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.

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.

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.