What is your Sports IQ?

Wayne Gretzky, Tom Brady, Michael Jordan…some of the greatest athletes to play their sport and backed by a long list of records and championships.

But what made them so great? Talent, hard work or is it something else?? When we think of great athletes one of the most common things we say is “how did they do that?”. Truly elite athletes are just smarter, but not in the academic sense, but rather their sports IQ is just that much better than others.

Sports IQ describes how an athlete excels in terms of the thinking side of the game, but it is not as simple as that. Sports IQ is a combination of vision, reaction time, decision making and sports skills. An athlete who can see the whole field of play, make quick and accurate mental decisions, send those message to their body and properly execute the skills needed will be the most successful in the end. The best athletes don’t always have the best sport skills like the fastest shot or being the fastest runner, but rather they have brains that can just flat out think faster!!

Some athletes are born with an excellent sports IQ, but for the rest of the us, the good news is that this can be developed with practice and appropriate training. In particular, developing cognitive skills has shown to best the best way to improve your Sports IQ.

At Honsberger Physio+ we can evaluate your sports IQ by examining your:

* Visual skills

* Decision making

* Hand eye coordination

* Concentration and focus

* Cognitive skills

Are you at risk of Cognitive Decline? Your partner might know best 😉.

Researchers at Penn State university examined over 800 middle-aged men over a 12-year period to determine their risk for cognitive decline.

In this study, published in the journal Gerontologist, researchers measured a variety of cognitive skills such as memory and processing and compared these to sexual health. In particular, they evaluated erectile strength, orgasms, and intercourse satisfaction.

Erectile dysfunction is often linked to negative changes in the circulatory system and men with ED issues have an increased risk for cardiovascular disease. Research has shown that poor cardiovascular health is a risk factor for dementia and other cognitive declines.

A conclusion of this study was a decrease in erectile function and sexual satisfaction were both associated with cognitive decline which matches results from earlier studies.

Tracking sexual health in middle-aged men may help identify those at risk of cognitive decline. Examples of tracking may include discussions with family practitioners, pharmacists, or physiotherapists, especially those involved in pelvic health physiotherapy, to help men at risk mitigate this potential cause of cognitive decline.

Healthy Aging Brain Program

Overview and program rationale at Honsberger Physio+

Cognitive testing checks for problems with cognition. Cognition is a combination of processes in the brain that is involved in almost every aspect of life. It includes thinking, memory, language, judgment, and the ability to learn new things. A problem with cognition is called cognitive impairment.

There are many causes of cognitive impairment. They include side effects of medicines, blood vessel disorders, depression, and dementia. Dementia is a term used for a severe loss of mental functioning. Alzheimer’s disease is the most common type of dementia.

• 10% of people over the age of 65 live with mild cognitive impairment. 
• 65% of these people go on to develop some form of dementia.

We take our vehicles in for regular check ups, our furnaces gets annual maintenance work, and people go for regular physicals with their family MD (less often for men), yet less than 20% of those over 65 get a regular cognitive assessment.

Honsberger Physio+ is excited to be offering a comprehensive cognitive assessment which will launch in the next few months. Our expertise and reputation in concussion management as well as sports vision training opens the door to another form of neurocognitive health. Using a validated cognitive assessment tool and Honsberger Physio+ own concussion assessment protocol as leading components, the goal is to provide a one of a kind cognitive evaluation experience without rivals.

Cognitive testing is often used to screen for mild cognitive impairment (MCI). People with MCI may notice changes in their memory and other mental functions. The changes aren’t severe enough to have a major effect on daily life or usual activities. But MCI can be a risk factor for more serious impairment.

A person may need cognitive testing if they show signs of cognitive impairment. These include:

• Forgetting appointments and important events
• Losing things often
• Having trouble coming up with words that you usually know
• Losing your train of thought in conversations, movies, or books
• Increased irritability and/or anxiety

Many people who are developing dementia or already have it do not receive a diagnosis. A study showed that physicians were unaware of cognitive impairment in more than 40 percent of their cognitively impaired patients. The problem of underdiagnosis is even more pronounced in underserved populations and in those with lower educational attainment. Another study found that more than half of patients with dementia had not received a clinical cognitive evaluation by a physician. The failure to evaluate memory or cognitive complaints is likely to hinder treatment of underlying disease and comorbid conditions, and may present safety issues for the patient and others. In many cases, the cognitive problem will worsen over time.

Benefits of early detection:

• Ensuring individuals receive the most benefit at the earliest point possible from treatment options
• More time to plan for the future
• Lessened anxieties about unknown problems
• Increased chances of participating in clinical drug trials, helping advance research
• An opportunity to participate in decisions about care, transportation, living options, financial and legal matters
• Time to develop a relationship with doctors and care partners
• Benefit from care and support services, making it easier for them and their family to manage the disease

Program Goals

Goals of the Program for our Clients

• Provide a detailed cognitive evaluation of the aging healthy brain
• Annual/ semi-annual re-evaluations to monitor changes in cognitive status
• Identify lifestyle goals that may out an individual at risk for cognitive decline
• Create an intervention plan to assist in maintenance a healthy brain
• Referral back to the family doctor for a more detailed evaluation for those at risk

In general, one should consider having an annual cognitive evaluation :

1.Age
Baseline creation in the early 30s is ideal to see the brain at its best capacity
Age 50 is when many cognitive issues may be self-identified
2.Lifestyle factors
Smoking history, sedentary lifestyle, or cardiovascular risk factors ( high blood pressure, high cholesterol, diabetes)
3.Family history of dementia or Alzheimer’s
4.Gender
· In women, menopause and the decreased estrogen may accelerate the cognitive decline.
5. Concerns regarding brain function such as memory, decision making, following instructions or concentration.

Efan Gonsalves PT

efan@honsbergerphysio.com

Cognitive Decline: the aging brain

Do you struggle for words or forget why you came into a room?

If so, your might be dealing with a condition called mild cognitive impairment (MCI). Up to 10% of individuals over 65 years of age deal with this daily.  Of greater concern is that 65% of these individuals may develop Alzheimer’s or other forms of dementia.

Age related changes in the brain are normal. Many thinking abilities peak at the age of 30 then subtly decline as age increases.  Normal changes include a slowness in thinking, difficulty sustaining attention, difficulties with multitasking holding information in mind, and word finding. Normal age-related declines are subtle and mostly affect speed of thinking and attention control.

With abnormal brain aging, declines in cognition are more severe and may include other thinking abilities such as rapid forgetfulness, difficulty navigating, challenges with solving common problems, losing the ability to organize tasks, expressing oneself in conversation or behavior outside of social norms. This may also include motor symptoms such as tripping falling or tremors.

Cognitive Decline risk factors:

• Head injury history
• Type 2 diabetes
• High blood pressure
• Midlife obesity
• Smoking
• Depression
• Little or no physical activity
• Little or no mental activity
• Sleeping less than 7 to 8 hours per night

In a study release earlier in 2021, researchers analyzed 25 years of data on more than 14,000 people in the Atherosclerosis Risk in Communities Study. When compared to people who never sustained a head injury, one previous head injury upped dementia risk by 25%. A history of two or more head injuries was associated with more than two times the risk of developing dementia 25 years later, the study showed. Almost 10% of all dementia cases in the study were related to history of head injury after age 45, and this elevated risk was seen for all types of dementia, including Alzheimer’s disease.

Although a cognitive decline is normal, this can be slowed or even reversed through a variety of interventions such as:

• Regular moderately high exercise
• Controlling cardiovascular risk factors
• A healthy diet with fresh fruit and vegetables whole grains and lean proteins
• Participating in mentally and social stimulating activities

Another important step, just like an annual physical check up, is a brain health check up in which signs of cognitive decline can be assessed, tracked and best of all intervened.  A good brain health assessment should include an evaluation of concentration and focus, decision making, memory, visuospatial awareness, motor function and balance, as well as assessing sleep, activity levels and overall mood.

Although Cognitive decline is a natural part of aging, you can take steps now to see where you currently stand and then plan a positive intervention, which is key to a healthy and enjoyable life.

Concussion and Cognitive Decline

A study published in The Lancet in April 2018 was one of the largest of its kind to look at the link between dementia risk and traumatic brain injury (TBI). A TBI is defined as any head injury that disrupts brain function brain, with leading examples including motor vehicle accidents, assaults, and falls.

After studying the link between TBI and cognitive decline, the Danish and US researchers concluded that the younger a person is at the time of the injury, the greater their risk of developing Alzheimer’s and other forms of dementia. Individuals who had a TBI in their 20s were at a 63% greater risk of developing dementia over the next thirty years, compared with people who had no such injury.  However, if the injury was sustained when they were in their thirties, this risk only increased by 37%.

Of importance in this study is that even though a concussion is classified as a mild TBI, these findings were apparent in moderate and severe TBI.

What is the risk of cognitive decline in those who have had a true concussion?

The long-term effects of concussions on the aging brain are poorly understood. Researchers from UCSF Weill Institute for Neurosciences and the San Francisco Veterans Affairs Health Care System, published in May 2018, tracked more than one-third of a million veterans and the likelihood of dementia was found to more than double following concussion. They found that concussion without loss of consciousness led to 2.36 times the risk for dementia. These risks were slightly elevated for those in the loss-of-consciousness bracket (2.51) and were nearly four times higher (3.77) for those with the more serious moderate-to-severe traumatic brain injury.

There are several mechanisms that may explain the association between traumatic brain injury and dementia. Trauma may hasten the development of neurodegenerative conditions. One theory is that brain injury induces or accelerates the accumulation of abnormal proteins that lead to neuronal death associated with conditions like Alzheimer’s disease.

A small subset of individuals who have experienced a concussion may experience persistent cognitive deficits more than a year following the head injury. Neuroimaging studies suggest that changes in frontal areas of the brain are exacerbated when loss of consciousness is experienced and indicate that these changes may be progressive in nature for some people. Analyses were run on Canadian Longitudinal Study on Aging (CLSA) neuropsychological data, consisting of individuals who experienced concussion with loss of consciousness more than a year prior, compared against no-head injury comparisons. These same individuals were re-assessed three years later. At three-years follow-up, those who experienced concussion with longer duration of unconsciousness were more likely to exhibit cognitive decline relative to those who experienced less unconsciousness or comparisons.

A different study done approximately 20 years after a concussive event, looked at differences in brain volume, white matter microstructure, and brain activity relative to those with no history of concussion. A prior concussion was associated with differences between groups in both temporal and frontal regions of the brain. In addition, brain volume atrophy was noted. Despite these group differences in brain structure and function, no concussion-associated group differences in cognitive performance were found!

Together, these results suggest that concussions result in long-term functional and structural alterations in the brain, but these differences do not always significantly impact cognitive performance. One reason may be related to the extent and severity of the alterations. While the changes on average were examined more than 20 years after a concussion, the sample may not have reached the critical stage of pathologic change where functional outcomes are affected.

While this study provides further evidence of long-term consequences that often mimic the acute and chronic phases of concussion, the results also somewhat support the regional specificity of neurodegeneration seen in Chronic Traumatic Encephalopathy and Alzheimer’s Disease. The clinical features of CTE show some resemblance to the progressive cognitive decline and neuropsychiatric presentation associated with Alzheimer disease, including an insidious onset with amnestic mild cognitive impairment, and similar hallmark pathological features. However, CTE has been described as a separate condition, although the pathology is potentially overlapping with that of Alzheimer diseases in up to 25% of the cases.

While it is not clear if a concussion injury, or multiple injuries, can lead to cognitive decline, traumatic impacts to the brain may lead to the accumulation of abnormal proteins often seen in Alzheimer’s disease. It may be that other lifestyle factors may then change the risk profile to determine whether dementia develops at some stage in the individual’s life.

References

https://jnnp.bmj.com/content/91/5/455

https://www.ucsf.edu/news/2018/05/410361/dementia-risk-doubles-following-concussion-ucsf-study-shows

https://www.sciencedirect.com/science/article/pii/S1053811920306686

https://alz-journals.onlinelibrary.wiley.com/doi/abs/10.1002/alz.041309

https://www.news-medical.net/health/Can-Concussions-Increase-the-Risk-of-Dementia.aspx

Reflections on life during Covid

It’s hard to believe that it’s been over a month since we stopped seeing people in person at Honsberger Physio Plus. Virtual treatments have been fun and helpful, but I truly do miss the physical attractions, and I don’t mean being able to use my hands, but rather the personal connection I feel with my awesome clients and engaging in your lives.

So many things have changed over that time and unfortunately much of it has varied between uncomfortable to downright scary, but at the same time I’ve seen so many positives around me.

In my own home we spend hours every night having dinner together and playing a variety of  games. With my three boys ranging in age between 16 and 22, I have to admit that I truly can’t remember when this happened on a regular basis, let alone nightly!

I’ve talked to more neighbours over the past month especially as the weather has warmed up; faces that were new now truly feel like old friends.

I have been amazed and pleased to see all levels of our government and political parties getting along to work together to help all Canadians- who would have believed that!

My parents are happy that I’ve been talking to them daily.

I’ve reconnected with friends that I had lost touch with over the past few years, as well as making new ones.

I’ve listened to people in stores being genuine in their thanks for those who work there versus some kind of complaint or indifference.

I love the satellite pictures of how our World looks with so much of the world shutting down in the past 3 months- Mother Nature breathing deeply again!

As much as this is a scary time, I’ve been impressed by the resiliency, compassion, intuitiveness and versatility of people around me and the greater world.

I try to dwell on the positives in life and I put my faith and trust in the good around me in the world which makes me confident that we can come through this stronger, and I truly hope we don’t forget the good things that we have learned along the way.

I hope that you have also had a chance to see the positives around you amidst the fears and uncertainty.

Until we can get together in person, please remember that I am only an email or a virtual therapy session away, whether it is to say Hi or for help with your injury.

Efan

Concussions and Mental Health

At this present time, Covid-19 has created a large worldwide impact on our overall health and the economy. This pandemic state which has put everyone in crisis mode can also have a large impact on our mental health. Thinking about this with a little more free time on my hands, has led me to look a little further on the effects of concussion injuries on mental health.

1 in 5 may experience mental health symptoms up to six months after mild traumatic brain injury.

6% experience some form of depression.

Long-term risk of suicide increases up to three times among adults and children after a concussion.

Research has shown that those with a mental health history (themselves or their family members), use of certain medications, or a history of multiple concussions may be at a greater risk.

https://fherehab.com/learning/mental-health-dangers-of-a-concussion/

Common emotional symptoms that can occur after a concussion include irritability, mood swings, anxiety, depression, sleep difficulty, fatigue or tiredness.

http://mihockey.com/2019/08/nhl-nhlpa-release-new-video-to-help-players-parents-coaches-id-signs-symptoms-of-concussions/

At times many of the emotional symptoms may be related to sympathetic nervous system dominance ( which I discussed in my previous article), an inability to fully participate in sports, school, or work, or an emotional manifestations over their lack of control over their physical symptoms. Is it as simple as managing your overall symptoms to minimize the emotional symptoms or we do need to start with managing the emotional symptoms first?  Maybe this direction is guided by the specific profession of healthcare provider that is working with them and their specific scope of practice. My recommendation comes with the idea of determining the primary domain that is creating the symptoms and addressing this domain first.

Of concern is that depression can have a profound negative impact of mild TBI recovery it has been demonstrated to worse outcome and prognosis in those who sustain mild TBI. Depression patients have more severe post-concussion symptoms compared to non depressed patients and this includes symptoms such as headache, blurred vision, dizziness and memory impairment.

Often education on lifestyle strategies, coping mechanisms, energy conservation and stress management can benefit both the emotional symptoms as well as the other group of symptoms.

The bottom line is to be aware that emotional symptoms can be present post-concussion. These can affect the recovery process, and also put an individual at risk for serious emotional challenges. When these are present, a referral to a more qualified member of your concussion healthcare team may be required.

Written by

Efan Gonsalves, PT, AT (retired) Clinical Director- Markham

Corporate Professional Services Director

References

https://www.nih.gov/news-events/news-releases/mental-health-disorders-common-following-mild-head-injury

https://primarycare.ementalhealth.ca/index.php?m=fpArticle&ID=57588

https://www.healio.com/primary-care/neurology/news/online/%7Baf725a34-4383-4356-96b3-b9982a02d0c2%7D/experts-discuss-rare-link-between-concussion-suicide

https://www.sciencedaily.com/releases/2019/11/191125145546.htm

Kontos AP et Al.  Mental health implications and consequences following sports related concussion. Br J Sports Med 2016 50(3):139-140

Kreibig SD. Autonomic nervous system activity in emotion: A review. Biological Psychology. 2010 84(3): 394-421.

Concussions and the Sympathetic Nervous System

Concussions usually involve symptoms from six physical domains that are sequelae of functional brain disturbances, but is there one domain that is more primary?  In a large variety of concussion clients, they often experience disruptions in multiple domains.

Concussion domains are usually clustered in the following physical groups:

• Visual
• Neurocognitive
• Vestibular
• Autonomic
• Structural
• Neurological

Meanwhile concussion symptoms are grouped into 4 subgroups including physical, cognitive, sleep and emotional.

https://reachphysio.com/concussion-signs-and-symptoms/

A common outcome measure used to evaluate these symptoms is the Post-Concussion Symptom Scale as part of the SCAT 5, and this outcome measure includes 22 symptoms for total score 132.

 

Key to treating concussion injuries is determining the primary domain that is most responsible for the symptoms. Being able to isolate the main domain is key to a quicker and full recovery. But which one is it and where do you start?  For example, visual ocular motor (VOMS) testing is one of the group of tests that can help isolate between vision, cervical, and vestibular symptoms.

 

 

 

 

 

 

 

 

 

https://www.natafoundation.org/for-the-profession/

Literature shows that a common area involved in post concussion symptoms (ongoing symptoms lasting greater than 30 days) is the autonomic nervous system (ANS). Over the past year in our practice at Honsberger Physio+, we have found that addressing the autonomic nervous system first with many of our concussion clients has resulted in quicker improvements in their symptomology. Using a system of tests proposed by Dr. John Beck and others, we have been able to isolate whether the ANS is the primary cause of symptoms. For example, clients often note aggravation of their symptoms with VOMS testing such a saccades (rapid side to side or up-down movement of the eyes with the head fixed). When the ANS has been normalized or taken out of the equation, saccade testing was symptom free. The importance of normal saccades is being symptom free for looking, reading, driving, and many other daily functions.

 

The premise of this approach is that the ANS balance is not present. The ANS consists of 2 parts: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). Each of responsible for different functions in the body but must work together to keep the body in homeostasis.  The parasympathetic nervous system is the “rest and digest” system, whereas the sympathetic nervous system is the “fight or flight” nervous system. In the ideal situation, the human body desires to spend most of its time in the parasympathetic state, but it needs to be easily able to switch to the sympathetic nervous system when needed.

http://www.dysautonomiainternational.org/page.php?ID=122

At Honsberger Physio+ we have seen that many clients post-concussion are often stuck in a constant SNS state, often referred to as sympathetic dominance or sympathetic dystrophy. In this state the body can manifest the following symptoms:

• Sensitivity to light
• Sensitivity to sound
• High blood pressure
• Sleep issues
• Shoulder or neck muscular tightness
• Tiredness
• Irritability
• Headaches
• Anxiety/ depression
• Digestive upsets

These symptoms should look very familiar to concussion symptoms!

A study in March 2020 in the journal of Gait and Posture evaluated the effect of forward head posture on the ANS and cervical sensorimotor control. They found that those with forward head posture showed a decrease in eye movement control, greater errors in cervical joint testing, and decreased postural balance stability, as well as a difference in ANS function. They hypothesized that normal cervical alignment is essential for sensorimotor control affecting neck proprioception, vestibular system, and visual system, and is essential for maintaining normal function of the ANS. A normal cervical lordosis may improve PNS activation and decrease the overall sympathetic tone, decreasing the adverse neck tension acting on the brainstem and cranial nerves.

 

Two common examples we have seen resolve quickly are VOMS symptoms as described in the earlier example with the saccades. A second example involves cervical hypermobility and postural positioning. Cervical restrictions such as upper neck joint limitations, which are often linked to headaches, are normalized quickly when the SNS dominance is reduced.

 

To get a full post concussion recovery all concussion domains need to be normalized, but focusing on the primary domain has a greater opportunity to return an individual to their pre-injury lifestyle in a faster manner. Clinical experience at Honsberger Physio+ has shown that addressing the autonomic nervous system first, especially the sympathetic nervous system seems to have a greater impact on overall concussion recovery.

 

References:

SCAT5 https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

Beck J. Neurodevelopmental Basis for Chronic Regional Pain Syndrome. A primer on the first level of evaluation in the practical application of neuropostural evaluations (P.A.N.E. process).  https://www.practicalpainmanagement.com/pain/neuropathic/crps/neurodevelopmental-basis-chronic-regional-pain-syndrome?page=0,1

Feddermann-Demont et al. Br J Sports Med. 2017 Jun;51(11):903-918. What domains of clinical function should be assessed after sport-related concussion? A systematic review.

Keenan A. Mo Med. 2017 Sep-Oct; 114(5): 340–343. Concussion Care: Moving Beyond the Standard

Moustafa IM1, Youssef A2, Ahbouch A3, Tamim M3, Harrison DE4. Gait Posture. 2020 Mar;77:29-35.  Is forward head posture relevant to autonomic nervous system function and cervical sensorimotor control? Cross sectional study.

Pertab JL et al. NeuroRehabilitation. 2018; 42(4): 397–427. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review.

Concussion injuries: Are all athletes treated the same?

In February 2018, the Canadian Olympic and Paralympic Sports Institute Network released their sports related concussion guidelines for Canadian national and national development high performance athletes.

In these guidelines they suggest that all of their athletes in high risk sports undergo:

• Concussion history evaluation
• SCAT5 testing
• Vestibular/ oculomotor assessment
• Web based neurocognitive assessment

They also recommend that a medical team member ( athletic therapist, physiotherapist, chiropractor or physician )  trained and experienced in assessment and management of acute sports-related concussion be on site during practice training and competition.

These recommendations for Canadian national athletes are interesting departure from the 2017 Canadian Guidelines on Concussion in Sport released by Parachute Canada’s expert advisory concussion subcommittee. In these guidelines, one of their key recommendations was that baseline concussion testing of youth or adult recreational athletes using any tools or combination tools was not required to provide post-injury care of those who sustained a concussion or suspected concussion. Furthermore baseline testing was not recommended in youth athletes regardless of sport or level of play.

As a parent with children who play high risk sports, as a minor hockey league trainer, and as an experienced physiotherapist working with concussion injuries, these new Canadian national athlete concussion guidelines strike me as both confusing and maybe even a bit hypocritical.

One way to read these guidelines is that even though trained concussion medical personnel must be at all practice or competitions for National level athletes,  baseline testing and concussion process are strongly suggested for high-performance Canadian athletes. These athletes would have immediate access to medical personnel should an injury occur, and effective management would be initiated immediately.

But what if you are recreational athlete (the majority of Canadian athletes) who takes part in the same high-risk sports? Are you at a greater risk of poor concussion management or long-term post concussion issues? In many recreational sports the presence of trained medical professionals are limited (or non-existent), access to experienced concussion healthcare providers may be slow, and athletes may be left on their own to manage return to learn and return to sport.

Does it not make more sense to have better concussion policies and processes in place for sports association and athletes who do not have immediate access to experienced concussion healthcare providers, or who do not have the same trained personnel onsite at their sporting events? Making preseason evaluation and baseline testing procedures mandatory for lower-level athletes would provide a higher degree of safety and efficient post-concussion management.

Exactly what this should look like and what baseline testing procedure is best is the topic for another day!

Baseline Concussion Testing: is it needed?

The 1st concussion consensus statement was published after the 2001 international Concussion in Sport group met in Vienna, and one of their findings was that neuropsychological testing was the cornerstone of concussion management.

(The Concussion in Sport group is an international panel of the leading researchers in the field of concussions.  They have released 5 statements since 2001 that amalgamate the latest research and best practice recommendations.)

Since 2001 there has been proliforation of baseline testing methods from the various versions of the SCAT put forward by the Concussion in Sport group, to various pen and paper tests, and computerized tests. The one common goal is that they were put into place to create objective data to be utilized for post-concussion comparisons to help in management and recovery.

So a little disclaimer, I’m a physiotherapist involved in concussion management, which includes Baseline concussion testing (BCT) as part of our management.  I direct the Concussion Solutions Program at Honsberger Physio+, and have been involved in concussion management for over 20 years.

In July 2017, Parachute Canada’s expert advisor concussion subcommittee released the Canadian Guidelines on Concussion in Sport. One of their key recommendations was that BCT of youth and adult recreation athletes using any tools or combination tools was not required to provide post-injury care of those who sustained suspected or diagnose concussion. Baseline testing was not recommended in youth athletes regardless of sport or level of play.

This has created some confusion in the world of baseline testing, just as more athletes were becoming familiar and proactive in concussion management.

These recommendations did not totally align with the most recent concussion consensus statement from the Concussion in Sport group from Berlin 2016.  In the Berlin statement, they indicated that “baseline or preseason neuropsychological testing was considered by the panel and was not felt to be required as a mandatory aspect of every assessment; however it may be helpful or add useful information to the overall interpretation of these tests. It also provides an additional educational opportunities for the healthcare provider to discuss the significance of this injury with the athlete.”

As a physiotherapist, baseline concussion testing serves three key functions in my practice:

1. Educate before a concussion injury happens to ensure the proper process is followed immediately from the moment a possible concussion suspected. Concussion education is also a key recommendation from Ontario’s Rowan’s Law that was passed in 2017 regarding concussion injuries.
2. Provides a point of comparison in terms of neurocognitive status to assist in the post concussion management.
3. Adds another layer of information regarding the recovering athlete with respect to their ability to return to learn and return to play. This information, in addition to a change in symptoms, family feedback and successful completion of progressive activity in the return to play stages provides a detailed awareness of an individual’s status.

If we take the educational process out of the Baseline concussion testing equation, why should an individual still have a baseline concussion test done?  The majority of healthcare providers that treat individuals after concussion injury do find that having a baseline concussion score does allow for better management- safer, structured to meet the individuals neurocognitive needs, and provides an objective comparison throughout the overall recovery process. But according to the Parachute Canada guidelines a baseline test is not needed for proper management, so why still do it?

Several studies over the past three to four years have shown that even with proper medical clearance, current research does show that within the first year of return to play after concussion injury, athletes have a 2-4 times increase risk in developing musculoskeletal injuries.

Studies evaluating professional soccer, Australian football, as well as collegiate Sports such as football, basketball, soccer and lacrosse all noted this evidence with a peak musculoskeletal injury levels within the first 3 months after return to play.  This trend has been seen up to one year after return-to-play was also seen up to 2 years post injury in a military specific study.

Various researchers have postulated theories for this increase musculoskeletal injury risk such as:

• decreased cardiovascular fitness
• decreased neural cognitive ability
• unresolved neuromuscular impairments
• delayed reaction times
• short-term brain changes
• decreased psychological “readiness”
• altered trunk movement patterns
• lower extremity stiffness
• gait changes

Studies have shown that after symptom resolution, there lingering effects in postural control, gait sequencing and dynamic balance. These effects can affect neuromuscular control and most notable during physically and cognitively challenging athletic activities.

It has been found that deficits from concussion injury may last longer than reported and may be present even after the return to unrestricted activity suggesting that current clinical assessment tools may lack sufficient sensitivity to accurately track functional recovery.

One of the main areas that has been evaluated is that of neurocognitive abilities.  Neurocognitive performance encompasses the domains of visual attention, self-monitoring, agility, fine motor performance, processing speed, reaction time, and dual tasking ability. Neurocognitive performance is often a key measure in baseline concussion testing.

After concussion injury there are short-term changes in reaction time, visuospatial awareness, attention, executive decision making, and movement coordination. Any deficits in these areas can result in a decrease overall neurocognitive performance.

The presence of an increase risk of a subsequent musculoskeletal injury after concussion, as well as lingering effects in postural control, gait sequencing, and dynamic balance, leads to the speculation that current return-to-play protocol are not effective for ensuring a safe return to play for the athlete as a whole versus focused on being “brain” safe only.

Although some current concussion guidelines call into question the use of concussion Baseline testing, the ability to create baseline neurocognitive scores in the pre-injury state is valuable. This allows for a neurocognitive comparison post-injury, to ensure an athlete to has returned to normal neurocognitive levels to minimize the risk of musculoskeletal injuries, or other lingering post-concussion neuromuscular issues. Based on the scores post-injury, a health care provider can better determine whether an athlete is ready to return to play for all health states.

As the data continues to show, recovery from a concussion can be more prolonged than the standard post concussion symptoms demonstrate. Ensuring that an individual has returned to their pre-concussion neurocognitive levels via training and post-injury testing allows for a safer return with a minimized risk of prolonged issues. Ensuring a full neurocognitive recovery via an extra step of neurocognitive training is key.

Although the rationale for baseline concussion is contradictory based on the current concussion guidelines, the BCT process can be used for athlete education, planning of post injury recovery, and also ensuring a full return to pre injury neurocognitive levels to minimize musculoskeletal injury risk.