Being a strong proponent of active care I encourage many people to become more active, to move with better quality, and to then move more frequently. For the majority, I think this is quality advice, but as with all clinical interventions a key component lies in knowing when not to apply that strategy. Active care may be contraindicated in a few different conditions, but one is in those experiencing concussion symptoms.
Recently I had the opportunity to attend the 9th Annual Sports-Related Conference on Concussion and Spine Injury (May 18, 2012). While I must admit that my background in concussion management is not as strong as I would like it to be, I felt compelled to attend to strengthen my understanding so I would better be able to discuss this hot button topic with my patients and community. Ultimately I see my role as a chiropractor in recognition of symptoms, prescription of sparing advice, reassurance, and referral for appropriate monitoring. To do this effectively I needed to know more. I found this conference to be a top notch assembly of exceptional health care professionals, former elite athletes, and researchers. I left with an appreciation for all that goes into studying and managing concussions and appreciating that there is still a lot to learn. Some points of interest, reviewed concepts, and things that peaked my curiosity below.
From William Meehan III, MD, the history of concussion was discussed. It was known from the slaughterhouse that rotational acceleration was necessary to stun the animal and that blunt head trauma alone (head stabilized during the trauma) did not produce the dazed reaction they were looking for. {Upcoming post on how often we know things before science catches up…. Soon.} The role of second impact syndrome or repeated concussion is a hot topic these days, but was first described by Gronwall in 1975 who noted in his research that the 2nd concussion commonly took longer for recovery of symptoms. Why are we sometimes so far behind ourselves?
(Overview) Management of a concussion:
- Rule out other injury (on the field ABCs, then consider fracture, intracranial hemorrhage, and other life threatening conditions)
- Physical rest (avoid working out so ATP & glucose is not stolen from the brain where it is needed for recovery efforts.)
- Cognitive rest (avoid mental activity using precious ATP & glucose that’s needed for healing.)
- Emotional rest (same rationale as above)
- Follow up and reassess for patient to be symptom free.
- Evaluate with PCSS- Post Concussive Symptom Scale
- BESS Balance Error System Score: Double leg stance, Single leg stance, Tandem Stance (20s)
- Neurocognitive (ImPACT and similar tools): Verbal memory, visual memory, processing speed, & reaction time
- When symptom free return to participation (RTP) stages
- Rest (physical, emotion, cognitive; as described above)
- Light aerobic
- Sport specific (low intensity) training
- Non-contact training drills
- Full contact
- Game play
Neuropsychologist Alex Taylor, PsyD reminded us that concussion is a silent disease. Those suffering with it often appear healthy and normal. Considering that 90% of concussions do not involve a loss of consciousness, MRI and/or CT are likely to be negative, and there are no dramatic outward signs (seizures, emesis, blood, bruise, cast, splint, etc), these injuries can often go under appreciated. Particularly in students this can include parents, teachers, coaches, and friends.
He also noted significant role of computer based testing. His explanation was that this testing was more sensitive than symptom reports only, but he emphasized the greatest sensitivity when combining the two:
- 64% accuracy with symptom reporting
- 83% accuracy with neuropsychologic (computer) testing
- 93% accuracy when combining both (the comprehensive approach is best).
- As each individual recovers differently, evaluation and reevaluation is essential.
From Robert Cantu, MD - Ways to prevent concussions:
- avoid taking unnecessary hits (non-contact practice)
- CTE is more about repetition that significance of trauma; observe the most frequent positions in football – linebackers & lineman; mores than receiver.
- Consider ‘hit’ count for kids, similar to pitch count in baseball. Considering that pitching produces surgically repairable injuries and head trauma causes irreparable damage this should be given strong consideration.
- proper technique (don’t lead with the head)
- adequate hydration
- having the right genetics (good luck modifying this risk factor)
- rules changes
- strengthen your neck *** see discussion below***
My side comment: (Note: I have no strong evidence to support this, just my thoughts.)
Dr. Cantu was not the first or last to note ‘neck strength’ as a primary factor in concussion prevention during the conference. As this was discussed my mind immediately jumped to the role of ‘core strength’ in prevention of back pain. Core strength is/was commonly discussed as being preventative for back pain. Research on this tends to be less decisive than the commonly accepted statement that a ‘strong’ core is protective for the back. I wonder if this statement on ‘neck strength’ is equally well liked for it’s plausibility, but will also result in marginal or less than perfect correlation during research. I suspect that the role of ‘timing’ of neck muscle activation plays a more significant role that ‘strength’.
This was demonstrated well in Cholewicki’s work. [Here or even more clearly here.] To look at this in more common terms, let’s compare it to a car accident. I don’t think the ‘strength’ of the brake is the best determinant of injury during a motor vehicle accident, it is much more likely that the ‘speed’ or ‘timing’ of applying the brake has a more significant correlation on how well injury can be avoided. Particularly when considering the role of external perturbation in Cholewicki’s study and the fact that some of the concussion-causing trauma is unanticipated. The natural timing and response of the cervicocranial stabilizers appears to have the best chance of being protective by mitigated rotational forces. (Again, this is just my speculation.) During a brief conversation with Dr. Cantu he noted that he was unaware of any research done on concussions and cervical timing.
Childhood concussions with Dr. Gerard Gioia – a wealth of info, but this one resonated with me as it sounds much like what we (should) do to properly manage so many NMS conditions. Have them do activities they can tolerate, help them learn what they can and can’t do, and “Teach them the sweet spot”. This results in active rest and active management which is then gradually increased.
Clinical Pearls:
-Younger brains need to be managed more conservatively.
-For unknown reasons, concussed females show a greater decrease in neuropsychological scores than males.
Ted Johnson (former NFL All-pro middle linebacker (paraphrased):
This is an exciting time for medical providers and scientists with all the new research. It’s a terrifying time for patients as there is much attention, but so little is known.
Most of my concussions came in practice, not in games.
Players don’t know the long term effects of concussions. I didn’t know & don’t tell me I did!
Before meeting my current concussion specialist, I was recommended for electroconvulsive therapy (ECT) because they didn’t know what else to do with me.
Links of interest:
Ted Johnson @ Harvard Concussion Conference NESN story & video
Ben Utecht: Tell me if his story makes you wonder about the significance of these injuries. Not only did he not recall being at his friends wedding, he didn’t recall that he sang at the wedding. Doesn’t seem like an occasion you should need photographic evidence to refresh your memory. http://espn.go.com/nfl/story/_
CDC Concussion info (with good video for the lay public)
It is wonderful to be able to increase awareness about Concussions and to remove the player from contact and potential further injury.
The stages of returning is where everyone is missing the big picture and why we are seeing kids getting second concussion or even worse.
We have found the problem that occurs when there is a Concussion and we have shown it to 100% of our patients families before able to help them rather than wait and test.
It is literally two different worlds with two entirely different outcomes.
What can I say, we just have the simple explanation and correction which yields the desired result.
Now my task is to meet the right people so we can get this vital information to the world.