Concussion Testing and Treatment. Is it necessary?16 Sep 2014, Posted by Blog in
Concussion Testing and Treatment. Why is Baseline Testing so important?
I get it, you’re skeptical, I was too. This is surely just another money grab by health care providers trying to cash in on the mass media attention of concussion, right? WRONG and here is why. Preventative care could be the biggest key in preventing long term problems after a concussion and even in rare instances save someone’s life. Sounds dramatic doesn’t it, and you may well be fed up of hearing about the potential dangers of concussion, but unfortunately they are real and it seems that it is due to second impact syndrome. This is when a person who is still in the “vulnerable stage” after a concussion suffers a second hit to the head (often requiring much less force than the original injury). In the lucky cases (Sidney Crosby), this causes increased symptoms which last longer than the expected course of recovery (of a mild traumatic brain injury (mTBI)/ concussion), in the unlucky cases (Rowan Stringer) it causes death. Scary right. What we see is that when a person is allowed to recover fully from a concussion a second hit acts just like the first, and there is absolutely no irreversible damage (Weil et al 2014). So, how do we know when someone is out of the “vulnerable period”? Unfortunately, right now we cannot be 100% sure, so this is where baseline testing comes in.
Current practice based on the Zurich consensus guidelines 2012 states that as long as someone progresses through the 6 stages of the return to play guidelines, based on symptoms, they are safe to return to contact sport. Sounds pretty standardized and safe doesn’t it? Unfortunately this system has floors. Let us put this into some context…if you fracture/break your wrist, you are put in a cast and sent you home. A couple of days later, the initial pain has actual gone away but you are still stuck in the cast. Would you visit the doctor, say “hey doc I’m not in pain anymore, can you snip this cast off and clear me to go play hockey?” No, sounds ridiculous doesn’t it? Well that’s what we are doing with concussions right now. At no point are there any objective tests of performance or healing other than self-report of symptoms following each “stage” of rehab. Surely there has to be a better way I hear you cry…why can’t we MRI everyone before they go back to sport? Unfortunately, because a concussion is purely a metabolic injury (energy deficiency in the brain) and not a structural injury, there is no evidence of injury on an MRI or any other imaging. So, how else can we measure how someone is doing? At the moment it is all down to just symptoms. So, are we heading for potential disaster with every child forever destined to be suffering the consequences of playing contact sports? The answer is an overwhelming no at this point.
So here is the good news, the research tells if we have a baseline of performance over a wide variety of different tasks we are better able to predict that a player is performing at a level suggestive of full recovery. We know that during the “vulnerable period” performance on many tasks is diminished compared to pre-injury or post recovery (Lovell et al 2004). We know also that performance will actually recover back to the pre-injury levels with increased time and rehabilitation (Vagnozzi et al 2010). Research shows that although the symptoms may have gone, the level of production of brain fuel (Adenosine Triphosphate) is still at considerably lower than normal levels, suggesting that metabolically the brain hasn’t recovered (Vagnozzi et al 2007). Therefore is using symptoms as a guide to recovery and as a determinant for returning to the playing environment a wise call? Wouldn’t you much rather be able to say well I, or your child feels great symptomatically AND have performed to the same level on both physical and cognitive testing as prior to a concussion?
A recent position statement from the American Medical Society on concussion in sport stated that “neuropsychological tests should only be used as a part of comprehensive concussion management strategy and should not be used in isolation”. At all clinics associated with Complete Concussion Management Inc. (of which Back in Motion Physiotherapy and Active Rehab. is) the imPACT (Neurocognitive test); which is used by most NFL and NHL teams, is only one small part of a battery of baseline and retesting measures that are used to determine return to play readiness.
– Matt Peters, Surrey Manager& Physiotherapist, BSc. (Hons) CAFCI PT