concussion

After concussion, athletes should undergo neuro-cognitive testing before returning to play

Published: January 31, 2013

Image: iStockphoto

Too many athletes may be going back onto the field, court or rink too soon after a concussion, according to a new study that recommends athletes undergo post-exertion neurocognitive testing before being cleared to return to play.

Three UPMC clinicians and researchers were co-authors of a study published in the January edition of Brain Injury showing that cognitive concussion issues may linger undetected in athletes at rest. That’s what the Boston-based study, by lead investigator Neal McGrath, Ph.D., and Wayne Dinn, Ph.D., of Sports Concussion New England, found in more than one in four high-school age athletes. They reported being symptom-free and returned to baseline neurocognitive-test levels, meaning most clinicians and state laws would allow them to return to their sports. Yet, in spite of feeling ready to return, 27.7 percent of these athletes displayed at least one area of cognitive decline after moderate physical exertion.

Those players were then kept from contact sports, allowed more time to heal and ultimately passed post-exertion cognitive testing before being cleared to return to play. Thus, the researchers concluded that computerized neurocognitive testing following moderate exertion should be part of the standard procedure when making return-to-play decisions for athletes for whom activity or exercise shows that they remain cognitively impaired.

“For years now, it has been widely understood that no contact-sports athlete should return to play until all signs point to a full recovery,” McGrath said. “We have also known that computerized neurocognitive testing can show lingering cognitive deficits even when recovering athletes feel symptom-free. It has been standard practice to progress symptom-free athletes back through increasing physical activity over a few days while checking for a recurrence of symptoms. These findings suggest that post-exertion neurocognitive testing may be an important way to help verify that recovering athletes are ready to sustain hits again in football, hockey, soccer and other contact sports.”

“We feel the issue is less related to heart rate and more related to the vestibular system, which is responsible for helping us to navigate our environment—space, motion, movement, balance,” said Michael “Micky” Collins, Ph.D., executive and clinical director of the UPMC Sports Medicine Concussion Program and a participating investigator in the study. “The role and importance of exertion in recovery from concussion is ubiquitous; that’s why we have a full-time exertional physical therapists in our program. This study looked at physical exertion. But I think in future studies we need to look at return-to-school and cognitive function back in the classroom as well.”

From a pool of more than 800 concussion cases reviewed over a two-year period, 54 contact-sports athletes from 15 high schools and a junior-hockey team met the criteria for the study, which used their scores from the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and clinical examinations by an attending sports-medicine professional. McGrath, a clinical neuropsychologist, also independently confirmed the findings of a concussion in each athlete. When the players exhibited no more symptoms and their neurocognitive scores returned to baseline levels—determinants used by most clinicians and state laws in permitting athletes to return to play—participants were put through moderate exercise for approximately 15 to 25 minutes on a treadmill, elliptical or stationary bicycle. After a brief rest period, they completed neurocognitive testing again.

Fifteen of those athletes (the aforementioned 27.7 percent) displayed cognitive deficiencies that would categorize them as still injured with a concussion and therefore unfit to return to play. In particular, these athletes scored significantly lower in the verbal and visual memory portions of the neurocognitive testing. However, processing speed and reaction scores did not worsen following exertion.

“This suggests that tests focusing primarily on reaction time or processing speed may not be as effective at detecting post-exertion impairment,” said Anthony Kontos, Ph.D., assistant research director of the UPMC Sports Medicine Concussion Program. “As such, a comprehensive test that includes verbal and visual memory in addition to these other tests should be used by clinicians.”

“Moving forward, we plan additional research involving a larger sample that includes more girls,” Kontos added, citing this study’s small number of female participants (11 of the 54). “We also plan to examine the effects of different levels of exertion on cognitive performance.”

ᔥ University of Pittsburgh

Returning to Sports After Concussions

Published: May 29, 2012

Image: iStockphoto

Be careful not to rely on what adolescent athletes tell you about their recovery from concussions as the sole criterion for making return-to-play decisions, researchers from UPMC and the University of Pittsburgh warn sports medicine practitioners.

In findings published online in the inaugural issue of Applied Neuropsychology: Child, researchers found that young athletes neglect the more subtle symptoms — neuropsychiatric and sleep issues — and base their perceptions of their recovery primarily on physical (somatic) symptoms such as headache and nausea.

Results indicate that when athletes gauge their own readiness to return-to-play, their physical symptoms account for 56 percent of their self-assessment, whereas their performance on objective neurocognitive testing only accounts for 28 percent. While the statistical analyses revealed that they judged their recovery on somatic and cognitive symptoms almost twice as strongly as neurocognitive testing, the sleep and neuropsychiatric symptoms ranked ahead of their performance on the objective test data by only a few percentage points.

“Our findings suggest that young athletes may not perceive their cognitive deficits as well as they perceive their somatic symptoms,” said Anthony Kontos, Ph.D., assistant research director with the UPMC Center for Sports Medicine Concussion Program. “Therefore, it is important to assess their cognitive deficits using neurocognitive concussion tests and a comprehensive clinical evaluation.” [continue reading…]

Chase for the 2011 Stanley Cup

Published: May 20, 2011

Concussion – getting hockey players healthily back on the ice

Here in Vancouver we are in the midst of hockey fervour, as the Vancouver Canucks are in the chase for the the 2011 Stanley Cup. As the series heads to the finish, several players are off the ice suffering from concussion, an injury all too common in this contact sport.

Deciding if a player is ready to return to the ice has been left primarily to each team’s physician, with no standardized across-the-sport method to assess when the time is right.

“Premature return to a sport after concussion greatly increases the risk of a follow up concussion, with more devastating results than the first concussion,” says Willer, who has done extensive research on hockey injuries. “We believe this approach could change the way professional and amateur sports team physicians make decisions about concussion recovery.

“For a number of years,” Barry Willer, PhD, UB professor of psychiatry and rehabilitation medicine relates that “the consensus has been that players are finally ready to return when they can exercise to the level of their sport without exacerbation of symptoms. In the past how a team physician and the team trainer made this decision was left to chance.

“Some team officials would ask the player to skate hard or run fast at a practice and then ask them if they had any symptoms. There was no systematic nature to the decision, which is so critical to the health of the player.”

The UB study was conducted in a consecutive sample of 21 athletes and non-athletes who came to UB’s concussion clinic. The test, developed at the clinic, uses a single approach to assess readiness to return to the sport.

Athletes are evaluated while exercising on a treadmill, as the angle of the treadmill increases the workload, and are watched carefully for any signs or symptoms of exacerbation as they exercise to voluntary exhaustion.

Athletes are reevaluated after 1-2 weeks of increasing exercise [continue reading…]

Parents Ill-Prepared to Reduce Kids Concussion Risks

Published: June 14, 2010

Despite available information, parents are little aware of concussion risks but support school policies to minimize them; most know other parents who would have young athletes return to play too soon

With growing media attention to concussions among athletes young and old, and recent actions of the National Football League to reduce dangers from multiple concussions among its players, the spotlight is now on what schools are doing to protect their student-athletes. Do parents feel that their kids are safe, and do parents agree with school policies?

The latest C.S. Mott Children’s Hospital National Poll on Children’s Health finds that nearly two-thirds of parents of young athletes, ages 12 – 17, worry that their children will get a concussion while playing school sports—yet half don’t know if their children’s school has a concussion policy.

[continue reading…]

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