Concussion Management and Expectations

The goal of this summary is to give you as a parent an overview of our concussion management program.  Following this summary we have attached a more detailed outline of Our Concussion Management Protocols and our Cognitive Baseline Testing.

There are still many misconceptions about concussions and what should be done when an individual is concussed.   We primarily follow the lead of the University of Pittsburgh’s Medical Centre (UPMC) which is one of the leading concussion centers in North America.

We try to manage concussions from 2 perspectives;

  1.  Baseline Testing – Ideally establish a pre-injury cognitive baseline
  • ImPACT Test
  • NeuroTracker
  • Binocular Vision Screen
  • Vestibular Screen
  • Ocular Motor Screen
  • Postural and ROM Evaluation
  1.  Clinical Management – Evaluation as close to within 48 hours to establish the nature and severity of the injury.  Referral to emergency or appropriate specialist if necessary. Actively manage the concussion and any associated clinical conditions such as whiplash through the following:
  • Altitude Simulation
  • NeuroTracker Training
  • Referral Program with Binocular Vision Specialist
  • Vision Rehab
  • Vestibular Rehab
  • Manual Therapy and Whiplash Rehab

A concussion itself is NOT dangerous BUT what IS dangerous is the mismanagement of a concussion.  Reliance on symptoms alone especially with young athletes is dangerous. Returning an athlete back to play too early IS dangerous.  If you suspect a possible concussion do NOT let your child return to play until they have been evaluated by a clinic specializing in concussions.  Baseline testing is a key to a faster and safer return to play.

Our approach focuses on pre-injury cognitive testing and post-injury active care and education to get the patient reintegrated into their normal lives as quickly as possible.  The critical caveat to this statement is that the patient does NOT partake in any activity which poses any danger to another hit to the head or potential whiplash related injury.  This policy remains in effect until the client is cleared following completion of standardized return to play protocols and subsequent restoration of objectively quantified cognitive baseline measurements.

We will provide any required letters for school and coaches/leagues as part of our service at no additional charge.  If you have any questions or concerns about your child’s care, please feel free to contact me directly either through my cell phone 416-937-3343 or email docfletch@beyondsports.ca.

Dr. Sean Fletch

Clinical Management

What to do within the first 24-48 hours

Depending on your level of confidence you may or may not want to take your child to the closest emergency room.  The goal at emergency will be to examine them for severe head trauma; such as a fracture or cranial bleed where a ruptured blood vessel is bleeding within the skull (intracranial haemorrhage – ICH).  While there are different types of ICH which I won’t explain for this article’s purposes, lCH is very dangerous and must be dealt with immediately. If your child is unconscious or there is evidence of any the following then a trip to emergency is recommended to rule out ICH.

  • Loss of consciousness at the time of the injury
  • Confusion or disorientation after the injury
  • A severe headache (especially increasing) along with nausea and/or vomiting (especially recurrent)
  • Evidence of deteriorating mental status

Especially in younger athletes (or elderly individuals) symptoms from a ruptured blood vessel within the skull can sometimes come on slowly i.e. beyond 24 hours.   If your child complains of one of more of the following symptoms it would warrant a trip to the closest emergency room.

  • Unusual behavior or confusion
  • Progressive or worsening symptoms
  • Weakness, numbness, slurred speech
  • Difficulty with eye movements
  • Worsening or severe headache
  • Seizure
  • Vomiting multiple times
  • Difficulty waking up or arousing
  • Discharge of clear fluid or blood from the nose or ears

Bottom line if you have any doubt as to the health and safety of your child get them straight to your local emergency room.  The next step regardless of whether they have been assessed and cleared at emergency or not it is to have your child evaluated and at a local clinic that specializes in managing concussions.  It is ideal to have them evaluated within the first 48 hours of the injury; variations from normal cognitive baselines are most apparent during this time and thus the ability to rule out concussion from whiplash injuries of the neck is easiest.

It is normal and common that a concussed athlete will act lethargic and sleepy and during the initial 24 to 48 hours and it is appropriate to let them sleep.  DO NOT constantly wake them. Doing so will impair their recovery. By all means monitor them and regularly check on them. If you notice in particular that their breathing is distressed or that they are in any other way under duress, or any of the above listed ICH symptoms begin to develop then I recommend taking them immediately to emergency.  Otherwise let them sleep.

Electronics

I would recommend at least limiting if not completely restricting their cell phone use.   Very limited texting is ok but not watching any videos on the phone. Watching television (i.e. on a larger screen at typically a distance) is potentially ok, but watching video on a small screen like on a cell or computer at generally very close range (inches to a couple feet) is potentially very taxing on the eyes and brain.  It is also important to restrict any visual technology use after dark and close to bedtime. Generally this is always a bad idea but especially so for an injured brain. The principle is to NOT isolate them socially, but direct them to allow both their eyes and brain some rest from the typical extended hours that the average student spends on electronics.  Use can be gradually increased back to normal over time following the same type of aggravation of symptoms scale that will be explained later and will be followed in home exercises and drills.

Guidelines for Physical Rest

While we recommend physical rest for the first 24-48 hours, we do NOT recommend forced isolation into a “dark room”.   Research and clinical experience has demonstrated that the dark room isolation doesn’t improve recovery rates and often increases anxiety and depression.  If the athlete voluntarily chooses to just sleep and remain lethargic during the initial 24-48 hours, let them. That being said beyond the initial 48 hours they should NOT be encouraged to sleep all day, this creates both sick behaviour and disrupts normal sleeping habits.

The most important piece of advice to stress is that until the patient has been evaluated outside of and in addition to the emergency room, it is important to NOT allow your child to return to play or engage in ANY activity which could lead to any type of whiplash type injury or head contact of any kind.  Remember a concussion is NOT dangerous. Mismanagement of a concussion and too early a return to play by reliance on symptoms and how the athlete “feels” IS dangerous.

Once we have evaluated your child, depending on the degree of ongoing symptoms we will begin treatment.  Treatment may include visual, vestibular or physical rehab. Physical rehab will include spinal exercises and balance exercises and what is typically called a Return to Play Protocol (RTP).  This will involve a graded progression through non-contact physical exertion; beginning with light aerobic exercise, followed by moderate levels of aerobic non-contact activity (sport and non-sport specific), followed by heavy levels of non-contact activity (sport and non-sport specific).  The athlete must remain symptom free during and through each stage prior to progressing. Symptoms must NOT reappear for a minimum of 24 hours for progression to occur. If symptoms do reappear within that 24 hour period then the athlete will return to the next lowest stage of activity that they were able to maintain symptom free.   Once asymptomatic status is achieved through the final stage of RTP we then want to ensure that the athlete has achieved/maintained pre-injury cognitive baselines. At that point they can transition into the controlled setting of a full contact practice. Once they demonstrate normal playing behaviour in unrestricted practice they may return to a game situation.

Guidelines for Cognitive Rest

The physical symptoms of concussion vary greatly such as headache, sleep disturbance, and dizziness.  It also produces deficits in short-term memory and learning, attention and multitasking. Based on the severity of symptoms, the overall level of impairment may make full attendance at school impossible or ill-advised.  Schoolwork and the school environment can exacerbate symptoms, so the extent of school participation must be carefully considered.

The goal with all aspects of recovery is to be aware of and empathetic and accommodating of symptoms, but not afraid of them.  Thus realize that the patient will have diminished endurance to physical and mental tasks. They will NOT be able to maintain their normal level of performance and activity.  That being said symptoms do not need to be feared and completely avoided. As we outline in the next section (Treatment) approach activities which elicit symptoms in the following manner; if any activity brings on symptoms allow the student to rest.   Generally symptoms of less than 5/10 might be encouraged to be worked through.   If through rest they recover from their symptoms within 5 minutes, then they can continue with the activity.  If recovery requires more than 5 minutes rest, or exceeds a symptom score of 5/10 then they should stop those activities for the day.

Aggravation of symptoms should not exceed a 5/10 because primarily it will lead to the patient feeling horrible for a day or more.   This will sometimes loose the athlete a day in the recovery process. While a limited occurrence of this won’t create permanent harm it will none the less loose them a day of school and rehab.  We will advise you through this process.

Some students may require a few academic accommodations and we will be happy to provide written recommendations for your child’s school.  Basic accommodations for concussion include notifying teachers of the injury, refraining from gym class and other physical activities, taking breaks to control symptoms (e.g. putting their head down, resting at the nurse’s office etc.), and taking extra time on given tasks.  Generally testing prior to full recovery is not a fair evaluation of the students ability and/or knowledge.

When a concussion is severe, additional accommodations may be warranted.  Dramatic symptoms and memory impairment may indicate temporary removal from school, enrollment in homebound education, or half day attendance until symptoms improve.  In addition, students with sensitivity to light and noise may need to eat lunch in a quiet place, avoid auditorium programs, or wear sunglasses to lessen symptoms. Students with severe memory problems may be unable to learn information as quickly or accurately as before.  They may also feel that they have learned information but are unable to recall it. In these cases, it is helpful to provide students with cueing (e.g. multiple choice instead of free recall, note cards that contain useful formulas) or allow them to use appropriate notes or books when completing tests.  Cognitive rest can also be increased by simply reducing a student’s overall workload. For example, a 50 item homework assignment could be reduced to 25 items by completing every other item, essays can be shortened, and redundant assignments or items could be eliminated.

Certainly, all accommodations will not be appropriate for all classes or all students.  Concussion presentations and severity vary among students and accommodations should be tailored to each case.  In the end what must be realized is that this is a concussion is a brain injury and beyond physical limitations cognitive functions such as problem solving, mental calculations, reading and memory tasks can be even more taxing than the physical activity.  It may be helpful for you as parents to have a meeting with the guidance counsellor or principal to establish which recommendations could be implemented.

Treatment

In our management of concussion we primarily follow the lead of the University of Pittsburgh’s Medical Centre (UPMC) which is one of the leading concussion centers in North America.   Currently it is believed within health care that concussion recovery has occurred when an athlete is symptom free at rest, symptom free with non-contact exertion and ability to react, and has achieved baselines on neurocognitive testing.

Many still believe that full rest and inactivity is the treatment of choice for concussion.  This is out dated. While it is still believed that physical and cognitive rest is important to recovery we are learning that controlled stimulation of the brain is very important to recovery. In our evaluation we will determine what functional issues and resultant symptoms are a problem.  Treatment will then follow controlled intentional stimulation of symptoms through a variety of drills and exercises. Generally, the principles followed will be stimulation of symptoms to a 4-5/10 level followed by rest and recovery. If recovery occurs with less than 5 minutes rest then stimulation will continue.  If recovery doesn’t occur within 5 minutes then stimulation will cease for the rest of the day. If symptoms last for an hour or more then in future we will limit stimulation to a max 2-3/10 as opposed to 4-5/10.

Management will involve both in clinic and at home exercises/drills.  In clinic management may involve some or all of the following:

Altitude Simulation

Altitude simulation may be a suggested treatment modality in your child’s concussion recovery.  Research is demonstrating that a drop and/or interruption in growth hormone production may be an issue in the concussed brain.  Altitude simulation is known to stimulate growth hormone production. While no specific research has been done using altitude simulation in the management of concussion, this relationship to growth hormone may be why we have seen a consistent and usually an immediate improvement in symptoms using altitude simulation with concussed patients.

Regardless, what is known and widely accepted with respect to recovery is the importance of controlled cardiovascular conditioning.  Altitude simulation is a simple way to stimulate and improve cardiovascular fitness without placing a physical demand on the patient or aggravating symptoms.  It is common for an athlete to actually be in better cardiovascular condition post injury due to the use of altitude simulation in rehab.

NeuroTracker

NeuroTracker stimulates visual and cognitive performance through 3D Multiple Object Tracking (3D MOT) a highly demanding cognitive task.  NeuroTracker isolates, trains and tests the high-level mental resources that are necessary for the perception of complex movement in a dynamic sports environment i.e. keeping track of the location and movement of teammates, opponents and a ball or puck.  These perceptual-cognitive resources are known be sensitive to concussion-related damage, particularly during late recovery stages when impairments are measureable but the patient is otherwise symptom free and feeling normal.

Maximal stimulation is achieved by an automated staircase procedure that pushes an athlete just above and below their processing threshold, activating relevant regions of the visual cortex in the same way team-sports do, but with strict functional isolation.  Baselines can reliably quantify an athlete’s normative perceptual-cognitive ability. A return to these levels can offer us clinically a measureable indicator of return to performance level status in the post-concussion return to play stages, supporting other contemporary assessments.

The NeuroTracker uses varied computer generated programs in a virtual 3d environment on a 60 inch 3d television.  A session/baseline consists of 3 sets of 20 trials with each trial lasting 8 seconds.

Visual and Vestibular Rehab

Following concussion individuals often experience problems  coordinating their eye movements when tracking objects or reading text; Binocular Vision.  Our evaluation evaluates and screens for binocular vision function and we work extensively with one of the world’s top vision specialists in binocular vision.  Often with minor dysfunction we are able to deal with issues in clinic and for those who require more extensive work, a referral to the specialist we deal with will be set in motion for more in depth evaluation and treatment.

The vestibular system allows our brains to orient where our body and its parts are in relation to space and time.  Problems within the vestibular system following a concussion typically cause symptoms of dizziness and nausea and sometimes headaches.  Special exercises/drills will be given following the principles mentioned previously of stimulation followed by rest and recovery.

Whiplash

Sometimes whiplash can mimic a concussion and when there are established cognitive baselines prior to injury we can more readily differentiate what is a concussion and what is a whiplash injury.  Regardless, whiplash and neck issues are almost always a component within concussion. In fact some research suggests whiplash mechanisms are the primary cause of concussion as opposed to a head contact injury.

We manage concussion through chiropractic, using both manual manipulation and other manual techniques which involve no manipulation.  While manipulation of the neck still remains safer than taking an Advil or Tylenol we understand some individuals don’t like this form of treatment for a variety of reasons.  In such cases we use a technology called ProAdjuster. ProAdjuster utilizes a computerized technology and a piezoelectric sensor to evaluate the spine. We then treat problem areas using a gentle

low force percussion to adjust the segment by gentle vibration.  Thus there is no “popping” or twisting of the spine. Some clients prefer manual techniques and some clients prefer the ProAdjuster.  Some clients actually have no preference and such cases we use a combination of manual and ProAdjuster. Either way we orient treatment around the comfort of the client.

Recovery Expectations

The bottom line is that there is no way to definitively tell anyone how long the recovery process will be with a concussion.  Most will recover within 1-2 weeks but some can take months. There is a wide variation with individuals and the length of time doesn’t usually coincide with the severity of the injury or initial symptoms.

There are two primary reasons why active clinical care should be implemented with the recovery process, as opposed to the rest, wait and see approach.

  1.  We can expedite the recovery process.
  2.  We can ensure a safe and objective return to play.  Making sure that an athlete doesn’t return to play prematurely.  This is critical because the athlete WILL in most cases feel normal before their brain has actually fully recovered.  If an athlete returns to play before the brain fully recovers then they can create significant impairment ranging from a more severe concussion requiring many months of symptoms to permanent disability and even death.

We will not release your child to return to play until they have completed all internationally standardized return to play protocols and we are satisfied that they have established cognitive baselines through multiple testing protocols.  Once they have been released then you can feel confident that they can return to their sport with no greater risks than they were exposed to prior to injury. The many horror stories reported with concussion have primarily involved those who have returned to action prior to full recovery.

The best and most ideal management utilizes baseline cognitive testing of the athlete established prior to injury.  We are happy to provide you with more information on baseline cognitive testing. Once your child has been released from active concussion care we will have established a new cognitive baseline for future reference should they become concussed again.

Baseline Testing

Recent advancements in concussion management have resulted in the widespread use of computer-based cognitive testing protocols, and evidence now shows that concussed athletes demonstrate subtle cognitive deficits that may persist beyond symptom resolution – emphasizing the fact that return-to-participation once “symptom-free” is no longer an accurate measure of readiness.  We use a combination of computer-based cognitive testing protocols, computerized visual testing, balance testing using force plates and physical examination of the nervous system and vestibular system.

The ImPACT Test

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most-widely used, and most scientifically validated computerized concussion evaluation system.  It is part of baseline testing and concussion management with every single major sport within North America. It is a standard within MLB and MLB umpires are not allowed to step onto a field without an ImPACT baseline.

Developed in the early 1990’s by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages. ImPACT Applications, Inc. was co-founded by Mark Lovell, PhD, Joseph Maroon, MD, and Michael Collins, PhD.

The ImPACT test is done in a clinical supervised setting using a computer.  The test includes a demographic and concussion history questionnaire which is factored into the final report.  The questionnaire is followed by a symptom evaluation/scale. The primary body of the test measures 8 neurocognitive functions including; verbal memory, visual memory, reaction time and processing speed.  The test has built in baseline validity checks to minimize false scores. There are currently over 125 peer reviewed studies on ImPACT test since 2000.

NeuroTracker

NeuroTracker was developed by CogniSens Athletics, a neuroscience-based company that has developed cutting-edge technologies to assess and condition perceptual-cognitive abilities.  NeuroTracker isolates, trains and tests the high-level mental resources that are necessary for the perception of complex movement in a dynamic sports environment. These perceptual-cognitive resources are known be sensitive to concussion-related damage, particularly during late recovery stages when impairments are measureable but the patient is otherwise symptom free and feeling normal.  For this reason combined with the reality that NeuroTracker is a direct objective measurement of brain function and processing speed, NeuroTracker is an ideal baseline measurement in any concussion program.

NeuroTracker has substantial scientific research in its history and development.  Initial research was based on managing dementia and the aging brain, and rehabilitation of severe brain trauma.   Due to its impact on brain function it has also shown significant benefit for the treatment of attention deficit disorders and more recently it use in elite athletic performance.  Due to its effectiveness both the Canadian and US military’s Special Forces use NeuroTracker with all of their personnel.

A NeuroTracker baseline involves 3 trials each consisting of 20 repetitions lasting 8 seconds.  Each trial lasts approximately 6 minutes. Between each trial the athlete is given a 5-6 minute rest.  The testing is done using proprietary software and using 3D virtual technology. A baseline session lasts approximately 30-40 minutes.

Binocular Vision Screen

It is estimated that 25% of the population has an undiagnosed binocular vision problem that can either affect athletic performance, academics or both.  Current concussion research has also demonstrated that those with binocular vision problems are also more vulnerable to complications from head shots and/or concussions.   For this reason we include a functional binocular vision screen in our comprehensive baseline testing and post concussion management. Our screen is done through a combination of physical examination and computerized testing of the eyes.

If problems are found in our screen, clients will be referred out to an eye specialist who can better evaluate the root cause of the problem and render treatment to eliminate the dysfunction.

Ocular Motor Screen

Oculomotor means eye movement.   An oculomotor evaluation tests and measures how and when an individual’s eyes move in response to images, light, moving objects and head motion.   Not only does this serve as an important aspect of comprehensive baseline testing, but problems with this aspect of function pre-dispose individuals to problematic recovery from a concussion.  If problems are found during the evaluation, appropriate referral and/or treatment can be given.

Vestibular Evaluation

Vestibular testing helps to determine if there is something wrong with the vestibular (balance) portion of the inner ear. These tests especially in combination with Occulomotor testing provide important baseline information in comprehensive pre-concussion testing.  In addition problems with vestibular function can predispose individuals to more severe concussions. If problems are found, appropriate referral and/or treatment can be given.

Musculoskeletal Testing

Whiplash and cervical spine dysfunction can also mimic and/or complicate concussion.  A spinal and postural evaluation is done both as a protocol of comprehensive baseline testing and post concussion examination.

Expectations

A basic test will require approximately 30 minutes in clinic.  A comprehensive baseline evaluation will require approximately 90-120 minutes in clinic.  The tests are not indicative of intelligence or anything beyond a baseline of how the brain normally functions.  For this reason there are no reports or summaries provided at the end of the test. However if any problems are found such as binocular vision problems or vestibular dysfunction we will provide a consultation to parents to discuss what was found and what are the recommended action steps.

If your child is concussed and it is NOT feasible to return to our clinic for testing and examination, we will ask for a standard medical release signed by the parents/legal guardian and we will provide baseline testing details to your chosen health care practitioner at no charge.  Please contact us for more information on pricing.

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