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Concussion Evaluation with SCAT2

Posted by on Feb 7, 2013 in Brain Injury, Brain Testing | Comments Off on Concussion Evaluation with SCAT2

Concussion Evaluation with SCAT2

The article below points out the short coming of concussion management in the NHL and the lack of validity of sideline measures like the SCAT2. It is my opinion that the SCAT2 is more appropriately used as a means of identifying progression of recognized concussion and not necessarily as a means of identifying concussion. The importance of recognizing the progression of a traumatic brain injury, that is the deterioration of function suggesting more serious injury, and need for emergency transport is obvious.  I concur with the author and the latest research that the SCAT2 should not be used to identify concussion on its own and certainly should not be used to return a player to the game in the face of other signs and symptoms of concussion. Moreover, the sensitivity of any test is diminished without a prior baseline test as a comparison point. I recommend comprehensive baselines that include at the very least a functional neurological exam, posturography, VNG for visual motor function and neurocognitive testing with ImPACT test. Additionally, it is my opinion that making a return to play decision solely based off of symptom reporting is a serious mistake. Objective functional  assessments over symptom tracking is the approach at Brain Centers NW. Dr. David Burns

 

NHL Looking For Solutions on its Own Concussion Protocols

by WARREN NYE on Feb 5, 2013 • 2:23 am1 Comment

Thoughts From Coach Nye

I was searching the other day through the NHL rule book and came across the proper protocol for players to go through when they have been told they have received a concussion. They must go throught the SCAT2 evaluation process before proceeding back into any type of play.

As I was checking all this out I came across another article written by Jeff Klein in regards to Colorado’s Gabriel Landeskog, who was ‘clocked’ in a game recently in San Jose. After going through all the proper procedures, the NHL started to realize something that maybe they needed to have done a while back.

Let’s take a look at what they have found out!

 

NHL GRAPPLES WITH APPLYING ITS OWN CONCUSSION PROTOCOLS

Colorado’s Gabriel Landeskog, the youngest captain in N.H.L. history and last season’s Calder Trophy winner as the league’s top rookie, did not play last week. But what happened to him in the aftermath of a heavy body check he received raised concerns that the league’s concussion protocols may be out of step with current scientific research.

On Jan. 26 in San Jose, Landeskog was on the wrong end of a crushing first-period hit from Sharks defenseman Brad Stuart, whose shoulder cracked into Landeskog’s head.

The hit was deemed legal by the referees, a call that passed review by Brendan Shanahan and the N.H.L.’s hockey operations department. Although Rule 48 on head checking was strengthened two seasons ago to penalize players who target an opponent’s head, if contact is made in the course of delivering a full body check, the hit is legal.

Additionally, the rule permits hits in which “the opponent put himself in a vulnerable position immediately before or simultaneously with the hit or the head contact.”

Landeskog, 20, said the hit was hard but clean. “I was kind of reaching for the puck and didn’t brace myself enough,” he said.

Another aspect of the episode, however, was troubling. Immediately afterward, Landeskog skated off and needed assistance to get to the dressing room. He remained out of the game and was examined by a doctor, in accordance with N.H.L. protocols on head injuries, until late in the second period. He passed the examination and returned to play part of that period and all of the third.

But in Edmonton last Monday, two days after the hit, Landeskog did not play. The team said he was out with head and leg injuries. He continued to travel with the team to Vancouver and Calgary, but he remained out of the lineup.

The Avalanche followed N.H.L. protocol in allowing Landeskog to return after he passed the SCAT2 evaluation exam, the standard for on-the-spot concussion assessment. But the latest research suggests that players suspected of having a concussion should be kept out of games no matter how they do on the SCAT2.

The team has not announced that Landeskog sustained a concussion but did place him on the injured reserve list Friday with a head injury. There is no timetable for his return. It is well known, however, that concussion victims sometimes do not show symptoms until days after an incident.

“When it comes to evaluating concussions, SCAT2 or any of those sideline screening tests really have no reliability,” said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, who has done two recent studies of concussions in hockey. “If you see it happen and you see the reaction, then you don’t let the player go back in. That’s the worst thing you can do, expose him to a second or third hit that can be really dangerous.”

The most well-known example was Sidney Crosby’s concussion sustained at the Winter Classic on Jan. 1, 2011, when he was clipped by Washington’s David Steckel near the end of the second period. Crosby played the third period, then started the next game on Jan. 5 at Tampa Bay. But a relatively routine shove into the boards from behind by Victor Hedman triggered symptoms that kept Crosby out of the Penguins lineup for 10 months.

That March, the N.H.L. revised its concussion protocol, mandating a player’s removal from the game if he reports symptoms or shows signs of loss of consciousness, impaired motor coordination, balance problems, or slowness to get up; or if he has a blank or vacant look, is disoriented, clutches his head after a hit or has a visible facial injury in combination with any of the above.

According to the protocol, the player is to be examined by the team doctor, not the trainer, in a quiet place free from distraction, using “an acute evaluation tool” like the SCAT2, as opposed to a quick rinkside assessment.

Still, on Nov. 26, 2011, Crosby’s teammate Kris Letang was rocked by a hit from Montreal’s Max Pacioretty that broke his nose. He left the game, reportedly passed the concussion protocol and came back to score the winning goal. But symptoms emerged later, and Letang was out for almost two months.

The N.H.L. has made strides on concussions in many areas, but cases like Letang’s and Landeskog’s suggest that even the league’s current protocol for concussion assessment may be too lenient, allowing players to return to the ice too soon after a jarring hit to the head.

Last November in Zurich, scientists and sports administrators gathered for the Fourth International Consensus Conference on Concussion in Sport to review the latest research. According to Ken Dryden, the Hall of Fame goalie and former member of Canada’s Parliament who attended the event, “the Zurich conference agreed to a clear, certain message: ‘When in doubt, sit them out.’”

That is not yet the standard in the N.H.L., where teams and the players are ever eager to shake off injuries, even from blows to the head, and get back in the game.

 

Article posted at http://fullerworks.biz/uhs/?p=600&goback=%2Egde_4240776_member_211084158

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Duel for Concussion Testing?

Posted by on Feb 1, 2013 in Brain Injury, Brain Testing, Research | Comments Off on Duel for Concussion Testing?

Duel for Concussion Testing?

Dual tasking? Am I talking about a medieval sword fight? No that is “duel”. A dual task involves performing two things at once, from a clinical standpoint it means to engage or challenge a motor function (e.g. walking) at the same time as you perform a cognitive challenge (e.g. counting backwards by 7’s from 100). One would think that walking is automatic and that thinking would not impact it at all. Walking does take up some of your brain power and if the mental task is too heavy a load for your brain because of a concussion or other brain health reasons, than you might see changes like slowing down, going of course or angulation changes in limbs.

Have you ever walked beside someone who seemed to constantly bump into you while walking and talking, or they slow down every time they spoke? Well those are examples of failure of function while dual tasking. As suggested in the research below dual tasking helps “isolate specific mental processes” and should be part of any concussion evaluation and baseline screening. I’ve used these strategies for years for both brain baseline assessments and brain rehabilitation and if your concussion evaluation did not include this component than a potentially important “window” into your brain function was missed.

Now, let’s take it a step further to try and understand why I do some of the crazy brain training things I do. Last year I asked myself, “If I can help someone return to “normal” by employing dual tasking exercises can I help an athlete go from their “normal” to an improved level of function that entails faster thinking and better performance on the field?” The answer is YES I can. These are strategies that have been employed in military training and with professional players; it is not a completely novel idea. Now the tasks employed should ideally be relevant to you, that is, address your weaker areas of brain. Function is not from symptoms to no symptoms but rather a continuum that continues on past no signs or symptoms toward optimization of function. Simultaneously challenging brain and body builds a stronger, faster brain that may very well be more resilient to injury.

 

J Athl Train. 2011 Mar-Apr;46(2):170-5. doi: 10.4085/1062-6050-46.2.170.

Balance performance with a cognitive task: a continuation of the dual-task testing paradigm.

Resch JE, May B, Tomporowski PD, Ferrara MS.

St. Mary’s Athletic Training Research and Education Laboratory, Athens, GA, USA. resch@uta.edu

Abstract

CONTEXT:

To ensure that concussed athletes return to play safely, we need better methods of measuring concussion severity and monitoring concussion resolution.

OBJECTIVE:

To develop a dual-task model that assesses postural stability and cognitive processing in concussed athletes.

DESIGN:

Repeated measures study.

SETTING:

University laboratory.

PATIENTS OR OTHER PARTICIPANTS:

Twenty healthy, college-aged students (10 men, 10 women; age  =  20 ± 1.86 years, height  =  173 ± 4.10 cm, mass  =  71.83 + 35.77 kg).

INTERVENTION(S):

Participants were tested individually in 2 sessions separated by 2 days. In one session, a balance task and a cognitive task were performed separately. In the other session, the balance and cognitive tasks were performed concurrently. The balance task consisted of 6 conditions of the Sensory Organization Test performed on the NeuroCom Smart Balance Master. The cognitive task consisted of an auditory switch task (3 trials per condition, 60 seconds per trial).

MAIN OUTCOME MEASURE(S):

For the balance test, scores for each Sensory Organization Test condition; the visual, vestibular, somatosensory, and visual-conflict subscores; and the composite balance score were calculated. For the cognitive task, response time and accuracy were measured.

RESULTS:

Balance improved during 2 dual-task conditions: fixed support and fixed visual reference (t18  =  -2.34, P < .05) and fixed support and sway visual reference (t18  =  -2.72, P  = .014). participants’ response times were longer (F1,18  =  67.77, P < .001, η2  =  0.79) and choice errors were more numerous under dual-task conditions than under single-task conditions (F1,18  =  5.58, P  =  .03, η2  =  0.24). However, differences were observed only during category-switch trials.

CONCLUSIONS:

Balance was either maintained or improved under dual-task conditions. Thus, postural control took priority over cognitive processing when the tasks were performed concurrently. Furthermore, dual-task conditions can isolate specific mental processes that may be useful for evaluating concussed individuals.

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“Which Way Is Up?” Post Concussion

Posted by on Jan 30, 2013 in Brain Injury, Brain Testing, Research | Comments Off on “Which Way Is Up?” Post Concussion

“Which Way Is Up?” Post Concussion

When I talk to patients or even healthcare providers about the approach at Brain Centers NW, there is at times an erroneous belief that what I am suggesting is simply Dr. Burns’ philosophy and maybe has merit. To quote one of my teachers, “Nay, nay, we say”. Brain Centers NW’s clinical applications stem from present day research. The clinical recommendation that we should be paying attention to how well the brain is working versus simply symptom management is not just a nice daydreamed idea, it is sound clinical advice based off the research.

If you or someone you know is being managed for a traumatic brain injury simply by asking “How are you feeling today?”, than you or they are not be “treated” at all. The research below serves as example supporting Brain Centers NW’s approach to assessment and management of traumatic brain injuries. The research below would suggest that even after concussion symptom resolution an athlete’s brain may still be functionally compromised. “Well how are we to know Dr. Burns?” Simple…. you TEST them with advanced functional diagnostics and a functional neurological exam. For the record I’m not talking about an MRI or CT. The doctor needs to look through as many “windows” of brain function as he or she can. Oh! FYI a clean CT does NOT mean you don’t have a concussion.

This study also begs the questions, “If the athlete is still functionally compromised are they likely to be playing their best?” Answer… probably not. More importantly, “If the concussed athlete is still functionally compromised are they likely to be more at risk of another injury?” My money is on, YES.

 

CONCLUSIONS: Athletes with concussion appear to still show navigational deficits in environments well after being considered fully recovered according to current return-to-play protocols. Although still preliminary and requiring further study, the present findings suggest that functional assessment within complex environment contexts could be considered before sending athletes back to play following a concussion, even in the absence of postconcussion symptoms or with normal clinical outcomes.

 

J Head Trauma Rehabil. 2012 Apr 10.

Altered Integrated Locomotor and Cognitive Function in Elite Athletes 30 Days

Postconcussion: A Preliminary Study.

Fait P, Swaine B, Cantin JF, Leblond J, McFadyen BJ.

Université Laval (Drs Fait and McFadyen), Quebec Rehabilitation Institute (Dr Cantin), and Centre for Interdisciplinary Research in Rehabilitation and Social Integration (Drs Fait, Leblond, and McFadyen), Quebec City, and Université de Montréal, Montreal (Dr Swaine), Quebec, Canada.

Abstract

OBJECTIVE: To begin to understand changes in locomotor navigation in elite athletes following concussion.

METHODS: Clinical measures and gait analysis were undertaken on average 37.33 days (SD = 4.8) postconcussion for 6 athletes as well as for a control group of athletes matched for age, sex, and team. The locomotor task consisted of walking at a self-selected speed along an unobstructed or obstructed path with and without a visual interference task. The trends for 4 dependent variables were described (2 for gait behavior and 2 for cognitive behavior). A principal component analysis was used to reduce data to root sources of variance among these variables. General group differences were tested with Wilcoxon matched-pairs tests on factorial scores.

RESULTS: Athletes with concussion were symptom free at the time of testing and their neuropsychological test results were not different from those of athletes in the control group. However, when the laboratory data between paired groups were compared, descriptive analyses suggested potential group differences in navigating the obstacle. The simultaneous Stroop task appeared to present difficulty for both groups. A significant group effect was found on the component of the factorial analysis that was highly loaded with both gait and cognitive variables (minimum clearance, Stroop task errors, and cognitive dual-task costs), generally supporting the descriptive analyses by suggesting that athletes with concussion do not navigate the targeted complex environments like the control group.

CONCLUSIONS: Athletes with concussion appear to still show navigational deficits in environments well after being considered fully recovered according to current return-to-play protocols. Although still preliminary and requiring further study, the present findings suggest that functional assessment within complex environment contexts could be considered before sending athletes back to play following a concussion, even in the absence of postconcussion symptoms or with normal clinical outcomes.

PMID: 22495102 [PubMed – as supplied by publisher]

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