Sports-Related Concussions in Youth Improving the Science, Changing the Culture (2014) / Chapter Skim
Currently Skimming:
3 Concussion Recognition, Diagnosis, and Acute Management
3 Concussion Recognition, Diagnosis, and Acute Management
Pages 99-180
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 99... ...
In this chapter, the committee responds to the portions of its charge concerning cognitive, affective, and behavioral changes that can occur during the acute phase of concussion; hospital- and non-hospital-based diagnostic tools; and the treatment and management of sports concussion. The chapter provides an overview of concussion screening and diagnosis, including sideline assessments at the time of injury, subsequent clinical evaluation, and the use of evaluation tools such as symptom checklists, and neuropsychological testing.
|
From page 100... ...
along with the message that players suspected of having sustained a concussion should be removed from play for the remainder of the day, referred to a health care provider for evaluation, and not permitted to return to play until they have been cleared by a health professional trained in concussion diagnosis and management (CDC, 2012a)
|
From page 101... ...
It is important to note, however, that because of the natural evolution of concussions, not all concussed athletes will be identified at the time of (presumed) injury even when personnel trained in concussion recognition are present (McCrory et al., 2013b)
|
From page 102... ...
Reaction time Yes (Eckner et al., 2010, 2013) CLINICAL EVALUATION Concussion Diagnosis Given the absence of a diagnostic test or biomarker for concussion, the current cornerstone of concussion diagnosis is confirming the presence of a constellation of signs and symptoms after an individual has experienced a hit to the head or body.
|
From page 103... ...
uses focused X-rays together with computer imaging technology to make three-dimensional pictures of the head and can detect skull fracture, hemorrhage, and swelling. Diffusion tensor imaging (DTI)
|
From page 104... ...
Newer imaging techniques (see Box 3-1) , such as magnetic resonance spectroscopy, positron emission tomography, single-photon emission computed tomography, functional magnetic resonance imaging, and diffusion tensor imaging -- which all can be used to track metabolic, blood flow, and axonal changes -- build on animal work and clinical outcome measures in mild traumatic brain injury (mTBI)
|
From page 105... ...
, and cognitive testing as is often done with neuropsychological testing. Broglio and colleagues (2007b)
|
From page 106... ...
Symptom Assessment An athlete who has had a concussion often will complete a postconcussion symptom scale at each visit with his or her health care provider. These self-reports of symptoms not only provide information pertinent to concussion diagnosis but also serve as the foundation of monitoring recovery and decision making about the individual's return to school and physical activity.
|
From page 107... ...
compared performance and QEEG measures on 28 high school and college athletes who experienced sports-related concussions with those recorded from 28 matched, uninjured controls. All underwent pre-season baseline testing on QEEG measures as well as on measures of concussive symptoms, postural stability, and cognitive functioning.
|
From page 108... ...
Importantly, as in the case of QEEG, ERP studies show that such differences may continue even after other indications of concussive injury -- such as behavior tests and somatic complaints -- suggest recovery, indicating that persistent abnormalities in the P3b could reflect suboptimal compensation in concussed athletes. Thériault and colleagues (2009)
|
From page 109... ...
distinguishing individuals with a concussion from those with non-concussion head injury; (2) identifying individuals who may have a skull fracture or more severe intracranial injury (e.g., intracranial hemorrhage, cerebral swelling)
|
From page 110... ...
for intracranial injury. Adult studies have shown that S100B may be useful for identifying individuals with head injury who do not have intracranial injury thereby preventing unnecessary imaging procedures (Berger and Zuckerbraun, 2012)
|
From page 111... ...
. 3 The research-based scale is the Health and Behavior Inventory; the four clinical scales are the Post-Concussion Symptom Scale, Graded Symptom Checklist/Scale, Rivermead Post-Concussion Symptom Questionnaire, and Post-Concussion Symptom Inventory/Acute Concussion Evaluation (Gioia et al., 2009)
|
From page 112... ...
discussed the psychometric properties of these same symptom scales as well as of the Concussion Symptom Inventory (CSI) (Randolph et al., 2009)
|
From page 113... ...
. Description Reliability Validity 20 items, 4-point Internal consistency, Discriminates head injury Guttman scale parent-child correlation, from orthopedic injuries; 3-factor structure no test-retest reliability correlates with quality of life, (cognitive, somatic, family burden, educational, emotional)
|
From page 114... ...
The terms "neuropsychological" and "cognitive" are often used interchangeably (as in neuropsychological testing, cognitive testing, and neurocognitive testing)
|
From page 115... ...
The earlier neuropsychological literature on TBI has documented several specific areas of typical deficit, with processing speed, attention and memory typically showing the most significant deficits. Sports concussions may have the following effects: • Reduced planning and ability to switch mental set (Barth et al., 1983, 1989, 2000; Rimel et al., 1982)
|
From page 116... ...
Issues of reliability and validity as well as poor psychometric controls were felt to render testing useless for this specified purpose. They opined that athletic trainers and sports medicine professionals would do just as well using standardized graded checklists.
|
From page 117... ...
. Using trained test administrators and testing in appropriate environ Past history Psychological factors Genetic factors Previous concussions Test anxiety Age Other head injuries Depression/other emotional Intelligence Educational states Sex background Race Previous testing Handedness Drug use Visual acuity Alcohol use Auditory acuity Test performance Other factors Methodological Cognitive function factors Test setting/distractions Testing situation Motivation Practice/learning effects Fatigue Administrator expertise Random variance/chance FIGURE 3-1 Factors that impact the results of neuropsychological tests.
|
From page 118... ...
Unless tests have been shown to be insensitive to gender, they are expected to offer separate scoring parameters. Higher academic achievement has been linked to higher computerized neuropsychological test scores.
|
From page 119... ...
Using the symptom scale that is part of the ImPACT battery, Covassin and colleagues (2012b) found that athletes with high levels of depression reported more concussion-like symptoms and had lower ImPACT test scores on baseline tests.4 The ANAM battery has validated a mood scale and demonstrated its relationship to test scores (Johnson et al., 2008)
|
From page 120... ...
. With the growing use of neuropsychological testing in the identification and management of sports-related concussions has come controversy and criticism about the methods and outcomes.
|
From page 121... ...
• Does baseline testing improve the utility of neuropsychological test ing in the diagnosis and management of sports-related concussion? Can Neuropsychological Testing Assist in the Diagnosis of Sports-Related Concussions in Youth?
|
From page 122... ...
account for significant variance in test scores. As a practical matter the test scores may reflect the overall status of the individual, but, because neuropsychological tests are designed to assess brain function, the inclusion of symptom-related error into the test score interferes in the psychometric accuracy of the test.
|
From page 123... ...
Van Kampen and colleagues (2006) tested the diagnostic value of adding neuropsychological testing to assessments of symptom load.
|
From page 124... ...
Summary Neuropsychological tests have the ability to detect cognitive changes in injured athletes, although cognition as indexed by test scores appears to improve for the vast majority of injuries within 2 weeks. There are mixed results of the diagnostic utility of neuropsychological testing immediately (within 48 hours)
|
From page 125... ...
. Using that as the benchmark, studies have generally found neuropsychological testing to be a useful aid in determining when an athlete has recovered enough to return to competition.
|
From page 126... ...
Some studies have found continued cognitive declines on neuropsychological testing, even after individuals' concussion symptoms have resolved, although other studies show symptoms lasting longer than cognitive declines. The persistence of cognitive declines following symptom resolution in some individuals suggests there may be a role for neuropsychological testing in concussion management, for example, to help inform return-to-play decisions in these cases.
|
From page 127... ...
reviewed data from the High School RIOTM database of athletic injuries for the 2009-2010 school year (1,056 sports-related concussions) , they found that computerized neuropsychological testing was used for 41.2 percent of concussions.
|
From page 128... ...
Table 3-6 lists published reliability studies of several different computerized neuropsychological tests used in concussion management. Several approaches to reliability can be taken: Internal consistency can be measured using Chronbach's alpha test or one can examine the correlation between half of the items and the other half (split-half reliability)
|
From page 129... ...
As the previous sections document, a large number of studies have demonstrated the various aspects of validity of these computerized batteries. Table 3-7 lists published validity studies of several different computerized neuropsychological tests used in concussion management.
|
From page 130... ...
sample, code substitution Report delayed ANAM Sports battery 17-65 20-25 minutes Simple reaction time, code Demographics module, Modified (Cernich et al., 2007; Reeves et al., substitution learning, Stanford Sleepiness Scale, 2007) running memory continuous pseudorandomized items; performance task, "throughput score" is a speed mathematical processing, versus-accuracy measure delayed matching to sample, code substitution delayed memory test, spatial processing, Sternberg procedure, procedural reaction time CNS Vital Signs 8-90 25-30 minutes (Brief Composite memory, verbal General purpose (CNS Vital Signs, 2013; Gualtieri Core battery)
|
From page 131... ...
/ 13-35 25-30 minutes Processing speed, simple Basic demographics and health Headminder reaction time, complex history (Erlanger et al., 2001, 2003) reaction time Immediate Post-Concussion 12-60 20-25 minutes Composite scores: verbal Background and basic health Assessment and Cognitive Testing memory, visual memory, information; symptoms (ImPACT)
|
From page 132... ...
132 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-6 Reliability Studies on Common Neuropsychological Tests Test Study Author N/population Automated Segalowitz et al., 2007 29 adolescents, Neuropsychological age 15 Assessment Metrics (ANAM) ANAM Cernich et al., 2007 Review of previous tests; U.S.
|
From page 133... ...
CONCUSSION RECOGNITION, DIAGNOSIS, AND ACUTE MANAGEMENT 133 Subtest Statistic/Reliability Test Intervals Comment Matching to Sample ICC=.72 r=.72 2 times over 1-week Continuous interval Performance ICC=.65 r=.70 Math Processing ICC=.61 r=.71 Code Substitution ICC=.58 r=.81 Simple Reaction Time ICC=.44 r=.48 Simple Reaction Time 2 ICC=.47 r=.50 Code Substitution Delayed ICC=.68 r=.67 Matching to Sample ICC=.66 166 days Continuous Performance ICC=.58 Math Processing ICC=.87 Simple Reaction Time ICC=.38 Spatial Processing ICC=.60 Sternberg Memory ICC=.48 Matching to Sample r=.69; ICC=.67 21-42 days Sample likely is Procedural Reaction not comparable Time r=.62; ICC=.51 to youth Math Processing r=.70; ICC=.70 athletics Simple Reaction Time r=.65; ICC=.60 Simple Reaction Time repeated r=.41; ICC=.40 Code Substitution Learning r=.79; ICC=.79 Code Substitution Memory r=.68; ICC=.59 speed indices ICC 1 hr.=.69, 1 hour, 1 week 1 week=.90 accuracy indices ICC 1 hr.=.08, 1 week=.51 continued
|
From page 134... ...
134 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-6 Continued Test Study Author N/population CogSport Straume-Naesheim 232 male professional soccer et al., 2005 players (Norwegian and Spanish) ages 17-35 Concussion Sentinel Broglio et al., 2007cb 73 high school (CogSport)
|
From page 135... ...
CONCUSSION RECOGNITION, DIAGNOSIS, AND ACUTE MANAGEMENT 135 Subtest Statistic/Reliability Test Intervals Comment Simple Reaction Immediate Sample is Time ICC=.73 somewhat Choice Reaction atypical Time ICC=.65 for sports Complex Reaction concussion Time ICC=.69 management Monitoring ICC=.45 1-back Monitoring ICC=.71 Matching ICC=.69 Learning ICC=.79 Working Memory ICC 45 days=.65; T1 to T2: 45 days; 5 days later=.64 T2 to T3: 5 days Reaction Time ICC 45 days=.60; 5 days later=.55 Decision Making ICC 45 days=.56; 5 days later=.63 Attention ICC 45 days=.43; 5 days later=.39 Matching ICC 45 days=.23; 5 days later=.66 Simple Reaction T1-2, T2-3, T3-4, T1, T2, T3, T4 at Model and Time T4-5 ICC>.73 10-minute intervals, form of ICC T4-5 at 1 week not provided. Choice Reaction interval These ICCs are Time T3-4, T4-5 ICC>.71 for the reaction Complex Reaction times; very few Time T2-3, T3-4, T4-5 ICCs were >.60 ICC>.64 for accuracy Monitoring T2-3, T3-4, ICC>.68 measures 1-back Monitoring T1-2, T2-3, T3-4, T4-5 ICC>.62 Matching T1-2, T2-3, T3-4, T4-5 ICC>.71 Incidental Learn T3-4, T4-5 ICC>.60 Associative Learn T1-2, T2-3, T3-4, T4-5 ICC>.77 Detection Speed r=.77; ICC=.78 21-42 days Sample is Identification Speed r=.78; ICC=.77 atypical for One Card Learning sports-related Accuracy r=.25; ICC=.22 concussion One Back Speed r=.76; ICC=.74 management Composite r=.80; ICC=.79 continued
|
From page 136... ...
ImPACT Elbin et al., 2011 369 high school varsity athletes ImPACT Miller et al., 2007 58 Division III college football
|
From page 137... ...
306-307) Processing speed Random 1 to 110 Practice effects factor r=.78 days significant for Response speed Processing Speed factor r=.80 only Memory factor r=.68 Attention factor r=.74 Verbal Memory r=.70 1 week Significant Visual Memory r=.67 practice effects Visual-Motor Speed r=.89 for Visual-Motor Reaction Time r=.79 Speed Verbal Memory ICC=.62 1.2 year Visual Memory ICC=.76 Visual-Motor Speed ICC=.85 Reaction Time ICC=.76 Significant practice Preseason, mid- Raw scores at effects for Visual season, end of each time-point Memory and season compared Visual-Motor Speed composites only continued
|
From page 138... ...
138 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-6 Continued Test Study Author N/population ImPACT Schatz, 2010 95 collegiate athletes ImPACT Broglio et al., 2007cb 73 high school ImPACT Schatz and Ferris, 2013 25 undergraduates, no concussion history ImPACT Cole et al., 2013a 44 active duty military predominantly male (83%) ; ages 19-59 (mean 34)
|
From page 139... ...
=.45; Speed only, no T1-T2, T2-T3 age effects r p's <.002, T1-T3 r p=.023 Visual-Motor Speed ICC (T1-T2) =.71; all r p's <.001 Reaction Time ICC (T1-T2)
|
From page 140... ...
. Neuropsychological test scores at less than 2 days post injury were not predictive of which recovery group an athlete would be in.
|
From page 141... ...
The generally poorer performance of "memory" tasks is unfortunate because working memory has long been identified as a significant cognitive function that declines in all forms of TBI; the poorer performance may be a function of the computer presentation of the tests. The trend of speeded
|
From page 142... ...
142 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-7 Validity Studies on Common Neuropsychological Tests Test Study Author Age Range Subjects (n) Automated Bleiberg et al., 6 concussed, 6 control Neuropsychological 1997 Assessment Metrics (ANAM)
|
From page 143... ...
Predictive Percent exceeding reliable Sensitivity at 80%, 90%, and change index; reliable change 95% all <15%; specificity >90% index values based on separate healthy sample Concurrent Healthy athletes ANAM and Significant correlations between paper-and-pencil tests individual ANAM scores and Hopkins Verbal Learning test, Controlled Oral Word Association test, Digit Symbol Substitution test, Symbol Search continued
|
From page 144... ...
144 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-7 Continued Test Study Author Age Range Subjects (n) CogSport Collie et al., 2003 240 elite Australian rules football players CogSport/Axon Makdissi et al., 16-35 years, 88 concussed 2010 median=22 years Australian rules football CogSport/ Moriarity et al., Amateur boxers Axon 2012 CogSport Schatz and Putz, 18-23 30 college students 2006 Immediate Iverson et al., 2005 Mean age 17 years 72 amateur Post-Concussion Assessment and Cognitive Testing (ImPACT)
|
From page 145... ...
Both Trails correlated with processing speed continued
|
From page 146... ...
146 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE 3-7 Continued Test Study Author Age Range Subjects (n) ImPACT Schatz et al., 2006 High school 72 concussed athletes ImPACT Schatz and Putz, 18-23 30 college students 2006 ImPACT Schatz and Sandel, High school and 81 concussed 2013 college symptomatic athletes; 37 concussed asymptomatic athletes, ages 13-21 ImPACT Tsushima et al., High school 26 concussed versus 2013 25 controls ImPACT Maerlender et al., College 54 non-concussed 2010
|
From page 147... ...
with paper-and-pencil and other Complex Reaction Time computer tests; memory tests do to Headminder r=.407; to not correlate (no memory tests in CogSport r=.649; to Trails A paper-and-pencil battery) r=.641; to Trails B r=.442; to Digit Symbol r=–.455 Memory no significant r Processing Speed to Headminder r=–.373 Predictive 81 concussed evaluated within Symptomatic athletes: hours of injury compared to Sensitivity=.75; specificity=.89; 81 controls' baseline testing; PPP=.91, NPP=.69; also compared scores of Asymptomatic: Sensitivity, 37 symptomatic athletes to Specificity, PPP, NPP=.97 (only 2 asymptomatic athletes to 37 cases were misclassified)
|
From page 148... ...
ImPACT Allen and Gfeller, College 100 non-concussed 2011 Pediatric ImPACT Newman et al., 5-12 years 164 concussed 2013 Pediatric ImPACT Gioia et al., 2013a 5-12 years, 22 ages 5-7, <7 days post 67 ages 8-12 concussion Concussion Erlanger et al., 13-35 years 414 Resolution Index 2003 (CRI)
|
From page 149... ...
(Processing Speed, Simple correlated with all three factors; Reaction Time, Complex Trails A correlated with Simple Reaction Time) and Complex Reaction Time; Trails B and Stroop interference correlated with Processing Speed; Digit Symbol (WAIS-III)
|
From page 150... ...
tests showing better performance than the accuracy measures may be reflecting the strengths of the computerized platform. Does Baseline Testing Improve the Utility of Neuropsychological Testing in the Diagnosis and Management of Sports-Related Concussion?
|
From page 151... ...
processing speed correlate with Simple Reaction Time to paper-and-pencil and ImPACT Trails A r=.428; to Digit Symbol r=–.526 Complex Reaction Time no significant r Processing Speed to Trails B r=.601; to Digit Symbol r=–.610; to ImPACT r=–.373 1999; Lovell and Collins, 1998)
|
From page 152... ...
have pointed out, group testing has its disadvantages. In addition, baseline testing is expensive and time-consuming, and there is the question of whether the use of baseline testing in concussion management actually reduces risks of recurrent injury or long-term functional deficits.
|
From page 153... ...
1410) The 2013 position statement of the American Medical Society for Sports Medicine states that most concussions can be managed appropriately without neuropsychological testing and also notes the lack of evidence that use of baseline testing in the clinical management of concussions improves short- or long-term outcomes (Harmon et al., 2013)
|
From page 154... ...
. Thus, although the initial injury may be mild, acute management is still needed to protect the individual from more significant harm.
|
From page 155... ...
The mean time to return to play was 4.8 days, with 18 percent showing symptoms for more than 7 days. Again, computerized neuropsychological testing revealed that abnormalities in neurocognitive performance persisted for 2 to 3 days after the athletes no longer were asymptomatic.
|
From page 156... ...
and noncontact physical activity, which may or may not exacerbate symptoms. Cognitive Rest Cognitive rest is also recommended for the initial period following a concussion (Halstead et al., 2010; Harmon et al., 2013; McCrory et al., 2013b)
|
From page 157... ...
. In another study, high school and college athletes who completed at least 1 week of cognitive and physical rest after injury showed significant improvement on concussion symptom scale ratings and neurocognitive scores, even when rest was prescribed weeks or months following a concussion (Moser et al., 2012)
|
From page 158... ...
Randomized controlled trials or other appropriately designed studies on the management of concussion in youth are needed in order to develop empirically based clinical guidelines; this includes studies to determine the efficacy of physical and cognitive rest following concussion and the optimal level and duration of rest.7 Return to Physical Activity The return of an individual to physical activity following a concussion is typically governed by his or her symptom load. Consensus opinion (McCrory et al., 2013b)
|
From page 159... ...
If concussion symptoms reappear, the athlete should revert back to the previous asymptomatic stage and resume the progression after 24 hours (Canadian Academy of Sport Medicine Concussion Committee, 2000)
|
From page 160... ...
6 Return to play Normal game play. SOURCE: Based on Canadian Academy of Sport Medicine Concussion Committee, 2000.
|
From page 161... ...
. The ImPACT test has a post-test symptom checklist that in effect documents the effect of mental exertion on neurocognitive testing.
|
From page 162... ...
and between government and the private sector to develop infrastructures for addressing issues associated with concussion in youth. FINDINGS The committee identified the following findings on concussion recognition, diagnosis, and management: • Currently concussion diagnosis is based primarily on symptoms re ported by the individual rather than on objective diagnostic mark ers, which might also serve as objective markers of recovery.
|
From page 163... ...
There is some evidence, however, to suggest that normal levels of S100B following head injury may predict individuals who do not have intracranial injury. • Neuropsychological testing has a long tradition in measuring cog nitive function after traumatic brain injury and is one of several tools (along with symptom assessment, clinical evaluation, and the like)
|
From page 164... ...
Similarly, there is little evidence regarding the efficacy of cognitive rest following concussion or to inform the best timing and approach for return to cognitive activity following concussion, including protocols for returning students to school. • Randomized controlled trials or other appropriately designed stud ies on the management of concussion youth are needed in order to develop empirically based clinical guidelines, including studies to determine the efficacy of physical and cognitive rest following concussion, the optimal period of rest, and the best protocol for returning individuals to full physical activity as well as to inform the development of evidence-based protocols and appropriate ac commodations for students returning to school.
|
From page 165... ...
2009. Dimensions of postconcussive symptoms in children with mild traumatic brain injuries.
|
From page 166... ...
In Mild Traumatic Brain In jury in Children and Adolescents: From Basic Science to Clinical Management, edited by M
|
From page 167... ...
British Journal of Sports Medicine 39(11)
|
From page 168... ...
2002. Effectiveness of bed rest after mild traumatic brain injury: A randomised trial of no versus six days of bed rest.
|
From page 169... ...
2001. Neuropsycho logical test performance prior to and following sports-related mild traumatic brain injury.
|
From page 170... ...
2008a. Improving identification and diagnosis of mild traumatic brain injury with evidence: Psychometric support for the Acute Concussion Evaluation.
|
From page 171... ...
2011. Agreement between parents and children on ratings of postconcussive symptoms following mild traumatic brain injury.
|
From page 172... ...
2004. Prospective functional MR imaging study of mild traumatic brain injury in college football players.
|
From page 173... ...
2010. Influence of poor effort on self-reported symptoms and neurocognitive test performance following mild traumatic brain injury.
|
From page 174... ...
British Journal of Sports Medicine 35(5)
|
From page 175... ...
British Journal of Sports Medicine 39(Suppl 1)
|
From page 176... ...
British Journal of Sports Medicine 46(14)
|
From page 177... ...
British Journal of Sports Medicine 43(Suppl 1)
|
From page 178... ...
British Journal of Sports Medicine 39(Suppl 1)
|
From page 179... ...
2012. Reliable change in postconcussive symptoms and its functional conse quences among children with mild traumatic brain injury.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.