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Current Concepts in Concussion: Initial Evaluation and Management

Current Concepts in Concussion: Initial Evaluation and Management

Am Fam Physician. 2019 Apr 1;99(7):426-434

Author disclosure: No relevant financial affiliations.

Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established.

Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.17 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9. Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.

therudedogshow@hotmail.comCurrent Concepts in Concussion: Initial Evaluation and Management
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Counting Head Injuries in Female Athletes

Concussions Don’t Discriminate Gender in Youth Sports

A few months ago, a news story circulated about retired US soccer player, Brandi Chastain. She made a statement to the press about her wish to donate her brain for research when she dies. She believes her brain has been concussed multiple times during the 40 years she played soccer. In turn, she’s opening the conversation about head injuries in female athletes during a time when the rest of the country is focused on the concussions of male football players.

It’s easy to think of men’s football, boxing, and hockey as the primary culprits of sport-induced concussions, and ignore the other gender. But the reality is that girls’ sports are just as intense and physical as boys’ sports, therefore the threat of concussions is the same. Some studies, like the one published in the Journal of Athletic Training, have even shown that girls are at a higher risk for concussions when playing sports.

Perhaps part of the reason why the number is higher for girls is that females are more likely to report their injuries to medical professionals. The same study mentioned above showed that girls required a longer recovery time than boys after a concussion. No matter the cause, the issue stands that athletes, coaches, and parents must be more cautious of girls getting concussions.

Concussions Caused by Cheerleading Stunts

Cheerleading as a sport has come a long way from the jazz-dance based, pom-pom shakers of the past. Nowadays,400,000 student-athletes participate in cheerleading, and over 25% compete. Modern cheerleading performances are heavily based in gymnastics, tumbling, and stunts. Imagine being tossed feet into the air while flipping, only to be caught by three of your peers. To add to the terror, cheerleaders don’t wear helmets or any protective gear. It’s easy to see why cheerleading is one of the top female-based sports for concussions. Tossing a team member into the air takes strength, recovering from an elbow to the head while catching her takes a skull of steel.

Fouls on the Brain in Girls’ Basketball

In basketball, the quick court coverage, aggressive blocking, and hard floors are a recipe for injury. Being under the net for a rebound is a risk team members take multiple times a game, but the results aren’t always 2 points. You’d be surprised how many collisions and falls result in head-to-floor landings. In a study that took place over 11 years, 109,000 children and teenagers were treated for basketball-related head injuries. “Among boys, the percentage of head injuries doubled over the period, but among girls, it tripled,” the New York TImes reported.

Head Shots Become Injuries for Girls’ Soccer

Soccer is an intense, physically demanding sport for both guys and girls. Here’s the picture that flashes across my mind when I think of soccer- a 60 mph ball bouncing off of an unprotected head. It’s not like that is a rare sighting in the game– headers are one of the main ways to keep the ball in play. A study in the Winter 2007-2008 edition ofJournal of Athletic Training found that girls playing high school soccer suffer concussions 68 percent more often than boys.

Concussion Therapy for Female Athletes

After a head injury, the cranial bone movement is altered, slowing down the cerebrospinal fluid movement, and making it impossible to efficiently remove the waste products that are produced within the brain. When this occurs, the brain tissue starts to die. Female athletes with concussions that don’t receive cranial movement therapy are susceptible to “second concussion syndrome.” In other words, their symptoms will continue to worsen.

Cranial movement therapy is the solution the Simkovich Cranial Institute uses to maneuver the cranial bones back into their original positions after a head injury. This correction restores their natural rhythm within the skull, with then reinstates the normal cerebrospinal fluid flow and circulation.

The evolution of youth sports is not on brain-safety’s side. The games are becoming more competitive and the players are tougher than ever. Girls are no exception to this equation. Parents, players, and coaches need to become aware of the increased risk in girls sports. While helmets may never make their way into cheerleading, basketball, or soccer culture, identifying and assessing concussions are a must.

AdminCounting Head Injuries in Female Athletes
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Curious about concussions?

Curious about concussions?

 

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Football season has begun, reviving concern and discussion over sports-related concussions.

The American Academy of Pediatrics defines a concussion as a direct hit to the head or jarring blow to the body that gets transmitted to the head, resulting in a rapid onset of short lived impairment of neurological function. However, some controversy surrounds even this definition. So I reached out to Jessica Little, PhD, director of clinical research and operations at the Stanford Concussion and Brain Performance Center, to learn more about concussion research and Stanford’s clinical study of teenage athletes.

What should we know about concussions?

I think it’s important to note that concussions are still not well understood. There are hundreds of different definitions of ‘what is a concussion’ and there is currently no single evidence-based consensus on how to identify and treat concussions.

Research has shown that one of the biggest risk factors for sustaining a concussion is a history of having a prior one. There is a ‘window of vulnerability’ — the concept that a person experiencing symptoms of concussion is more vulnerable to incurring a second concussion during this time, as the brain has not yet fully recovered. If a truly concussed athlete has problems paying attention or is not coordinated, they can then be vulnerable to another injury. Protocols are often used to track signs and symptoms of concussion, and athletes are not allowed to return to play until these have resolved. However, it would be helpful to have more precise ways to measure attention and coordination on the sidelines to keep impaired athletes out of contact sports until those skills recover.

The vast majority of people with a concussion recover fully after the injury, though not all symptoms may improve at the same rate and everyone recovers a little differently.

Describe your clinical study for athletes 12-17 years of age.

Our study just closed recruitment, and we’re prepping all the data for analysis, so this is an exciting time. The study was called EYE-TRAC Advance, short for Eye-Tracking Rapid Attention Computation. Our lab used a specific type of eye-tracking called ‘circular smooth pursuit’ where an athlete follows a dot that moves at predictable speed around a circle. The eye-tracking was in the form of custom-designed portable ‘goggles,’ using built-in cameras and infrared pupil detection.

Our hypothesis is that people without a concussion can ‘sync-up’ with the way the dot is moving pretty easily, while a person with a concussion has a disruption in their ability to focus and pay attention. You often hear people saying that they feel ‘off’ or ‘out of sync’ following a concussion, and we’re trying to quantify that experience. For the study, we baseline tested athletes (before sports participation) with the eye-tracking, as well as other neurocognitive tests that measured things like attention and reaction time. If the athlete later got a concussion, we tested them again as soon as possible and again at 1, 3 and 12 months after the injury. In this way, we’re able to get a clear picture of how their brain recovered over time.

Overall, we reached out to more than 60 different organizations and recruited more than 1,400 people. We had a specially outfitted ‘mobile testing center’ RV. This allowed us to literally drive up to the side of an athletic field and perform the testing on-site at the school or organization, which really reduced common barriers to participating in a research study, such as the costs and time associated with transportation to and from appointments.

Can technology play a significant role in preventing concussions?

A lot of current technologies focus on diagnosing a concussion, but there are far fewer that actually focus on preventing concussions. There are some technologies that measure an athlete’s gait and vestibular-balance ability. If there are impairments, the athletes can be provided skill training to improve any deficits, thus reducing the risk of injury. Other technologies, such as helmet technologies, may be helpful in reducing the instance of skull fractures and other serious injuries, but they haven’t yet proved effective at preventing a concussion — that is caused more by brain rotation, which a helmet can’t fully protect against. One possible preventative solution could come from a neck device that stabilizes the rotational forces while still allowing neck movement at low accelerations, so that athletes can move about freely until it senses a potentially dangerous level of force.

Are there issues with under-reporting concussions?

Historically, there have been some issues with individuals under-reporting symptoms that would lead to a diagnosis of a concussion. This is often motivated by the idea that they should ‘suck it up’ or ‘don’t want to let the team down’ or by the fact that their ability to perform athletically is tied to keeping an athletic scholarship. There is research happening in the field right now trying to figure out the best way to dismantle these types of beliefs and make it more likely that athletes can be properly identified, given the treatment they need, and hopefully continue to safely engage in their sport.

Previously: Building a concussion-proof helmet: A Stanford bioengineer shares his findings at TEDxStanfordStanford bioengineers and clinicians team up to shed light on how concussions affect the brain and Forces at work in concussions more complicated than previously thought, new Stanford study reveals
Photo by Steve – Body Slam

Maria CaligiuriCurious about concussions?
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No Pill to Cure Concussions

No Pill to Cure Concussions

In 2007, the Department of Defense spent over 100 million dollars on Traumatic Brain Injury (TBI)  research. A portion of those funds went toward pharmaceutical initiatives to try to find a medical cure for brain trauma. And while over 30 clinical trials and animal studies have been conducted, drug developers have yet to create a pill to treat concussions.

“There’s no pill to stop neurons from dying. No treatment to prevent inflammation in the brain. Nothing to pull patients more quickly out of the fog that can descend after a concussion,” Cassandra Willyard writes in her article for STATnews.com. Not even the highly anticipated progesterone studies from 2014 have revealed any promising leads.

Why Can’t Concussions be Cured by Medication?

The brain is a vast mystery among scientists; the functionality of cells and molecules are being studied and discovered everyday. Therefore, having a grasp on brain recovery is still very new category of research. As Willyard’s article states, a patient with a traumatic brain injury might be prescribed drugs to reduce brain swelling, but these drugs seemingly have no effect on regaining cognitive or motor skills.

The problem lies in the fact that the intricacies of the brain are so delicately balanced, that when a trauma knocks them out of place, it takes more than the function of a pill to restore the balance. In other words, the labs have not come up with a pill that can shift and realign the components of organs.

Concussion Complications on the Brain

Another consideration is that concussion injuries are often spread throughout the brain, not just in one area. Bruising, tearing, and stretching can occur as well as inner bones jolting out of place. Drug studies typically don’t focus on these individualized situations. They group study participants together and treat all brain injuries the same.

Trials and Tribulations

As stated on STATnews.com, These drug trials have no real way to measure results, so they rely on patients to fill out a questionnaire. Patients then grade their responses to the best of their ability. Questions like “Is the patient able to work?” is graded on an eight-point scale with no option to explain their answers further.

This results in skewed data because patients have no way of describing their situation. A patient might not be working at that time period due to another bodily injury obtained at the same time as the concussion. However, on the questionnaire it appears that the patient is not working because of the concussion itself.

Alternative Concussion Treatments

For patients battling the lasting symptoms of a TBI, a pill might not be the answer in this lifetime. But there is a treatment alternative that works to restore brain functionality after an injury– It’s called cranial movement therapy. Simkovich Cranial Institute uses this treatment method to maneuver the cranial bones back to their original positions.
This correction restores the natural rhythm of bone movement within the skull, which reinstates the normal cerebrospinal fluid flow and circulation. Concussion victims that don’t receive cranial movement therapy are susceptible to “second concussion syndrome.” Their symptoms will continue to worsen overtime.

For more information on cranial movement therapy and how it can help your concussion, schedule a free phone consultation, today!

Maria CaligiuriNo Pill to Cure Concussions
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Parents of Concussion Victims Speak Out

Parents of Concussion Victims Speak Out

Last year, The Total Learning Center in Wexford, PA hosted a seminar for parents to learn about concussions. I was joined by local pediatrician, Dr. Anthony Kovatch, and Dr. Carol Utay, director of the center. The presentation focused on what symptoms occur when a child suffers from a concussion and what warning signs need immediate emergency room care. These seminars typically revolve around parent education. But I can honestly say that what I learned that day from the listening to the parents was certainly eye-opening for me, as a practitioner.

I spoke to the group about the dynamics that occur during a concussion and the damage they cause. I explained the anatomy of the cranium, how all of the cranial bones move in a rhythmic motion, and that this motion has a direct affect on brain function. I described the role of the cerebrospinal fluid and how a concussion decreases the cranial bone movement, which decreases cerebrospinal fluid flow.

 

Central Nervous System Waste

I further stated that this decrease in cerebrospinal fluid flow inhibits the removal of the waste products produced in the central nervous system. This flow is critical, because the waste that remains in the cranial vault longer than normal will begin to kill brain cells. Dead brain cells leads to decreased brain function in both cognitive and motor function.

The damage to the brain cells and the decreased function is the reason so many of the retired NFL players have the severe issues that worsen with age. There has even been talk that ALS is caused by concussion. While this hasn’t been confirmed, it is, theoretically, very plausible.

I’m a bottom line kind of doctor. I attempt to reach the quickest, least invasive solution to my patient’s problems. The bottom line in treating a concussion is reestablishing the normal cranial bone movement. Without this, the brain simply can not, and will not, heal or return to pre-accident status.

 

Rest is Not a Treatment

‘Rest,’ which is the most commonly prescribed ‘treatment’ by doctors, simply does not ‘fix’ the problems caused by concussions. Resting will help the acute issues of the concussion go away (such as swelling, etc.), but rest does not return the cranial bones to their normal intrinsic movement. This needs to be done by a practitioner who practices that specialty.

 

Parental Feedback

So, why was I surprised by what some of the parents said that day? One woman, a nurse, explained that her daughter had a concussion. It interested her enough that she was invested herself into the concussion field through one of the local facilities. She acted as a self-appointed advocate, telling the other mothers that “it will get better,” and that her daughter had “fully recovered.”

She spoke about how they had a terrible road, and that her daughter suffered for a long time with the issues from her concussion. I listened and wondered how it was possible for her daughter to have a full recovery if she hadn’t been treated? Because of the knowledge of the physiology and mechanics of cranial bone movement and concussion, I knew it was impossible for her daughter to be fully recovered. To clarify, if the normal cranial bone movement hasn’t been restored, a patient will not recover.

I began to ask her questions about her daughter. Slowly, she admitted that her daughter was still experiencing difficulty in school and working slower than she did pre-accident. Her daughter even needed special consideration from her college to get through her course work. It was clear that this woman didn’t understand what actions were needed to recover from a concussion. I consider it a tragedy that her daughter will have to deal with special accommodations in college when her problems can easily be corrected.

Another eye-opening parent was a mother of a high school student who was more concerned about that fact that the school wasn’t paying attention to the legislated accommodations from the state. While these accommodations are a good thing and assist in the early stages of healing, she also missed the point. The problems her child was dealing with are treatable. The bottom line here is that the suffering from concussions is needless when there is a solution for the problems caused by them.

If you or someone you know suffers from a concussion, please sign up for a free phone consultation so we can get them on the road to a true recovery.

 

Maria CaligiuriParents of Concussion Victims Speak Out
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