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Research leads to paradigm shift in testing, treatment of concussion
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Increased studies and advances in the treatment and testing of concussion have led to the fall of long-held theories and the creation of new legislation aimed at improving the treatment of concussed athletes.
“During the last 20 years, there has been an impressive amount of research focused on understanding the effects of concussion and the process at a neurobiologic level,” pediatric neuropsychologist Michael W. Kirkwood, PhD, ABPP/CN, of Children’s Hospital Colorado, told Orthopedics Today.
“For quite a while, decades really, concussions were thought to be a trivial injury to the head,” Kirkwood said. “Athletes were told to tough it out — no pain, no gain.”
But, new research has shown that concussions are serious injuries that may initially appear to be benign. One misconception is that concussions only occur with a loss of consciousness, according to Stanley A. Herring, MD, director of Sports, Spine and Orthopaedic Health for the University of Washington Medicine Health System and co-medical director of the Seattle Sports Concussion Program.
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Image: Clare McLean/UW Medicine |
“Concussions are brain injuries, and all brain injuries are potentially serious,” Herring told Orthopedics Today. “You cannot discount them. Each one has to be addressed. You do not know how significant a concussion is until you see it fully develop in terms of signs and symptoms. You cannot make a determination within an hour of the concussion or in the emergency room on how bad the concussion is going to be.”
Athletes may have more serious brain injuries that are not apparent on initial examination.
“Most athletes recover within days or weeks, but a small percentage take a while longer to recover,” Kirkwood said. “They are probably the ones that have more severe initial injuries, ones associated with prolonged loss of consciousness, or findings on neuroimaging like CT scans or MRIs, like bruises on the brain or bleeding on the brain. Those are atypical outcomes.”
Determining return to play
Recent studies suggest that such patients should not return to play until they are fully recovered. Symptoms may be gone, but the athlete may still have severe brain injuries.
“Soon after injury, athletes are encouraged to rest so the brain has time to heal. As athletes feel better, gradually transition them back to sports or activity once they are free of all symptoms,” Kirkwood said.
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Herring recommends that after an athlete has returned to baseline, a period of rest for at least 24 hours be undertaken to “make sure the athlete does not have symptoms with daily activities” and then a stepwise exercise challenge “to make sure the athlete does not have recurrence of concussion signs or symptoms before he or she returns to play.”
This return to play protocol is performed during the span of several days to several weeks and is individualized.
“For someone who has had a concussion that lasted for 10 days, his or her return to play protocol may have a steeper slope than someone who has had concussion symptoms for 3 or 4 months; it may take much longer for that athlete to return to play,” Herring, who is also a team physician for the Seattle Seahawks and Seattle Mariners, said.
Athletes may undergo neuropsychological testing as an adjunct to comprehensive concussion care, according to Herring. They should also be cleared to return to play by a medical professional trained in the diagnosis and management of concussion, which is now required for many youth athletes based on new legislative efforts, and is the policy in many collegiate and professional sports leagues, he said.
Age as a factor
Younger athletes are more vulnerable to concussions because the immature brain has not developed fully and the “musculature around the neck is not as strong,” according to John A. Bergfeld, MD, of Cleveland Clinic Sports Health and Orthopedics Today Sports Medicine Section Editor.
“It’s kind of alarming, for the Centers for Disease Control and Prevention (CDC) suggests that over 130,000 kids between the ages of 5 [years] and 18 years make emergency room visits every year because of concussions,” David A. Wong, MD, MSc, FRCS(C), of Denver Spine, told Orthopedics Today.
The younger the athlete, the longer he or she will take to recover. The average recovery time for an adult athlete is 5 days to 7 days compared with 10 days to 14 days in a younger athlete, according to Herring.
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He recommends a more conservative approach to younger athletes, using the adage, “When in doubt, sit them out.”
In addition, Bergfeld noted that second impact syndrome, where an athlete has another concussion and then has a severe reaction, occurs in adolescent brains and is extremely rare in the mature brain.
New legislation
The increasing awareness of the gravity of concussions has led to new and proposed legislation at the state and federal levels.
Middle school football player Zackery Lystedt, of Washington State, suffered a blow to the head and, after sitting out briefly, was returned to the game by his coach. There were no medical personnel on site as is often the case, Herring noted. As the game progressed, Zackery took several more blows to his head and became increasingly confused as well as complaining of a worsening headache. At the end of the game, Zackery collapsed and was airlifted to Harborview Medical Center where he underwent emergency brain surgery. Zackery survived, Herring noted, but faces a life time of significant physical and cognitive challenges. This event motivated many organizations and individuals to work along with the congressional representative from Zackery’s district to pass a concussion law requiring education of athletes, parents and coaches, removal from practice or play at the time of a suspected concussion, and written medical clearance for return to practice or play. This was the first law of its kind in the country, Herring noted, and now is known the Zackery Lystedt Law. According to Herring, there is similar legislation in place in 27 states and in the District of Columbia, and many other states are actively considering concussion laws.
Herring also testified to Congress about a new federal law, Protecting Student Athletes from Concussions Act of 2011 (H.R. 469).
The federal law, if passed, would enact new rules about return to play for student athletes. Among the provisions, many of which are similar to the Lystedt law, student athletes must:
- be removed from play immediately after sustaining a concussion;
- receive written consent from a health care professional stating the student is capable of returning to play; and
- have a plan that helps students prepare for return to sports activity including cognitive and physical rest on a progressive basis.
The law would call for the removal of federal funding from institutions if the law is not followed. The law is based on recently released CDC guidelines about return to play for athletes called the Heads Up Program.
“For health care providers, increased awareness and legislation has made return to play a medical decision — and not a coach or parent decision — as it should be,” Herring said.
New baseline test methods
In the past, there were more generalized criteria for evaluating concussions, according to Wong.
“We used the gross types of evaluations similar to the things that you do in the emergency department, and assessed levels of consciousness and orientation to person, place and time,” Wong, an Orthopedics Today Editorial Board member, said.
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The recently developed Sports Concussion Assessment Tool 2 (SCAT2) and the National Football League’s (NFL) Sideline Concussion Tool allow physicians, athletic trainers and other healthcare providers to systematically approach a sports concussion, and if baseline assessment is performed, allow comparison of athletes’ baseline data to their current, specific physical and cognitive symptoms.
“[The SCAT2] brings out some of the subtle changes that might not be apparent if you just took a visual look at somebody,” Wong said.
Wong also recommends educating trainers and other professionals to use this tool as a precaution against athletes immediately returning to play after concussion.
Another type of baseline testing, computerized neuropsychological testing, has seen rapid growth, and post-injury testing can be compared to baseline testing checking for residual symptoms and cognitive problems after a concussion, Herring noted.
However, Kirkwood recommends against depending solely on baseline testing.
“It is somewhat controversial because some of the tests being used are not as statistically reliable as we would want them to be, and it is not real clear that those tests actually made a difference in outcomes,” Kirkwood said. “From a scientific perspective, there are still some questions that need to be answered.”
If used, Herring noted, that such testing is best done as part of a complete concussion management diagnosis and treatment plan.
Patient evaluation
Most importantly, according to Kirkwood and Herring, evaluations must remain comprehensive and systematic. Assessments must be done in a standardized fashion using tools such as the SCAT2 or NFL form, according to Herring.
“Approaching evaluations in an organized fashion will improve care,” Herring said. “Having baseline data is helpful. It allows something for comparison after an athlete gets concussed. You want to know how well someone can do a balance test before they get concussed. You want to know if they can repeat five numbers backwards before they get concussed.”
More comprehensive evaluations assess both physical problems like balance disturbance and mental changes such as processing speed, attention and memory, according to Kirkwood.
While rest is the standard treatment for concussion, submaximal exercise has been reported to expedite recovery for athletes with persistent symptoms, according to Herring.
“Initial work is being done with submaximal exercise on athletes with persistent symptoms to see whether lower doses of exercise can be tolerated to perhaps not delay recovery, but improve it,” Herring said.
Education efforts
Herring and Wong suggest orthopedists educate themselves to become comfortable with diagnosing concussions. As a first step in preventing concussion, they also recommend educating coaches, athletes and parents about the seriousness of concussions and young age as a risk factor.
“We want to make people aware of the dimensions of the problem,” Wong said.
Online programs such as the CDC’s Heads Up and the Safe Concussion Outcome and Recovery Educational Program (SCORE) aim to increase education about concussions. Concussion education for health care providers is also important, and the CDC will soon release a free online course for the medical community, Herring noted.
Bergfeld also recommends that all team physicians speak with their coaches about recent concussion medical guidelines and legislation.
“Let the coaches know ahead of time that no return to play following any concussion is what the policy is going to be, because coaches are used to athletes getting a mild concussion and being put back in the game,” Bergfeld said.
Future research, technologies
Studies continue to investigate the effects of long-term repetitive head injuries and whether they cause brain diseases such as chronic traumatic encephalopathy, dementia or amyotrophic lateral sclerosis.
“It is difficult to prove because these are things that take a lifetime to evaluate, and there are people who never had a concussion and who have dementia,” Bergfeld said.
Herring recommends that athletes with repeat concussions be monitored between concussive episodes to “make sure they are all the way well.” He also said that the athletes should be monitored for modifiers or risk factors — including the number, severity and proximity of previous concussions, learning disabilities, attention deficit disorder/attention deficit hyperactivity disorder, migraine headaches, depression and anxiety — that may make the decision for continued participation more challenging.
Newer imaging technologies may hold promise, such as diffusion tensor imaging and functional MRI, he said.
“These allow newer ways to look at brain function and neuronal pathways” Herring said.
However, researchers are not yet sure what the results of these tools mean.
“Currently, the diagnosis and management of concussion is a clinical skill,” Herring said. “It remains within the purview of the practitioner’s knowledge and experience. If you are going to make the decision to take care of someone with a concussion, then you have to be comfortable with your skill set. This is just like you do if you are going to see an athlete with knee pain and shoulder pain — only this one can have life-threatening consequences.” – by Renee Blisard
References:
- www.cdc.gov/concussion/HeadsUp/youth.html www.childrensnational.org/score/
- www.thomas.loc.gov
- John A. Bergfeld, MD, can be reached at Cleveland Clinic, 9500 Euclid Ave., A-41, Cleveland, OH 44195, 216-444-2618; email: bergfej@ccf.org.
- Stanley A. Herring, MD, can be reached at Harborview Medical Center, 325 Ninth Ave., Box 359721, Seattle, WA 98104; 206 744-0401; email: sherring@uw.edu.
- Michael W. Kirkwood, PhD, ABPP/CN, can be reached at University of Colorado School of Medicine, Department of Physical Medicine and Rehabilitation, B285, Children’s Hospital Colorado, 13123 E. 16th Ave., Aurora, CO 80045; 720-777-6193; email: michael.kirkwood@childrenscolorado.org.
- David A. Wong, MD, MSc, FRCS(C), can be reached at Denver Spine, 7800 East Orchard Road, Suite 100, Greenwood Village, CO 80111; 303-860-1500; email: ddaw@denverspine.com.
- Disclosure: Bergfeld, Herring, Kirkwood and Wong have no relevant financial disclosures.
What are your thoughts on baseline concussion testing? Is this necessary and, if so, at what level of play?
No clear evidence for this practice
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Baseline neurocognitive testing for management of sports-related concussion has been widely touted as standard of care for athletes involved in contact sports. The utility of such testing lies in its ability to identify athletes who claim to be asymptomatic after a concussion but, in fact, are at risk for more severe injury from a repeat concussion, such as the second-impact syndrome, post-concussion syndrome or problems later in life. Unfortunately, evidence proving concussion testing can do any of this is lacking, and in fact, these tests have been shown to have relatively low sensitivity and poor reliability.
We know that concussions occur very commonly during contact sports, like football, and often go unreported. However, the vast majority of sports-related concussions are minor and do not result in known serious sequelae. On the other hand, serious complications from concussions are rare. The second-impact syndrome, perhaps the primary reason for doing baseline neurocognitive testing, has been estimated to occur once in every 18 million player seasons. Given the extremely low incidence of this complication and no clear evidence that concussion testing can help prevent it, one must be very skeptical about adopting routine testing as a standard of care. It is also important to understand that concussion testing can do nothing to prevent the most common catastrophic complication of sports-related head injury, acute subdural hematoma.
The use of concussion testing today has been driven largely by publicity surrounding the rare catastrophic complications from a sports-related concussion and a lack of understanding about how to prevent them, along with concerns about liability. However, during times of stretched school budgets, it does not make sense to recommend a costly test (in the range of $5,000 per team each season) until there is more clear evidence for its utility.
Robert Sallis, MD, FAAFP, FACSM, is
the past president of the American College of Sports Medicine and co-director
of the Sports Medicine Fellowship at the Kaiser Permanente Medical Center, in
Fontana,Calif., and head team physician at Pomona College, Claremont, Calif.
Disclosure: Sallis has no relevant financial disclosures.
Not essential, but desirable
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I do not think that baseline concussion testing is essential, and what we are talking about is testing with neuropsychological computer-based platforms, but I think they are desirable. I do think that a baseline neurologic assessment is very desirable. In other words, knowing what the neurologic exam of an individual shows prior to the season, especially doing a detailed balance assessment perhaps in using the BESS [Balance Error Scoring System]. Only when one knows what one’s baseline is can one make accurate assessments as to whether one has changed from that baseline. Whether it is doing computer-based neuropsychological testing or whether it be doing balance testing, it is very helpful to know what one’s baseline is. It’s not absolutely essential though to have those records, and it’s not absolutely essential to use neuropsychological computer-based testing to make return to play decisions.
The reason for the baseline testing is that the symptom checklist is something that the athlete cannot necessarily give you accurate answers to, and by having a baseline neurologic assessment including neuropsychological testing and/or balance testing, one has an accurate level to compare to.
It is most desirable to have this at all levels of play where you are going to be making return to play decisions. The realities are though that youngsters under the age of 10 years really cannot be tested with the same computer-based platforms as individuals over the age of 10 years. Essentially, we’re talking about people in the junior high, high school age especially the ages where this is of value, but it is of value at all ages above the age of 10 years.
Robert C. Cantu, MD, is co-director
for the Center for the Study of Traumatic Encephalopathy and clinical professor
of neurosurgery at Boston University School of Medicine.
Disclosure: Cantu has no relevant financial disclosures.