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.

What the heck is neurocognitive training…but more importantly why should you do it!

Neurocognitive performance and training involves the dimensions of visual attention, self monitoring, agility /fine motor performance, processing speed/ reaction time, and dual tasking. These traits are key to movement in everyday life, and even more critical to athletic performance.

Any deficits in neurocognitive performance may not allow an athlete to correctly interpret or react to an evolving athletic environment, thus negatively affecting athletic performance and ultimately athletic success.

Further evaluation of neurocognitive performance has shown a strong relationship with an increased risk of musculoskeletal injuries.

Herman et al. (2015) have postulated a proposed pathway (below) in which challenges to neurocognitive function lead to an increased risk of musculoskeletal injuries.

Figure reprinted from Herman et al (2015).

Studies have shown that there are 4 key areas that may affect neurocognitive function:

1. Inadequate sleep
2. Psychological stress
3. Poor baseline neurocognition
4. Concussion injuries

Inadequate sleep and psychological stress have been shown to:

• Increase risk of task error
• decrease musculoskeletal power decrease accuracy of throwing decreased motor reaction time
• narrow field of peripheral vision
• slow central vision reaction times

A poor baseline neurocognition has also been shown to increase the risk of musculoskeletal injuries. For example, children with ADHD may demonstrate deficits in reaction time, fine and gross motor skills, and attention deficits. Children with ADHD have been shown to have increased rates of fractures, soft tissue injuries and greater injury severity. In addition, increased injuries in athletes such as ACL injuries have been noted in those with lower baseline neurocognitive scores.

Concussions lead to a decrease in attention, reaction, time decision making and visuospatial skills. Several studies evaluating the risk of muscle skeletal injury after recovery from concussion in soccer, Australian football and various collegiate sports found a 2 to 4 increase musculoskeletal injury risk after return to play from a concussion injury, usually within the first 3 months.

The effect of these 4 areas on neurocognitive performance and increased musculoskeletal injury risk have been seen throughout the literature, but is there a way to increase neurocognitive performance? One key area is through the use of neurocognitive training, utilizing a variety of tools and equipment to address these skills, such as sports vision training, concentration training and executive decision making.

At Honsberger Physio+, the use of components including the Dynavision D2, Neurotracker, fitLight and PlayAttention has been shown to increase neurocognitive performance in a variety of sports across a wide spectrum of ages. Honsberger Physio+ has 2 state of the art Vision Performance Centres, which are dedicated to sports vision, athlete development, concussion testing and recovery, and for anyone wanting to perform at their best! They are one of the only facility in Canada to combine these 5 pieces of technology focused on reaction time, peripheral vision, depth perception and neuroplasticity. The only other institution in Canada to have the 3D FitLight wall is the Toronto Raptors.

Training the Neurocognitive domains can be helpful for improving athletic performance as well as decreasing the risk of musculoskeletal injury.

efan@honsbergerphysio.com

___________________________

References:

DuBose DF et al. Lower Extremity Stiffness Changes following Concussion in Collegiate Football Players.Med Sci Sports Exerc. 2017: 49(1): 167–172.

Gilbert FC et al. Association Between Concussion and Lower Extremity Injuries in Collegiate Athletes. Sports Health. 2016: 8(6):561-567.

Herman et al. Effect of Neurocognition and Concussion on Musculoskeletal Injury Risk.
Curr Sports Med Rep. 2015: 14(3): 194–199.

Howell DR et al. The Effect of Prior Concussion History on Dual-Task Gait following a Concussion. J of Neurotrauma 2017: 34(4): 838-844.

Mathias JL and Alvaro PK. Prevalence of sleep disturbances and problems following TBI: a mea-analysis. Sleep Medicine. 2012: 13(7): 898-908.

 

8 Tips To Being A Great Sport Parent

In a complex world full of stress and pressure, politics and wanting what is best for your child, having your child participating in sports from a recreational level to a high performance level can be overwhelming. We work with parents, athletes and coaches on a daily basis and it is our goal to help guide them through sport both physically and mentally. A common question we get is, ‘what is best for my child?’ The answer is different for everyone. Depending on your child’s age, ability level, level of commitment and passion for the sport. Below are 8 tips to help parents and guardians through supporting your children in sport and inspiring the pursuit of greatness!

1. Be a good role model

• Only 1 in 3 children are physically active every day
• Children are 3.5 to almost 6 times more likely to be active when one or both parents are active, compared to when both parents are inactive
• For every extra 20 minutes of physical activity for the parent, their child’s activity level rose by five to 10 minutes

The atmosphere set by organizations, parents, and coaches is a major factor in determining whether or not youth will have a positive experience in a sports program. Parents should involve their youth in programs that have clear positive goals about the sports experience, emphasizing fair play and sportsmanship as well as the skills to be taught and the lessons to be learned.

Here are some recommendations for parents of young athletes:

• Develop in your child a lifelong commitment to an active lifestyle.
• Encourage your child to try various physical activities.
• Encourage your child to play because he or she enjoys it.
• Focus more on skill mastery and cooperation.

2. Promote the long term athlete model

Early involvement in sports provides opportunities to develop gross motor skills that include, but are not limited to, hand-eye coordination, jumping, throwing, hopping, balancing, and running. Adolescent bodies are not prepared to be treated like an adult’s body. Diversification in sports at an early age has the potential to provide stimuli so that a child’s body can adapt and develop multiple motor skills that may crossover between sports. However, only once the mental, physical, and social aspects of a child are fully developed should specialization be considered.

The belief behind sport diversification is that physical and cognitive abilities may develop quicker via playing multiple sports instead of just one because of a potential crossover effect from playing multiple sports.

Early specialization has shown to be not only physically difficult but also mentally difficult. Athletic burnout can be an unfortunate effect of early specialization in one sport.

Any sport activity invites a chance of sustaining an injury and the potential for injury increases as the intensity level and training volume increases. Sports specialization increases the risk of repetitive movement patterns and repetitive strains on the growing body. A diversity of sports allow for a variety of movement patterns, varying physical loads in a growing body, and varying stimuli, while breaking the pattern of repetitive movement patterns with sports specialization.

3. Understand Physical Literacy

“Physical literacy is the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life.”
– The International Physical Literacy Association, May 2014

Research has shown that being physically active later in life depends on an individual’s ability to feel confident in an activity setting. That confidence most often comes from having learned fundamental movement and sport skills, or physical literacy, as a child. Research has also shown that without the development of physical literacy, many children and youth withdraw from physical activity and sport and turn to more inactive and/or unhealthy choices during their leisure time.

In developing and teaching a child, simple skills are broken down into key components to help the child learn and understand. Fundamental movement skills are very important in the physical development of a child. When a child is confident and competent with these skills, they can develop sport-specific and complex movement skills that allow them to enjoy sport and physical activity. Most importantly, having a firm grasp of the fundamental movement skills and being physically literate leads a child to enjoy a long life of physical activity.  Fundamental movement skills include throwing, catching, jumping, striking running, kicking and balance/ agility/ coordination.

4. Screening for injury risks

Many injuries and conditions are hereditary linked such as scoliosis, flat feet or back pain. If one or both parents have a history of injury, or the above injuries children would benefit from seeing a health care provider prior to starting activities.

Many sports injuries occur through repetitive motions. Proper pre-injury screening can determine current health status and help address risk factors, such as flexibility issues and muscle imbalances.  For example, teenage females are more susceptible to ACL knee injuries vs boys due to a poor hamstring to quadriceps ratio, poor landing patterns, and an increased hip to knee ratio.

If an athlete experiences unexpected long-term decreases in performance without evidence of injury, this may be a result of overtraining, and warrants a more detailed health evaluation.

Screening is valuable to detect current musculoskeletal conditions, establishes baseline & health state, and forms the basis for clinician-athlete relationship

5. Recognize injuries when they happen

Despite the overall health benefit of sports participation, any sport activity invites a chance of sustaining an injury.

Injuries should be managed properly from the beginning. Rest as needed. Ice or heat as appropriate.

In animal studies, use of anti-inflammatories such as Advil, has been shown to decrease the quality of tissue healing, even though it allows for a quicker recovery. Although an athlete may recover quicker, they may be at risk for a more serious problem later.

6. Understand concussion injuries

Concussion injuries can occur in any activity, although some activities promote a higher risk due to the contact nature of the sport, the speed of the activity, or the hardness of the playing surface and sports equipment.

Concussion do not just result from an impact to the head but rather any impact to the body that results in a sudden change in direction of the brain inside the skull.

Youth are more susceptible to concussion injuries compared to children and adults, and girls seem to have a greater risk of prolonged recovery to concussion injuries.

New research shows that after the acute stage of a concussion injury (first 2 to 3 days) an athlete can start light activity that does not increase the concussion symptoms. This does not mean returning to sports, but rather start with easy walking or stationary biking.

Evaluation by a health care professional experienced in dealing with concussion injuries can screen the athlete to see which systems of the body are most affected: visual, vestibular, cognitive, coordination/ balance, or autonomic nervous system. These deficits can then be addressed to enhance the recovery process.

Use of a baseline concussion test in the preseason stage, although not mandatory, can help educate the athlete and family prior to injury (to allow for better early management), as well as provide a framework for reference after a concussion injury occurs.

 7. Physical Activity promotes Brain health

Exercise helps memory and thinking through both direct and indirect means. The benefits of exercise come directly from its ability to reduce insulin resistance, reduce inflammation, and stimulate the release of growth factors—chemicals in the brain that affect the health of brain cells, the growth of new blood vessels in the brain, and even the abundance and survival of new brain cells.

Indirectly, exercise improves mood and sleep, and reduces stress and anxiety. Problems in these areas frequently cause or contribute to cognitive impairment.

Aerobic exercise appears to improve a person’s cognitive function, and resistance training can enhance executive function and memory.

With exercise the brain in general is more active and more alert. 45 to 60 minutes of moderate to vigorous exercise is good for the brain. Exercise increases blood flow to the brain and increases oxygen and nutrients.

Exercise increases the protein BDNF (brain derived neurotrophic factor) which helps repair and protect the brain cells from degeneration. Exercise increases new brain cells, especially in the hippocampus which is a key learning and memory centre. (The hippocampus seems to shrink in situations of depression illness and dementia).

Exercise can also help prevent the onset of depression by the release of certain hormones and chemicals such as endorphins.

8. Proper sleep can enhance athletic function

The following areas have shown the effect of poor sleep on athletic performance:

a. Decreased reaction time

Poor sleep has been shown to decrease reaction time by up to 300%

b. Increased injury rate and decreased overall health

Sleep time is one of the strongest indicators of injuries, even more so than the number of hours of playing/ training.  Some key reasons are:

• A decreased reaction time which increases the risk of some kind of hit
• Slowing of the immune system
• Lack of healing / regeneration at night due to decreased sleep and less likely to release hormones needed in healing

c. Decreased playing career length

Fatigue can shorten the playing career of professional athletes in a very linear relationship.

d. Decreased sport speed and decreased accuracy

Studies have shown that well rested athletes had better sprint speed and better accuracy compared to when they were sleep deprived.

e. Increased mental errors

Sleep loss impairs judgement especially motivation, focus, memory and learning.  Without proper sleep, the brain is challenged to consolidate memory and absorb new knowledge.  Sleep deprivation impairs decision making, risk taking analysis and moral reasoning.

f. Weight gain

Poor sleep patterns affect cortisol levels resulting in an increase in weight, which can negatively affect an athlete’s performance

g. Energy

Sleep deprivation decreases the production of glycogen and other energy stores that are needed for energy during physical activity.

Sports can be a great opportunity for children to create a lifestyle of health and wellness, promote a positive self image, and improve overall health. Parents play a key role in insuring a healthy lifestyle for their children.

EFAN GONSALVES, PT

References:

http://www.statcan.gc.ca/pub/82-003-x/2017006/article/14827-eng.htm

https://www.nsca.com/education/articles/ptq/early_sport_specialization_vs_diversification_in_youth/

https://extension.psu.edu/parents-making-youth-sports-a-positive-experience-role-models

http://sportforlife.ca/qualitysport/physical-literacy/

http://www.cbc.ca/parents/learning/view/what-is-physical-literacy-and-why-does-it-matter

https://www.health.harvard.edu/blog/regular-exercise-changes-brain-improve-memory-thinking-skills-201404097110

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699

http://www.fatigue science.com/blog/5-ways-sleep-impacts-peak-athletic-performance/

Ratey J  Spark: The Revolutionary New Science of Exercise and the Brain. 2008. New York. Little Brown and Company.

Biomedical Engineering and Concussions

My oldest son is now in his second year of Biomedical Mechanical Engineering at the University of Ottawa, with a passion to learn and an open mind as to what direction his career will lead.

Eighteen months ago we had the opportunity to meet with Dr. Frei of Carlton University to gain a better understanding of this field and some future possible directions for him. I also had explained that I was a physiotherapist and that I worked in many similar areas to biomedical engineers, but just from a different direction!  After we had a long discussion about hip replacements, I joked  that maybe my son could help me in the future with my area of passion- concussion injuries.

I’m not sure who was more excited when a new 3 year research study was announced linking the University of Ottawa, Carleton University and University of Waterloo to evaluate the effects of concussion impact on the human brain.

In search of a safer football helmet: Ottawa experts partner up for special brain-injury research

This study involves a link between biomedical mechanical engineering, aerospace engineering, neurology, and anatomy, and linking the 3 universities with a $700 000 government grant.

Cadavers will be used in impact testing labs, high speed x-rays and computer mapping of the brain to determine how the brain moves, deforms, and shears under the duress of contact.

For my son, this study might be beginning several years too early, but maybe he will be ready for part 2 of some kind!

Effectiveness of an injury prevention program

A recent study (Br J Sports Med published online first 17 May 2017. Hislop et al) evaluated the effectiveness of an exercise program on reducing musculoskeletal injury and concussion risk in youth rugby. (http://bjsm.bmj.com/content/early/2017/05/08/bjsports-2016-097434).

Over 3100 players were involved across 118 teams in which the schools were put into 2 groups.  The exercise intervention group performed balance/ pertubation training, whole body resistance training, plyometric training, and controlled rehearsals of sports specific landing and cutting with verbal coach feedback.  The control group followed an exercise program derived from best practice in school rugby with no coaching feedback.  The exercises programs were progressed over 4 phases during the study period. Each exercise session took about 20 minutes to complete

A clear reduction in injuries was found in those groups that performed the exercise program a minimum of 3x per week. The exercise group noted a decrease in injuries at the following rate:
1. 72% fewer match injuries
2. 72% fewer contact injuries
3. 50% fewer days lost to injury.
4. 81% fewer upper extremity injuries
5. 70% fewer lower extremity injuries
6. 59% fewer concussion injuries **

** Of note was that the reduction in concussion injuries was found even when the exercise program was completed less than 3 times per week.

This study builds on the growing body of research across a variety of sports showing the effectiveness of multifaceted preventative exercise programs to reduce musculosketal injury risk, as well as the benefits of improved neck strength on reducing concussion injuries.

Take home message:

1.  A focus sports specific intervention program in rugby can be helpful in reducing injuries in male players age 14-18
2. The exercise program requires approximately 20 minutes to complete and can be incorporated as part of the pre- activity warm up.
3. An effective program includes training of balance, whole body resistance (including the neck) , plyometrics as well as coached landing/ cutting drills.
4. Injury reduction results were clear when the exercise program was performed at least 3x per week
5. A reduction in concussion injuries was noted even when the exercises were completed less than 3 times per week.

Here is a sample of a program that integrates the above principles which can be used as a dynamic warm p or as a conditioning program.

Concussion Recovery in Baseball: does it take longer for optimal performance?

When thinking about concussions in sport, baseball is a sport in which the concussion risk is relatively low.

Can concussion have a greater effect on baseball players?

 
Effectively hitting a baseball requires excellent hand-eye coordination, strong visual acuity, quick reaction time, excellent attention and focus, and quick but accurate decision-making.
In a very similar way, a concussion injury can affect many of these same skill sets, as well as hamper balance and motor coordination among others. Normally a concussion clears up in 1 to 2 weeks, but studies have shown that concussion injuries are associated with a decreased batting performance. Although overall return to play in baseball players is similar to other sports, baseball batters can take several weeks longer to recover in terms of hitting performance.

 

After a baseball player recovers from their concussion symptoms a comparison to their baseline pre-injury scores is needed. This baseline concussion score needs to evaluate eye- hand coordination, visual acuity, concentration, executive decision-making, balance and agility, as well as helping to assure that an athlete has fully recovered from their concussion. Deficits that are still present after a baseline test then become crucial for full recovery.

 

Since a major league fastball takes approximately 0.4 seconds to reach the plate a batter requires many the skill sets that are hampered after a concussion injury while using a 2 1/4″ diameter bat to hit a 3″ diameter ball.

 
Functional MRI studies of baseball players identifying the types of pitch thrown demonstrated that multiple regions of the brain are involved in a hitting decision, and the number of brain areas involved increases with the increasing number of potential pitches.
The ability to successfully perform these tasks depends on the proper function of multiple nervous system networks. The visual network controls smooth eye movement and lateral eye movements which are involved in seeing the ball and making a prediction about its location and pitch type. Networks related to attention and concentration allow players to integrate extra information (e.g. pitch count, pitch sequence, pitcher arm position, defensive positioning) to enhance the prediction of ball location and pitch type, as well as block out extra non-needed stimuli. Finally the initiation and completion of a successful bat swing requires proper functioning of the motor circuits, vestibular and cerebellar network involved in posture stability and balance, circuits involved in visual reaction time, as well as brain areas that provides inhibition control over a swing once initiated.

 

Using advanced neurocognitive equipment and processes, Honsberger Physio+ provides a baseball specific baseline concussion test that identifies challenges in the recovering athlete and is able to enhance these deficits with the same process and training protocols.

Elimination of body checking in peewee hockey reduced concussion and other injuries: Maybe not!

As a physiotherapist, hockey trainer, and a father of three active boys, seeing the results from Carolyn Emery’s study looking at effects of  eliminating body-checking from Peewee hockey is not a surprise that it showed a significant reduction in total injuries as well as concussion injuries.  Reducing the impacts on the body should reduce the risk of injuries and the frequency of exposure to these risks.

Although the study showed that injuries were reduced, have we just pushed these injuries to an older age group (at the minor Bantam level)?

I recall when one of my boys was 11 an playing at the minor peewee level:  he was 5’4 and about 135 lbs but he played with teammates who were significantly different in size; one was  4’10” and seventy pounds and other boy was 5’10” and 170 pounds- a huge difference at that age group.  Fast forward another two years and those same three boys were now 6’1″, 5’8″ and 5’1″,  with still at least a hundred pounds difference in weight between the lightest and the heaviest. Now the kids were bigger and stronger but also moving faster.  More muscle strength and more weight means more speed and greater impact forces!

In 2007 Ontario and Saskatchewan both ended a five-year pilot study where they evaluated the effects of body checking starting at the minor Atom age group  (age 9).  Not surprisingly, the results showed that at the minor atom age group there were more injuries compared to those provinces that did not allow body checking. Interestingly enough, as they followed this group to the Bantam and even Minor Midget years they actually found those boys who started bodychecking in minor Atom were just as  likely to have injuries related to body checking in the later years. Studies showed that there were no protective effect from learning to body check at an earlier age. The evidence showed that the risk of a body checking related injury was the same for 14-15 year olds who had been introduced to body checking at a younger age, as their cohorts who had played without body checking in their younger years. Other evidence also suggested that early introduction to body checking is likely to increase the risk of injuries due to prolonged exposure.

 

I believe the next step for Carolyn Emery and her group at the University Calgary is to compare data of those players in minor bantam and bantam who started body checking in minor peewee with those who only began body checking in minor bantam to see what has happened in terms of overall injuries and concussion injuries. (They are probably working on this already!) The ideal scenario would be to see a reduction in injuries, but what if they found the opposite? Is there a learning effect or just more injuries at a later age?

At 13-14 years of age the brain is still as vulnerable to injury as 11-12, so have we made the problem greater by introducing body checking when players are bigger, stronger, and still vastly different in size?

Don’t get me wrong as I am not advocating that we start body checking earlier (or even later), but rather we need to look at the whole picture that the data presents before we say the switch to an older age for contact has been a success. The easy answer for parent of 11 and 12 year olds, is that the switch is a success due to a reduction of injuries, but if you are the parent of a 13 year old can you say the same thing?

Do we need contact in hockey? At what age and levels should it occur? These are topics for a raucous debate in any hockey loving community! As research continues into the short and long term effects of concussion injuries, prevention strategies, and advanced diagnosis and management, this debate may become more clear.

Post Concussion Rest May not be the Best!

Over the years, a commonality in concussion research is that greater than 70% of concussion injuries clear up in under 2 weeks.  The challenge has been managing those individuals whose concussions last longer.

Zemek et al released a study in 2016 (see previous post) which categorized the risk of persistent post concussion symptoms (PPCS)  at greater than 28 days in children aged 5-18 years.  In their study, the key traits were:

•  Age >12
• Female
• Prior concussion or symptoms longer than 1 week
• Physician DX migraine hx
• Answering questions slowly
• BESS tandem score of >4 errors
• Headaches
• Sensitivity to noise
• Fatigue

For years the conventional treatment for concussions has been complete rest until symptoms were over, including recommendations  from the 4th International Concussion in Sport Consensus statement as well as the American Academy of Pediatrics.  A growing body of evidence is calling this practice into questions\, and focusing on the benefits of activity.

Grool et al in a December 2016 publication in JAMA evaluated the effects of early participation in physical activity in children aged 5-18. They found that physical activity within 7 days of the acute injury compared with traditional; no activity was associated with a reduced risk of PPCS at 28 days.

Common activities in the study included light aerobic exercise, sports specific exercises and non contact drills.

Of those who began physical activity early, at day 7 31% were symptom free and 48% had 3 persistent post concussion symptoms.  By comparison, in those who rested in the 1st week, 80% had at least 3 PPCS.  By the end of day 28, those with at least 3 PPCS included 29% in the activity group and 40% in the resting group.

The key was that the activity was performed at a level that did not exacerbate symptoms, and by no means indicate that an athlete can immediately return to full sports activities, especially contact sports.

The researchers theorized that the early activity may have been helpful in several ways:

• Improve cerebral blood flow
• Promote neuroplasticity
• Release brain healing endorphins
• Psychological benefits, especially for active individuals

Although this study provides some ground breaking evidence, it was an observational study versus a randomized control study (RCT), meaning more study is needed to better evaluate the short and long term effects of early activity.  What is not known is whether exercise is better, but we do understand that strict rest is not the best way either.

Leddy et al at the University of Buffalo has been evaluating the effects of graded exercise post concussion since 2007.  Previous reports showed that individualized graded exercise using a modified treadmill protocol has been beneficial in the recovery of athletes greater than 3 weeks post concussion.  They are currently conducting an RCT of individualized exercise for sports concussion in adolescents within the 1st week after injury with the hypothesis that early controlled exercise below the symptom threshold will speed up recovery from a concussion.

Look for results near the end of 2017!

References:

Zemek et al.Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.  JAMA. 2016;315(10):1014-1025.

Grool et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents.  JAMA. 2016; 316(23):2504-2514

 

 

Post Concussion Prediction Symptoms

A new study based on the largest prospective cohort of children with concussion in the world was published in the Journal of the American Medical Association (JAMA) in March of 2016. The study introduced a validated clinical prediction score that will help health providers and researchers to predict the duration of pediatric concussion symptoms.

The published abstract and article can be found at: http://jama.jamanetwork.com/article.aspx?articleid=2499274

The 5P study: Predicting and Preventing Post-concussive Problems in Pediatrics, led at the Childrens Hospital of Eastern Ontario in Ottawa and including nine pediatric emergency departments across Canada, enrolled over 3,000 children. All participants were aged 5-18 years old and evaluated within the first 48-hours after head injury (with most patients presenting within 3 hours of their injury).

Experts from across Canada and the United States developed a PPCS risk score that when applied to a child within 48-hours of their head injury, was proven to be significantly better than the child’s physician was at predicting future PPCS. The score incorporates nine clinical variables containing information from demographics, history, initial symptoms, cognitive complaints, and a physical examination.

The 5P study unveiled a number of findings. For instance, while boys sustained more concussions, girls had twice the odds of boys for having symptoms last at least one month. In addition, older children and teens have a higher risk of PPCS than children under 8 years old do.

Key findings for increased risks of post concussion symptoms 28 days after injury include:

• Age >12
• Female
• Prior concussion or symptoms longer than 1 week
• Physician DX migraine hx
• Answering questions slowly
• BESS tandem score of >4 errors
• Headaches
• Sensitivity to noise
• Fatigue

Based on a points total of the key traits, PCSS risk categories were created.

In discussion with 10 family practice physicians in York Region, including several working in walk-in clinics, all were unfamiliar with these recommendations even though they were often the first point of contact with individuals with concussion injuries.

The Neuro Zone

Honsberger Physiotherapy has recently opened its updated Sports Vision and Neuro cognitive Performance Lab in Markham. A key ingredient of the new Performance Lab is the new Fitlight Reaction wall and floor set up which allows for use of both hands and feet for fitness, agility, vision, and mental reaction.

 

According to Fitlight CEO Derek D’Andrade, the Fitlight wall is only the 2nd setup of its kind in Ontario: the only other one is owned by the Toronto Raptors NBA team, while the fitLight floor is a totally unique feature

In combination with other components including the Dynavision D2, Neuro tracker, and PlayAttention systems, use of the Neurocognitive Performance Lab allows for training post concussion, post injury, as well as injury prevention, sports specific fitness and Neurocognitive training.

A big focus for HPBC with the new equipment and set up, will be the areas of sports performance, fitness training and injury prevention.

Whether it is for individual fitness training, sports vision training, team competition, tactical training or post concussion management the Honsberger Physiotherapy Neurocognitive Performance Lab allows for a one of a kind experience for sports, tactical training, industrial applications or post injury scenarios.