed. If no tool is available then it is recommended the athlete be withheld from play and closely monitored until he or she can be further evaluated. Documenting symptoms, cognition, balance and vision is recommended not only 5 minutes after the athlete is considered stabilized but a minimum of 15 minutes later. Studies show testing 20 minutes after the time of injury is more sensitive than immediately following the injury. Any deterioration in status warrants seeking immediate medical attention. It is also critical to document the athlete’s status at time of injury not only for liability purposes but to provide comparative information in the days that follow the injury.
- Post-injury – Studies show that symptoms, cognition, balance and vision can deteriorate hours to days following a concussion. Thus, it is important to closely monitor the athlete for a minimum of 3 days following the incident and/or until signs and symptoms of a concussion resolve.. Further assessment post-concussion is typically performed at the Emergency Department, in a physician’s office or through a referral of additional qualified medical providers. Experts agree that further medical examination and evaluation should include the following a comprehensive history and neurological examination that would include symptoms, mental status, cranial nerve function, reflexes, muscle tone, strength, balance, gait and vision. Any neurological findings and/or deterioration from the athlete’s status at time of injury warrants further neuroimaging.
- Rehabilitation – Rehabilitation following a concussion is most frequently referenced as using a graded exercise approach as part of a return to play (RTP) protocol. Such protocols, however, typically lack specific guidelines (e.g., “light” aerobic activity) and do not include balance and/or visual exercises when deemed appropriate. Another important component of the rehabilitation stage is to continually monitor symptoms, cognition, balance and vision throughout the process for a deterioration in any of these areas are suggestive of an incomplete recovery.
Rehabilitation
Optimize the recovery process through targeted protocols
Rehabilitation for sports-related injuries is well recognized although intervention is typically related to orthopaedic injuries (e.g., knee, shoulder, etc). Can we rehabilitate concussions? Experts agree that limiting both cognitive and physical exertion is critical in the early phases of treatment, which is then followed by a graded “step-wise” approach to closely monitor the athlete’s response to activity. More recently, however, there has been growing attention towards integrating specialized balance, eye-head coordination and/or visual retraining exercises into the concussion rehabilitation program. In a study by Kevin Guskiewicz, et al (1997), it was shown that athletes can demonstrate decreased stability until 3 days following mild head trauma and a more severe injury can take up to five or six days. Although not specific to athletes, another study found 79% of patients that were hospitalized (<2 days) after mild head trauma but had a normal neurological examination reported dizziness within three months following a head trauma. The use of exercises for dizziness and/or balance disorders began as early as the 1940s and has now evolved into a specialized and customized exercise approach commonly referred to as “vestibular rehabilitation therapy” (VRT). VRT is widely accepted and considered an integral part of the medical management care plan in regards to dizziness and balance disorders, which are commonly related to concussions.*
Enhancement
Use your baseline testing for athletic enhancement opportunities
There are a growing number of athletic enhancement centers around the world. Training focuses on mental and physical aspect of sport-specific activities, maximizing the athlete’s potential and, hopefully, reducing the risk for injury. How does athletic enhancement fit into a concussion management? The cornerstone of a comprehensive concussion program begins with baseline testing. Baseline testing not only provides comparative information of the athlete’s status pre- and post-injury but can also identify potential “at risk” indicators as well as establish a framework for athletic enhancement. Studies support the efficacy of cognitive and physical interventions for the enhancement of sport-specific performance but also recommend that more detailed serial testing be performed to monitor change over time, which correlates well into baseline testing.
Compliance
Training and tools to ensure your adherence to the latest state and federal regulatory requirements
There are over 20 published guidelines regarding concussion assessment and management and the number of legislative mandates continues to grow both at the state and federal level. Staying current on these changes is a challenge to all involved in the athlete’s care. In a 2007 study (published in the Clinical Journal of Sports Medicine and specifically targeting coaches), it was found that participating in coaching-education programs is the strongest predictor for coach recognition of symptoms. Unfortunately, however, this same study found nearly 30% of athletes were returned to play even when symptoms were present. Undeniable, the consequences of sports-related concussions is of utmost concern and the need for standardized guidelines is unprecedented.
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* Guskiewicz, KM, et al (1997). Alternative approaches to the assessment of mild head injury in athletes; Med Sci Sports Exerc, Vol 29, No 7 Supplement, pp S213-221.
* Sataloff RT, et al (1993) Minor Head Trauma – Assessment, Management, and Rehabilitation. Springer Verlag, New York, NY
