Concussion: Current Concepts in Diagnosis and Management

Influence of pre-existing conditions and concussion history on post-concussion symptom severity and recovery time in collegiate athletes

Mental health conditions and concussion history reported by a collegiate athlete may contribute to prolonged recovery and symptom severity after concussion. This work examined the potential associations among concussion history, pre-existing conditions, and sex relative to initial symptom severity and recovery duration following sport-related concussion (SRC) in a cohort of Division 1 NCAA athletes. This prospective cohort study analyzed symptom severity, recovery and return-to-play times reported post-SRC using data collected as part of the Pac-12 CARE Affiliated Program and Health Analytics Program. Health history questionnaires which included self-reported history of pre-existing conditions were completed at baseline. When consented athletes were diagnosed with a concussion, daily post-concussion symptom scores were evaluated until an athlete was clinically determined to be asymptomatic. Generalized linear and Cox proportional hazards models were used to determine associations between pre-existing conditions and recovery and return-to-play times. 92 concussions met inclusion criteria. Notable differences in initial symptom severity existed between females and males who had mood disorders ([Cohen's d] = 0.51) and ADHD (d = 0.93). The number of previous concussions was a strong predictor of athletes reporting pre-existing mood disorders, depression, anxiety, and ADHD (p = 0.008-0.04). Females with ≥2 previous concussions required more days to return-to-play than males (d = 0.31-0.72). Weekly recovery and return-to-play probabilities substantially differed between athletes that did or did not have learning disorders (HRRecovery = 0.32, HRRTP = 0.22, d = 1.96-2.30) and ADHD (HRRecovery = 3.38, HRRTP = 2.74, d = 1.71-4.14). Although no association existed between concussion history and acute symptom severity, collegiate athletes with a history of concussion had higher probabilities of reporting depression, mood disorders, anxiety, and ADHD. Having ADHD or learning disorders likely strongly affects time to recovery and return-to-play for collegiate athletes.

King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes

CONTEXT

The King-Devick (K-D) test is used to identify oculomotor impairment after concussion. However, the diagnostic accuracy of the K-D test over time has not been evaluated.

OBJECTIVES

To (1) examine the sensitivity and specificity of the K-D test at 0 to 6 hours postinjury, 24 to 48 hours postinjury, the beginning of a return-to-play (RTP) protocol (asymptomatic), unrestricted RTP, and 6 months postconcussion and (2) compare outcomes between athletes with and those without concussion across confounding factors (sex, age, sport contact level, academic year, learning disorder, attention-deficit/hyperactivity disorder, migraine history, concussion history, and test administration mode).

DESIGN

Retrospective, cross-sectional design.

SETTING

Multiple institutions in the Concussion Assessment, Research and Education Consortium.

PATIENTS OR OTHER PARTICIPANTS

A total of 320 athletes with a concussion (162 men, 158 women; age = 19.80 ± 1.41 years) were compared with 1239 total collegiate athletes without a concussion (646 men, 593 women; age = 20.31 ± 1.18 years).

MAIN OUTCOME MEASURE(S)

We calculated the K-D test time difference (in seconds) by subtracting the baseline from the most recent time. Receiver operator characteristic (ROC) curve and area under the curve (AUC) analyses were used to determine the diagnostic accuracy across time points. We identified cutoff scores and corresponding specificity at both the 80% and 70% sensitivity levels. We repeated ROC with AUC analyses using confounding factors.

RESULTS

The K-D test predicted positive results at the 0- to 6-hour (AUC = 0.724, P < .001), 24- to 48-hour (AUC = 0.701, P < .001), RTP (AUC = 0.640, P < .001), and 6-month postconcussion (AUC = 0.615, P < .001) tim points but not at the asymptomatic time point (AUC = 0.513, P = .497). The 0- to 6-hour and 24- to 48-hour time points yielded 80% sensitivity cutoff scores of -2.6 and -3.2 seconds (ie, faster), respectively, but 46% and 41% specificity, respectively. The K-D test had a better AUC when administered using an iPad (AUC = 0.800, 95% CI = 0.747, 0.854) compared with the spiral-bound card system (AUC = 0.646, 95% CI = 0.600, 0.692; P < .001).

CONCLUSIONS

The diagnostic accuracy of the K-D test was greatest at 0 to 6 hours and 24 to 48 hours postconcussion but declined across subsequent postconcussion time points. The AUCs did not differentiate between groups across confounding factors. Our negative cutoff scores indicated that practice effects contributed to improved performance, requiring athletes to outperform their baseline scores.

The "vestibular neuromatrix": A proposed, expanded vestibular network from graph theory in post-concussive vestibular dysfunction

Convergent clinical and neuroimaging evidence suggests that higher vestibular function is subserved by a distributed network including visuospatial, cognitive-affective, proprioceptive, and integrative brain regions. Clinical vestibular syndromes may perturb this network, resulting in deficits across a variety of functional domains. Here, we leverage structural and functional neuroimaging to characterize this extended network in healthy control participants and patients with post-concussive vestibular dysfunction (PCVD). Then, 27 healthy control subjects (15 females) and 18 patients with subacute PCVD (12 female) were selected for participation. Eighty-two regions of interest (network nodes) were identified based on previous publications, group-wise differences in BOLD signal amplitude and connectivity, and multivariate pattern analysis on affective tests. Group-specific "core" networks, as well as a "consensus" network comprised of connections common to all participants, were then generated based on probabilistic tractography and functional connectivity between the 82 nodes and subjected to analyses of node centrality and community structure. Whereas the consensus network was comprised of affective, integrative, and vestibular nodes, PCVD participants exhibited diminished integration and centrality among vestibular and affective nodes and increased centrality of visual, supplementary motor, and frontal and cingulate eye field nodes. Clinical outcomes, derived from dynamic posturography, were associated with approximately 62% of all connections but best predicted by amygdalar, prefrontal, and cingulate connectivity. No group-wise differences in diffusion metrics or tractography were noted. These findings indicate that cognitive, affective, and proprioceptive substrates contribute to vestibular processing and performance and highlight the need to consider these domains during clinical diagnosis and treatment planning.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review

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Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness.

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Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers.

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The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete.

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Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.

White Matter Integrity and Its Relationship to Cognitive-Motor Integration in Females with and without Post-Concussion Syndrome

Fifteen percent of individuals who sustain a concussion go on to develop post-concussion syndrome (PCS). These persistent symptoms are believed to be attributed to damage to white matter tracts and impaired neurotransmission. Specifically, declines in white matter integrity after concussion have been found along the long-coursing axons underlying the frontoparietal network. This network is essential for the performance of visuomotor transformation tasks requiring cognitive-motor integration (CMI). We have previously observed deficits in performance on CMI-based tasks in those who have a history of concussion, but were asymptomatic. The aim of this study was to investigate performance on a CMI task, as well as white matter integrity differences along frontoparietal-cerebellar white matter tracts, in those with PCS compared to healthy controls. We hypothesized an association between the behavioral and brain structural measures. Twenty-six female participants (13 with PCS for ≥6 months and 13 healthy controls) completed four computer-based visuomotor CMI tasks. In addition, diffusion tensor images (DTIs) were acquired. No statistically significant differences were found in CMI performance between groups (p > 0.05). Further, there were no statistically significant differences between groups on any DTI metrics (p > 0.05). However, examination of the data collapsed across participants revealed significant associations between performance on a CMI task and white matter integrity. Further investigation into additional causes of symptoms in those with PCS (including psychological and cervicogenic factors) will strengthen our understanding of this diverse group. Nonetheless, this study demonstrates that white matter integrity is related to levels of performance in tasks that require rule-based movement control.

Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol

Background

Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated.

Objective

To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week).

Methods

In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used.

Discussion

Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations.

Trial registration

ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.

Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby

The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.

A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union

AIM

The aim of the present study was to utilise a systems thinking approach to explore the perceived responsibilities for identifying and treating concussion held by different actors across the community rugby system (e.g., players, coaches, parents, medics, referees, and management), as well as their role-specific concussion management strategies.

METHODS

A systems approach was taken to assess what different stakeholders within rugby systems perceive their roles to be regarding concussion identification and treatment. Through an online survey, 118 members of the amateur (community) rugby union system were asked about their role-specific concussion management responsibilities and strategies. Respondents included players, parents, medics, coaches, club managers, administrators, and volunteers.

RESULTS

The majority of respondents indicated that they were able to identify the symptoms of rugby-related concussion, however, only medics stated their responsibility to use formal concussion assessments (e.g., SCAT2). A smaller number of the respondents indicated that they were involved in treating concussion within their current role/s (majority of which were medics).

CONCLUSIONS

This study illustrated that the current challenges in the identification and treatment of rugby-related concussion in community sport may be due to role/responsibility confusion and possible overreliance on field-side medics. These findings offer insight into the possible limitations of the current concussion management guidelines and may offer empirically based direction for future revisions.

Review of Assessment Scales for Diagnosing and Monitoring Sports-related Concussion

Sports-related concussion has emerged as a public health crisis due to increased diagnosis of the condition and increased participation in organized and recreational athletics worldwide. Under-recognition of concussions can lead to premature clearance for athletic participation, leaving athletes vulnerable to repeat injury and subsequent short- and long-term complications. There is overwhelming evidence that assessment and management of sports-related concussions should involve a multifaceted approach. A number of assessment criteria have been developed for this purpose. It is important to understand the available and emerging diagnostic testing modalities for sports-related concussions. The most commonly used tools for evaluating individuals with concussion are the Post-Concussion Symptom Scale (PCSS), Standard Assessment of Concussion (SAC), Standard Concussion Assessment Tool (SCAT3), and the most recognized computerized neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The strengths and limitations of each of these tools, and the Concussion Resolution Index (CRI), CogSport, and King-Devick tests were evaluated. Based on the data, it appears that the most sensitive and specific of these is the ImPACT test. Additionally, the King-Devick test is an effective adjunct due to its ability to test eye movements and brainstem function.

The effect of concussion history on cognitive-motor integration in elite hockey players

AIM

To observe the effects of concussion history on cognitive-motor integration in elite-level athletes.

METHODS

The study included 102 National Hockey League draft prospects (n = 51 concussion history [CH]; n = 51 no history [NC]). Participants completed two computer-based visuomotor tasks, one involved 'standard' visuomotor mapping and one involved 'nonstandard' mapping in which vision and action were decoupled.

RESULTS

We observed a significant effect of group on reaction time (CH slower) and accuracy (CH worse), but a group by condition interaction only for reaction time (p < 0.05). There were no other deficits found. We discussed these findings in comparison to our previous work with non-elite athletes.

CONCLUSION

Previously concussed elite-level athletes may have lingering neurological deficits that are not detected using standard clinical assessments.

Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review

Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.

Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists

BACKGROUND

A concussion is considered a mild traumatic brain injury that may cause physical, cognitive, affective, and sleep dysfunction. Physical therapists have been identified as health care providers involved in the multidisciplinary care of a patient with concussion.

OBJECTIVE

The purpose of this study was to describe the current attitudes and beliefs, knowledge, and practice of physical therapists in the treatment of patients with concussion.

METHODS

A 55-question electronic survey divided into 6 sections-(1) demographics, (2) current practice in concussion, (3) youth concussion legislation, (4) attitudes and beliefs toward concussion management, (5) concussion knowledge, and (6) clinical decision making-was developed and distributed online through selected American Physical Therapy Association sections.

RESULTS

A total of 1,272 physical therapists completed the survey. Seventy percent of the respondents (n=894) reported having concussion training. Although supportive of the role of the physical therapist in the treatment of a person with concussion, the respondents demonstrated less confidence when making return-to-play decisions. Respondents correctly answered, on average, 13 (out of 15) concussion knowledge questions, with gaps exhibited in understanding the clinical utilization of concussion severity scales, the conservative treatment of youth who sustain a concussion, and anticipated normal computed tomography and magnetic resonance imaging after a concussion. When provided with clinical scenarios, respondents were able to recognize when a referral to a physician was indicated; however, they demonstrated variability in identifying a need for vestibular or manual physical therapy.

LIMITATIONS

Convenience sampling was utilized, limiting generalizability of the results of the study to the physical therapy profession as a whole.

CONCLUSION

Physical therapists demonstrated a solid foundation of concussion knowledge, but gaps still existed. Future professional development opportunities should be developed to target identified gaps in knowledge and current practice patterns.

Prolonged cognitive-motor impairments in children and adolescents with a history of concussion

Aim:

We investigated whether children and adolescents with concussion history show cognitive–motor integration (CMI) deficits.

Method:

Asymptomatic children and adolescents with concussion history (n = 50; mean 12.84 years) and no history (n = 49; mean: 11.63 years) slid a cursor to targets using their finger on a dual-touch-screen laptop; target location and motor action were not aligned in the CMI task.

Results:

Children and adolescents with concussion history showed prolonged CMI deficits, in that their performance did not match that of no history controls until nearly 2 years postevent.

Conclusion:

These CMI deficits may be due to disruptions in fronto-parietal networks, contributing to an increased vulnerability to further injury. Current return-to-play assessments that do not test CMI may not fully capture functional abilities postconcussion.

Factors associated with the onset and progression of neurotrauma: A systematic review of systematic reviews and meta-analyses

Neurotrauma, including traumatic brain injury (TBI) and spinal cord injury (SCI), is a preventable condition that imposes an important burden on the Canadian society. In this study, the current evidence on risk factors for the onset and progression of neurotrauma is systematically reviewed and synthesized. Searches of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Medline and Medline in Process (via OVID), EMBASE and PsycINFO from inception to February 2013 were conducted to identify relevant systematic reviews and meta-analyses published in English or French. Two referees screened and assessed the quality of the studies using the AMSTAR tool. Thirty-two studies examined at least one risk factor for the onset of neurotrauma. Thirteen studies passed the quality assessment and the majority evaluated the impact of protective equipment in sports. Helmets effectively reduce TBI from bicycling, skiing, snowboarding, ice hockey and motorcycling. There was no evidence of a protective effect of helmets for SCI. No studies contributed evidence on risk factors for the onset of SCI. Of two studies examining risk factors for the progression of neurotrauma, only injury severity was found to be associated with poorer post-injury outcomes. Substantial evidence supports the use of helmets for the prevention of TBI in sports and motorcycling and face shields in ice hockey. Addressing bicycle helmet legislation across Canada may be an effective option for reducing TBI caused by bicycle accidents. Limited evidence on relevant risk factors for spinal cord injuries and neurotrauma progression was available.

Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task

This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.

Concussion Treatment Using Massage Techniques: a Case Study

BACKGROUND

Concussion, its recognition, diagnosis, and treatment is a growing public health issue. Massage practitioners who specialize in rehabilitation deal with a variety of injury cases that involve concussion, including those incurred by falls, motor vehicle incidents, and sports injuries.

PURPOSE

This case study presents a unique massage therapy approach to concussion trauma treatment.

PARTICIPANT

Male 23-year-old intramural soccer player diagnosed with postconcussion syndrome resulting from a fall.

INTERVENTION

Assessment and treatment were completed in two sessions of 45 minutes spaced two days apart. Massage therapy techniques were applied to injury areas by a Licensed Massage Practitioner.

RESULTS

Using the Balance Error Scoring System (BESS) and self-report, the outcome measures showed diminished concussion symptoms and regained ease in range of motion in the cervical area.

CONCLUSION

Positive results for this case highlight the potential importance of massage therapy work to reduce headache, dizziness, and nausea in concussion recovery. In the presence of such outcomes, massage therapy may also have a supportive role in a person's return to function after concussion.

School nurses' familiarity and perceptions of academic accommodations for student-athletes following sport-related concussion

The purpose of this study was to evaluate school nurses' familiarity and perceptions regarding academic accommodations for student-athletes following sport-related concussion. School nurses (N = 1,246) accessed the survey School Nurses' Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC-SN). The BAKPAC-SN contained several questions pertaining to concussion management and academic accommodations. There were significant differences regarding personal experience as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an athletic trainer and school nurses who work at a school that does not employ an athletic trainer. There were significant weak positive relationships between years of experience and familiarity with academic accommodations (r = .210, p < .001), 504 plans (r = .243, p < .001), and individualized education plans (r = .205, p < .001). School nurses employed at a single school were significantly more familiar with academic accommodations (p = .027) and 504 plans (p = .001) than school nurses employed at multiple schools. Health care professionals should collaborate to effectively manage a concussed patient and should consider academic accommodations to ensure whole-person health care.