Course:KIN366/ConceptLibrary/Concussions

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
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A concussion is a form of traumatic brain injury that alters the way your brain functions ( Mayo Clinic, 2011). It usually results in rapid onset of signs, symptoms, and neurologic impairment, which typically resolve spontaneously (Weinberger, 2013). Brain functioning is altered due to the areas of localized ischemia and edema. This is the result of a direct external contact force or from the brain being slapped against the intracranial surfaces of the brain. Concussions can range from mild to severe, a severe concussion can be extremely dangerous and can result in possible death. Proper diagnosis and treatment are pivotal to the reduction of symptoms and possible syndromes that accompany a traumatic brain injury. Along with proper diagnosis and treatment, overall awareness is extremely important in reducing the prevalence of symptoms.

Causes

A concussion is a result of a direct hit to the head, neck, face, or another location of the body that creates biomechanical forces that are consequently transmitted to the brain (Weinberger, 2013). Concussions are most common in contact related sports, According to Weinberger (2013), the sports which result in the most concussions are, football, ice hockey, lacrosse, soccer, wrestling, field hockey, basketball, softball, and baseball. Amongst these sports, it is evident that football and ice hockey produce the most concussions.

Immediate Symptoms

Signs to look for at the time of the injury to check if the athlete has suffered a concussion.

  • Nausea,
  • Balance problems,
  • Confusion,
  • Retrograde and anterograde amnesia, (Forgetting events that happened before or after the time of injury)
  • Loss of consciousness
  • Fatigue
  • Slurred speech
  • Delayed response to questions
  • Appearing dazed
  • Vomiting
  • Ringing in the ears
  • Feeling "foggy"
  • Temporary loss of consciousness
  • Headaches or a feeling of built up pressure in the head region

List from reference (Mayo Clinic, 2011)

Post Concussion Symptoms

Post-concussive can be separated into three different fields. Firstly, the somatic symptoms, followed by the emotional disturbance symptoms, and lastly, the cognitive symptoms (Blume, 2011). The following list provides examples of all three types of symptoms.

  • Concentration and memory complaints
  • Personality changes
  • Irritability
  • Sleep disturbances (frequently waking up, increased/decreased sleep)
  • Disorder of taste and smell
  • Sensitivity to light and noise
  • Psychological adjustment problems and depression

List from reference (Mayo Clinic, 2011)

  • Lack of energy
  • Fatigue
  • Nervous
  • Anxious
  • Sadness
  • Frustration
  • Increased emotions

List from reference (Blume, 2011)

Major Risks with Concussion

Serious Risks that can happen after an individual sustains a concussion.

  • Intracranial Hemorrhage: leading to loss of consciousness or death (Kushner, 2001)
  • Post Concussion Syndrome: Where athlete or patient has persistent concussion symptoms such as headaches, dizziness, irritability and difficulty with thinking skills, memory and attention. These symptoms gradually taper in severity over days, weeks or even months after the traumatic brain injury. (Kushner, 2001)
  • Second Impact Syndrome: Where athlete or patient is more likely to sustain a second concussion after his or her first concussion (Kushner, 2001). With every added concussion long and short term symptoms increase in severity, along with the chances of serious risks such as brain swelling and long term effects on personality and brain functioning
  • Epilepsy: Those who suffer from a concussion have a 2x higher chance of developing epilepsy within the first 5 years following the concussion. (Mayo Clinic, 2014)
  • Post-traumatic Vertigo: Development of spinning or dizziness which can last from days to months. (Mayo Clinic, 2014)

Concussion Grading & Diagnosis

Concussions are usually graded as mild, moderate or severe based on the presence and durations of both loss of consciousness and post-traumatic amnesia. Assessment of the severity of the brain injury allows for determination of prognosis for recovery as well as management of the injury (Kushner, 2011)

Here is a table outlining the grading system used after a traumatic brain injury. See table 1.

http://www.aafp.org/afp/2001/0915/p1007.html

The diagnosis of traumatic brain injuries (concussions) is fairly extensive and difficult. There are several tests used to assess the severity of the injury. In regards to athletes, most often young athletes, frequently have difficulty recognizing concussion symptoms. This results in less accurate reports of concussions (Weinberger, 2013). Also, these athletes may be likely to completely ignore the symptoms of concussion. However, the athlete’s confusion can be lessened by the use of symptom scales. Symptom scales allow a patient of brain injury to grade his/her symptom severity. This method of diagnosis has evidently proven to obtain more accurate results from athletes than interviews (Weinberger, 2013).

To view an example of a symptom scale, click the following URL. See Figure 1.

https://www-clinicalkey-com.ezproxy.library.ubc.ca/#!/content/playContent/1-s2.0-S1522840113000748

Concussion diagnosis can also be done through the use of the Balance Error Scoring System (BESS). The BESS method is a proven tool for measuring postural stability, which is commonly impaired in those with concussion injuries (Weinberger, 2013). Along with the BESS, is the Standardized Assessment of Concussion (SAC). This particular test measures the cognitive function through examination of orientation, memory, and concentration. Although this test works well on young adults and older teenagers, it is yet to be demonstrated on younger children. (Weinberger, 2013).

Neuroimaging is another method of testing, one which goes beyond simply identifying a concussion. Neuroimaging includes magnetic resonance imaging (MRI) and computed tomography (CT) tests. These tests are used to identify more severe brain injuries such as skull fractures, intracerebral hemorrhage, or contusions (Weinberger, 2013).

Other potential diagnosis methods include:

  • Immediate Post-Concussion Assessment Testing (ImPACT)
  • Axon Sports Computerized Cognitive Assessment Tool (CCAT)
  • Sport Concussion Assessment Tool 3 (SCAT 3)

(Kutcher, 2014)

Management of Concussions

The management of concussions/traumatic brain injuries often begins prior to the patients actual injury. This is done through the use of Preinjury clinical neurologic assessments. The purpose of these assessments before an injury even occurs is to receive baseline information of brain functioning. This allows practitioners to have a comparison between before and after the concussion. The preinjury clinical neurologic assessments also collect past medical history and family history which may become useful in potential injury management (Kutcher, 2014). These assessments can also allow practitioners to provide proper rehabilitation plans based on previous concussion history. Depending on the symptoms shown after the brain injury a grade is assigned; this will determine the amount of rest needed and the rehabilitation protocol that will be taken to ensure there is no further damage to the brain. However, a grade cannot always be given, meaning each rehabilitation protocol is developed on a case-by-case basis.

After an initial evaluation, the implementation of both physical and cognitive rest is deemed the “cornerstone” of concussion management (Weinberger, 2013). Physical rest is defined as the avoidance of any activity, which increases ones heart rate or any exercise with a risk of head injury. Cognitive rest is defined as time off of school, work, homework, reading, and the use of any device containing a screen, such as televisions, computers, tablets, and smartphones (Weinberger, 2013). The importance of physical rest is to prevent exacerbation and prolongation of symptoms, while the significance of cognitive rest is similar but includes providing a mental state of relaxation (Weinberger, 2013).

It is extremely critical to avoid a second concussion when rehabilitating the initial brain injury. If by chance, a second concussion occurs before the symptoms linked to the first are cleared, this drastically increases the chance of diffuse cerebral swelling. Diffuse cerebral swelling is a rare condition in adults, but is more common in children, and is frequently fatal (Weinberger, 2013). The amount of previous insults on the brain plays a major role on the athlete’s recovery from symptoms. Evidently, the chances of serious side effects and long term symptoms increase along with the amount of concussions an individual has received, this is why treatment of multiple concussions tends to be more and more conservative.

As you can see the recommendations vary through different organizations and physicians, and the topic of concussion rehabilitation is highly debated. This makes proper rehabilitation and management hard to judge because there is no exact set of parameters to follow. If patients are unsure, they should always air on the side of caution when dealing with traumatic brain injuries.

Contact sports and Concussion

Participation in contact sport is a major cause of concussions. In previous research, some believe this may be due to the use of excessive equipment. Researchers believe this is due to a phenomenon know as over-reliance on protective equipment, since other contact sports that don’t involve protective equipment such as rugby and soccer don’t have the same incidence of concussions (Koh et al. 2003). Some sport organizations have looked to make changes to the rules of the game to help prevent brain injury in athletes, such as penalizing head and upper body insults. If the concept of over-reliance is looked at, some sports should decrease the amount of equipment used for protection, in hope that the athletes wont hit as hard. Sports in general are second only to motor vehicle crashes as the leading cause of traumatic brain injury among people aged 15-24 years (Gessel et al. 2007). With this high incidence of concussion in sport, prevention techniques need to be addressed as well as a proper agreed upon rehabilitation plan and return to play protocol. According to Kolt, “Understanding concussion in a sporting context is highly important for a range of involved personnel, whether they be coaches, sports trainers, physiotherapists, sports medicine practitioners, or simply volunteer parents on the sidelines” (p.177).

Return to Play Protocol

In regards to concussions, the most consistently debated and argued topic is the return to play protocol. This protocol is used to determine when an athlete is not only capable, but safe to return to physically intense activities. According to Weinberger (2013), the recommended return of play after suffering a concussion should be individualized depending on the injury as well as the person. While some believe that suspicion of a concussion should result in a player being disallowed to re-enter the game, other guidelines suggest that if sideline tests are negative, then returning to play is acceptable. For example, Weinberger (2013), believes that return to play protocols should only be commenced when an athlete is symptom free at rest for at least 24 hours, undergoes a physical examination, and cognitive function has reached baseline. The protocols in table 2 below offer a different guideline.

Here is a table of guidelines give by different organizations to deal with athletes returning to play after a concussion. See table 2.

http://www.aafp.org/afp/2001/0915/p1007.html

The possibility of returning to physical activity is generally discussed with coaches and medical staff, however, determining the return should be based on a follow up with a primary care physician, sports medicine physician, or neurologist with concussion experience (Weinberger, 2013). The clinicians who are given responsibility of this decision tend to follow similar guidelines. Initially, the patient will undergo physical and cognitive rest, followed by a gradual increase of exercise that is progressive only if post-concussion symptoms do not return. If these symptoms do not return a return period of 7-10 days can be expected. (Tucker, 2014).

Concussions and Childhood Movement Experiences

Mild traumatic brain injuries are very common occurences in young children and adolescents. Every year approximately 30-45 million children take part in sports and recreational events (Valasek, 2012). Of the sports that children participate in, those which include a high level of contact are the main cause of concussions (Valasek, 2012). The CDC, (Center for Disease Control and Prevention) reports that between 2001-2009 that 173, 285 children ages 0-19 who suffered sport-related brain injuries were treated in a hospital setting (CDC, 2011). Of these children, the movement experiences which caused the most concussions/traumatic brain injuries were, bicycling, football, playground activities, basketball, soccer, baseball, skateboarding, swimming, and hockey (CDC, 2011).

The following URL provides access to Table 2, which provides exact numbers of concussions per movement experience listed above.

http://www.cdc.gov/mmwr/pdf/wk/mm6039.pdf

Concussions in adolescents or youth can be extremely destructive, therefore the management of concussions in youth must be different than in adults. Depending on age, the vulnerability of a child’s brain to concussion increases. The recovery time for a child to return to cognitive baselines also is dependent on his/her age. The younger the child is, the longer it will take to recover from a concussion or traumatic brain injury (Valasek, 2012). Research has shown that having a history of concussion increases an individual’s chance of having a future concussion as well as prolongs the duration of abnormal cognitive functioning (Luke et al. 2007). This makes the importance of concussion management and education very important. In regards to fairly recent research, it is know that there can be enduring effects of two or more concussions in youth such as decreased overall neuropsychological functioning as well as decreased attention/mental speed (Shrey et al. 2011). Due to the high risk and dangers of concussions in young children, it is imperative to take whatever precautions necessary to remove concussions from physical activity. This has been attempted through newly innovated equipment, new legislation, and rule changes. It is important to deal with concussions in youth because they are a serious matter. In regards to the relationship between concussions and childhood movement experiences, one cannot remove concussions fully, but can try there best to manage, prevent, and diagnose.

References

American Academy of Neurology (1997). Practice parameter: the management of concussion in sports. Neurology, 48; 581–5. Retrieved from http://www.aafp.org/afp/2001/0915/p1007.html

Blume, H. (2011). Subacute concussion-related symptoms in youth. Physical Medicine and Rehabilitation Clinics of North America, 22(4), 665-681. Retrieved from https://www-clinicalkey-com.ezproxy.library.ubc.ca/#!/content/playContent/1-s2.0-S1047965111000787

Cantu, R. (1986). Guidelines for return to contact sports after a cerebral concussion. Physician Sports Med, 14(10): 75–6,79,83. Retrieved from http://www.aafp.org/afp/2001/0915/p1007.html

Cantu, R. (1998). Second-impact syndrome. Clin Sports Med, 171, 37–44. Retrieved from http://www.aafp.org/afp/2001/0915/p1007.html

Centers for Disease Control and Prevention (CDC). (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged <19 years. 60(39). 1338-1375. Retrieved from http://www.cdc.gov/mmwr/pdf/wk/mm6039.pdf

Colorado Medical Society (1991). Guidelines for the management of concussion in sports. Denver: Colorado Medical Society. Retrieved from http://www.aafp.org/afp/2001/0915/p1007.html

Koh, J., Cassidy, D., Watkinson, E. (2003). Incidence of concussion in contact sports: a systematic review of the evidence. Brain Injury, 17(10): 901-917. doi:10.1080/0269905031000088869

Kolt, G. (2013). Concussion in sport. Journal of Science and Medicine in Sport, 16(3), 177. Retrieved from https://www-clinicalkey-com.ezproxy.library.ubc.ca/#!/content/playContent/1-s2.0-S1440244013000601

Kushner, D. (2001). Concussion in sports: minimizing the risk for complications. American Family Physician, 64(6): 1007-1015. Retrieved from http://www.aafp.org/afp/2001/0915/p1007.html

Kutcher, J., Giza, C. (2014). Sports concussion diagnosis and management. CONTINUUM: Lifelong Learning in Neurology, 20(6), 1552-1569. Retrieved from http://ovidsp.tx.ovid.com.ezproxy.library.ubc.ca/sp-3.14.0b/ovidweb.cgi?WebLinkFrameset=1&S=KANEFPKADKDDEBALNCLKPEOBACKLAA00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.22.23%257c0%257c00132979-201412000-00009%26S%3dKANEFPKADKDDEBALNCLKPEOBACKLAA00&directlink=http%3a%2f%2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCOBPEALDK00%2ffs046%2fovft%2flive%2fgv025%2f00132979%2f00132979-201412000-00009.pdf&filename=Sports+Concussion+Diagnosis+and+Management.&pdf_key=FPDDNCOBPEALDK00&pdf_index=/fs046/ovft/live/gv025/00132979/00132979-201412000-00009

Luke, M., Gessel, B., Sarah, K., Fields, J., Christy, L., Collins, M., Randall, W., Dick, M., Comstock, R. (2007). Concussion among united states high school and collegiate athletes. Journal of Athletic Training, 42(4): 495-503. Retrieved from www.journalofathletictraining.org

Mayo Clinic Staff. (2014). Complications. Diseases and conditions: concussions. Retrieved from http://www.mayoclinic.org/diseases-conditions/concussion/basics/complications/con-20019272?reDate=24022015

Mayo Clinic Staff. (2011). Diseases and conditions: concussions. Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/concussion/basics/ symptoms/con-20019272

Saunders, R., Harbaugh, R. (1984). The second impact in catastrophic contact-sports head trauma. JAMA, 252:538. Retrieved from http://www.aafp.org/afp/ 2001/0915/p1007.html

Shrey, D., Griesbach, G., Giza, C. (2011). The pathophysiology of concussion in youth. Physical Medicine and Rehabilitation Clinics of North America, 22(4): 577-602. Retrieved from http://dx.doi.org/10.1016/j.pmr.2011.08.002

Tucker, A. (2014). Update on sports concussion. Current Reviews in Musculoskeletal Medicine, 7(4), 366-372. Retrieved from http://download.springer.com/static/pdf/716/art%253A10.1007%252Fs12178-014-9243-x.pdf?auth66=1424828352_2cb5f0bfaa4b3bd1a9bff94d9e8d6138&ext=.pdf

Valasek, A., McCambridge, T. (2012). Sports-related concussion. In J. Apps, Pediatric and Adolescent Concussion: Diagnosis, Management, and Outcomes. Springer. 22-26. Retrieved from http://site.ebrary.com/lib/ubc/reader.action?docID=10520941&ppg=35

Weinberger, B., Briskin, S. (2013). Sport-related concussion. Clinical Pediatric Emergency Medicine, 14(4), 246-254. Retrieved from https://www-clinicalkey-com.ezproxy.library.ubc.ca/#!/content/playContent/1-s2.0-S1522840113000748

Yeates, K. (2014). Predicting postconcussive symptoms after mild traumatic brain injury in children and adolescents. In S. Slobounov, Concussions in Athletics: From Brain to Behavior. Springer Science Business Media. Retrieved from http://download.springer.com.ezproxy.library.ubc.ca/static/pdf/220/chp%253A10.1007%252F978-1-4939-0295-8_15.pdf?auth66=1424650440_d07c849d4c8acca888e6733f97fea402&ext=.pdf