Why is diagnosis and management of sportrelated concussions challenging A physical and cognitive examinations are often normal B concussions are subtle and difficult to detect with existing concussion assessment tools ID: 763214
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Why is diagnosis and management of sport-related concussions challenging? A) physical and cognitive examinations are often normalB) concussions are subtle and difficult to detect with existing concussion assessment toolsC) may manifest with delayed-onset symptomsD) “Signal detection” on clinical measures (e.g., cognitive and balance testing) often quickly diminishesE) Student-athletes may underreport symptoms and inflate their level of recovery in hopes of being rapidly cleared for return to competition.F) Clinical assessment of sport-related concussion is an index of recovery and not a direct measure of brain structure and functional integrity. Diagnosis and Management of Sport-Related Concussion Guidelines. http://www.ncaa.org/health-and-safety/concussion-guidelines . Retrieved 2015-12-22
What are the Return to Play Guidelines? Appropriate diagnosis, referral, and patient/family education are critical for helping patients with concussions achieve optimal recovery and to reduce or avoid significant adverse health outcomes. A set of protocols designed to help health care providers direct their care appropriately progressing the concussed athlete back into active competition.http://www.cdc.gov/headsup/providers/return_to_activities.html Retrieved 2015-12-22
Return to Home/Community - Increased rest and limited exertion- Cautious about return to driving- Sleep at night and daytime naps/rest breaks - Symptoms guide the level of safe activity http://www.cdc.gov/headsup/providers/return_to_activities.html Retrieved 2015-12-22
Return to Work Physical: - fatigue/sleep disturbances require taking more breaks- reduce lights and noises- avoid symptom aggravationshttp://www.cdc.gov/headsup/providers/return_to_activities.html Retrieved 2015-12-22 Cognitive: reduce level of work demand, computer time, stressful situations/meetings, define tasks more clearly Emotional: time out breaks, a support/liason coworker
Return to School A student may feel frustrated, sad, and even angry because they cannot return to school right away and/or keep up with schoolwork. Support can include environmental adaptations, curriculum modifications, and behavioral strategies.- 504 Plan- Individualized Education Plan (IEP)- Response to Intervention Protocol (RTI) http://www.cdc.gov/headsup/basics/return_to_school.html . Retrieved 2015-12-07
The provision of a tutor/assistant to help with organizing homework activities and completing out-of-class assignments. The provision of a quiet, nondistracting room for taking exams.Allowing a laptop or other word processing device for typing notes in class and/or the provision of a note taker. Allowing tape recording of lectures for further review. The provision of extra time for exams with writing emphases. Allowing use of calculator and computer programs (e.g., spell checker) to complete assigned projects and examinations. The provision of written handouts from professors, whenever feasible, to minimize the need to write and organize information visually. RECOMMENDATIONS FOR EDUCATIONAL ISSUES
Return to Play Guidelines 1. rest until asymptomatic (physical and mental rest)2. light aerobic exercise (e.g. stationary cycle)3. sport-specific exercise 4. non-contact training drills (light resistance training)5. full contact training after medical clearance6. return to competition (game play)Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport , Zurich, November 2012. J Athl Train. 2013 Jul-Aug;48(4):554-75. doi: 10.4085/1062-6050-48.4.05. PMCID: PMC3715021 - An athlete should not return to practice or play the same day as the mTBI - Full recovery prior to their return to play
Graduated Return to Play Protocol - proceed to the next level if asymptomatic at the current level. - If symptoms occur, drop back to the previous level and try to progress again after a further 24-hour period of rest.- each step should take 24 hours so that an athlete would take approximately one week to proceed through the full protocolConsensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train. 2013 Jul-Aug;48(4):554-75. doi: 10.4085/1062-6050-48.4.05. PMCID: PMC3715021 - full competition once they are asymptomatic at rest and with provocative exercise.
Modifying Factors in Return to Play Protocol Symptoms: Number, Duration (>10 d), SeveritySigns: Prolonged loss of consciousness (>1 min), amnesia, dizzinessSequelae: ConvulsionsTemporal: Frequency - repeated concussions over time Timing - injuries close together in time Recency - recent concussion or traumatic brain injury Threshold: Repeated concussions occur with progressively less impact force or slower recovery after each successive concussion Age: Child and adolescent (<18 y) Comorbidities and premorbidities: Migraine, depression, or other mental health disorders; attention-deficit hyperactivity disorder; learning disabilities; sleep disorders Medication: Psychoactive drugs, anticoagulants Behavior: Dangerous style of play Sport: High-risk activity, contact/collision sport, high sporting level
The significance of dizziness Dizziness at the time of injury was associated with a 6.34 odds ratio of a protracted recovery from concussion.Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?Lau BC1, Kontos AP, Collins MW, Mucha A, Lovell MR. Am J Sports Med. 2011 Nov;39(11):2311-8. doi: 10.1177/0363546511410655. Epub 2011 Jun 28. PMID: 21712482 The other on-field signs and symptoms were not associated with an increased risk of protracted recovery in this study. The Dizziness Handicap Inventory ( DHI ) Questions are designed to incorporate functional (F), physical (P), and emotional (E) impacts on disability.
The intention of the sport specific guidelines is: - to maintain the integrity of the current six‐step RTP model- add a moderate activity phase highlighted by resistance training- provide contact and limited contact drills specific to the athlete's sport and/or position. American Academy of Pediatrics PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129 Pediatric RTP Guidelines (football)
Pediatric RTP Guidelines (football) - An athlete should not return to practice or play the same day as the mTBI- Full recovery prior to their return to play - Return to previous stage if symptoms recur1. Rest until asymptomatic (physical and mental rest) Objectives: Recovery and elimination of symptoms PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129
- Computers and video games - Television viewing - Texting - Reading or writing - Studying or homework - Taking a test- Complete significant projects - Loud music - Bright lights - Caffeine/Sugar PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129 avoid/limit exertion with activities of school/daily living that require concentration and/or mental stimulation including: Cognitive Rest
10‐15 min of walking or stationary bike 2. Light aerobic exercise Objectives: Add light aerobic activity,monitor for symptom returnPediatric RTP Guidelines (football) Neurogenesis and exercise: past and future directions. van Praag H . Neuromolecular Med. 2008;10(2):128-40. doi: 10.1007/s12017-008-8028-z. Epub 2008 Feb 20. PMID 18286389 Physical activity causes: - improved mood and cognition - a robust increase in neurogenesis [new hippocampal neurons may improve learning]
20‐30 minutes of jogging w/helmet Resistance training ‐ body weight squats and push‐ups [1 set of 10 reps each]3. Moderate aerobic activity, Light resistance trainingObjectives: Increase aerobic activity and monitor for symptoms Assessing an athlete's tolerance to resistance training is important because weight training can increase intracranial pressure and exacerbate post concussive symptoms. PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129 Pediatric RTP Guidelines (football)
4. Non-contact training drills Objectives: Maximize aerobic activityAccelerate to full speed with change of directions (cuts)Introduce rotational head movementsMonitor for symptomsMoving in/out 3 point stance, bear crawls through tunnel, tires, step over bags (vertical and lateral), QB/center exchange, QB drop backs, passing, jump cuts, backpedaling, match the hips, up/downs Pediatric RTP Guidelines (football) PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129 *Start w/o helmet; progress to helmet/shoulder pads if symptom free
workout in full pads(focus on technique‐head up, square up, stay low) Hit/push pads/sled, step and hit, run and hitleverage drill, punch drill5. Limited contact training after medical clearanceObjectives: Maximize aerobic activityAdd deceleration/rotational forces in controlled setting Monitor for symptoms Pediatric RTP Guidelines (football) PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129
Normal training activities 6. Full contact practice after medical clearanceObjectives: Reassess for symptoms every 30 minutes throughout the practice. Monitor for symptoms.Pediatric RTP Guidelines (football) PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129
Normal game play Consider one side of the ball onlyand/or no special teams play7. Return to competition (game play)Objectives: Assess frequentlyMonitor for symptoms Pediatric RTP Guidelines (football) PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May , D Marshall , T Burns , D Popoli , J Polikandriotis . Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129
RTP Medico-Legal Issues Torta wrong or injury suffered by a person as the result of another person's conduct[Negligence is an unintentional tort] A tort is committed when a provider fails to act as an ordinary and reasonably prudent person under similar circumstances and causes injury to another person. Intentional - the person intended to act vs. Unintentional - the person did not intend to cause harm
RTP Medico-Legal Issues The 4 legal elements of negligence are:1) a duty of care was owed as a result of a relationship that existed2) the defendant breached the duty owed to the injured party 3) the breach of the duty is proved to be the cause of the harm 4) actual harm, not just the potential for harm, must have occurred Negligence those who are harmed as the result of others' carelessness or failure to properly carry out responsibilities. All 4 elements of negligence must be proven in order for the plaintiff to be compensated by the defendant for damages.
- DC’s may evaluate, diagnose and manage concussed patients - providers have an obligation to maintain current knowledge- TBI patients should be observed directly, receive serial exams and not be left alone until symptoms are staticACBSP Position Statement on Concussion in Athleteshttp://acbsp.com/sites/default/files/2014%20CONCUSSION%20statement.pdf. Retrieved 2015-12-17Position Papers Only a health care professional properly trained in standard and accepted protocols should be allowed the responsibility of releasing a patient to return to cognitive and physical activities. We feel that today’s chiropractors are equipped with this knowledge and are qualified for this important role in concussed athletes. Concussion_CCC_Kansas_Testimony.pdf. Retrieved 2015-12-23
Auto accidents account for 17.3% of all traumatic brain injuries in the U.S., second only to falls (35.2%). Why are DC’s are positioned to be at the forefront of treating concussed patients?http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdfRetrieved 2016-01-04 Who is treating these people?
DC’s are at the forefront of treating concussed patients Neurophysiological effects of spinal manipulation.Pickar JG1. Spine J. 2002 Sep-Oct;2(5):357-71. PMID: 14589467Spinal manipulation impacts:1) sensory and motor neurons 2) pain processing Effectiveness of manual therapies: the UK evidence report. Bronfort G 1, Haas M , Evans R , Leininger B , Triano J . Chiropr Osteopat. 2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3. PMID: 20184717 Spinal manipulation/mobilization is effective for: -neck and low back pain, headache, dizziness, joint pain - we improve musculo-skeletal mobility and strength - we help restore normal neurological function - we help release nerve entrapment - we can evaluate, diagnose and rehabilitate proficiently - we can document RTP progression