In my last column I discussed the basics of concussions, including symptoms that may accompany a hit to the head. Today, I will touch on how medical personnel may assess concussions and also discuss new research that that is taking place right here in our community.
As I touched on in my last column, concussions can present with many different symptoms. To ensure concussions are managed properly, it is helpful to have an “action plan” at the venue where the sporting event takes place. Coaches, trainers, players, and parents should be made aware of a plan that will help to assist players after a hit to the head. A “safety person” or trainer on the team should be available to assist in managing injuries and particularly concussion related incidents. That person should be familiar with the action plan and understand what to do if a concussion is suspected. The first step the safety person should do is remove the player or athlete from the play. The player should not be left alone and signs and symptoms of a concussion should be monitored. It is important to note that medications should not be administered at this time. The athlete should then be evaluated by a medical professional as soon as possible and the parents or guardians should be informed that there may be a suspected concussion. The most important thing to take away from the action plan is that if a concussion is suspected it is very important that the player must not return to play in the game or activity that day. He or she should be evaluated medically prior to returning to the sport (which will be discussed in my next column). If the player is unconscious phone 911 immediately. Assume that there is a possible neck injury and continue to monitor the airway, breathing, and circulation of the unconscious player.
Many contact sports teams are now adopting a method of determining pre-season or baseline scores on specific concussion tests. These tests evaluate many factors such as memory, concentration, balance, coordination, orientation of time, and neck and concussion type symptoms. If a player were to sustain a concussion in the season, baseline scores can be compared with post-concussion scores to determine the presence and severity of a concussion. An assessment tool known as the SCAT3 (Sports Concussion Assessment Tool – 3rd Edition) is a standardized evaluation and can be used for those athletes 13 years of age and older. There is a Child SCAT3 version for those under 13 years. The SCAT 3 is designed to be administered by medical professionals and should not be used solely to diagnose a concussion without a professional medical opinion. An athlete may score “normally” on the SCAT 3 even when a concussion is present.
Components of the SCAT 3 include the following:
- Symptom Evaluation – athletes rate a list of symptoms from 0 (symptoms not present) to 5 (severe symptoms).
- Orientation Assessment – athletes are asked a series of questions such as the date, time, and year.
- Memory – a list of words are read aloud to the athlete. The athlete then repeats the list of words back to the evaluator.
- Concentration – a list of digits are read aloud to the athlete. The athlete then repeats the list in reverse order back to the evaluator.
- Neck Examination – range of motion, tenderness, sensation, and strength are assessed by the evaluator.
- Balance testing – various stances are evaluated for 20 seconds each. A tandem gait (walking along a line with one foot in front of the other) is performed.
- Upper limb coordination – athlete must touch their nose with their index finger and then return to the starting position (an outstretched arm) 5 consecutive times.
- Memory Recall – athletes are asked to repeat the words given to them in step 3.
In addition to the SCAT 3, there are new concussion assessment products being researched in our own backyard. As a physiotherapist with the Kelowna Chiefs Junior Hockey Club, we have partnered up with the Integrative Sports Concussion Research Group (ISCRG) at the University of British Columbia – Okanagan (UBCO). Researchers are investigating cerebrovascular, neurocognitive, and sensorimotor effects concussions have on young athletes in order to better understand how the brain responds to a concussion. One component of their research is having athletes wear an electronic patch (Xpatch) or electrode behind their ear when participating in sport. These patches are made by a company called X2 Biosystems and have the ability to monitor and record force and impact. For example, if an athlete sustains a hit to the head or upper body, the X2 patches will record the impact as a linear or rotational force, and can also determine the extent and direction of the impact. This information is uploaded by the researchers who then monitor the forces. If an athlete sustains a concussion he or she will undergo extensive concussion testing, comparing results to baseline scores, and with the help of the Xpatches researchers can determine the amount of force or impact the athlete sustained that may have contributed to the concussion.
All of this technology and information has proved to be invaluable to the Kelowna Chiefs Junior Hockey Club in helping us to make more informed decisions based the assessment, monitoring, and return to play of concussed players. As a team we are honored to be a part of such progressive research in hopes that the information gathered from the study may have the potential to better understand how concussions impact athletes. Two of the UBCO researchers that work closely with the Kelowna Chiefs are Colin Wallace and Sandy Wright. More information can be found on the ISCRG website at www.iscrg.ca.
In recent years there has been an increase in research dedicated to investigating concussions and their effects on the brain. Sports related concussions tend to generate the most interest in the media, but concussions can occur in everyday activities that pose a risk of impact, such as motor vehicle accidents or slip and falls. As research has accumulated and advanced especially over the last decade, researchers have been able to make more definite conclusions on the subject, yet much more research is required to fully understand the effect concussions have on the brain and its function. This three-part series over the next several weeks will discuss the following: What are the causes of a concussion and symptoms, assessment of a concussion, and finally recovering from a concussion injury and protocols for returning to sport/activity.
What is a concussion?
A concussion is a form of brain injury that can be caused either by a direct hit to the head or indirectly via another body part such as the neck or face that can transmit forces to the head. A concussion occurs when there is an acceleration, deceleration, or rotation force that causes the brain tissue to shift within the skull. This movement causes the brain tissue to brush against boney protrusions of the skull bone. Although researchers have yet to determine the exact effect of these forces on brain cells, they have determined that concussions result in an impairment of neurological function rather than structural damage. Therefore, diagnostic imaging, such as CT or MRI scans, will most likely not show any brain tissue abnormalities in concussed individuals. Concussion symptoms typically resolve within 7 to 10 days in 80 to 90% of individuals. Children and adolescents may require longer periods of recovery.
Symptoms of a concussion
Severity of concussion symptoms can be determined with an assessment tool called the SCAT 3 (Sport Concussion Assessment Tool – 3rd Edition). This assessment tool will be discussed further in my next column. There are several subcategories or domains of concussion symptoms that can help determine the severity. These include: clinical symptoms, physical signs, cognitive impairment, behavioral changes, as well sleep disturbances. It is also important to note any previous history of concussions.
Symptoms may include: Amnesia (loss of memory), headaches, a feeling of “pressure in the head”, neck pain, nausea, vomiting, dizziness, blurred vision, balance problems, sensitivity to noise and light, feeling “in a fog”, difficulty concentrating or remembering, low energy, insomnia, or being more emotional, irritable, or nervous than usual.
What to do if you suspect a concussion
Seek medical attention immediately after an impact to the head that results in the above symptoms. Often concussions go untreated as symptoms tend to go unnoticed by others. Symptoms can be aggravated by an increase in physical activity or exertion. Although symptoms are often present immediately after a blow to the head, physical, cognitive, or emotional changes may occur later that day or even the following day after impact. Therefore, it is important to seek help from your primary care provider as soon as possible. Stay tuned information on assessing concussions in my next column.
Whole body vibration (WBV) is a type of exercise training that has been used in sport, rehabilitation, and recreationally. The basis behind WBV is that the person is in contact with a platform that typically vibrates between 0.5 and 80 hertz (Hz). Points of contact include standing, sitting or performing other strengthening exercises such as planks or push-ups on the platform. It is thought that the vibration of the platform can help to build muscle mass and lean body mass, improving physical conditioning.
The mechanism by which muscular strength is improved via WBV is called the tonic vibration reflex. This reflex results in a continual contraction of the muscle being vibrated, which activates muscle receptors (muscle spindles) that are sensitive to stretch. The end result is an increase in strength of the muscle subjected to the vibration.
Researchers have determined that there are both short term and long term benefits of WBV. Short term benefits include greater activation of the contractile components of muscle, which aid in the efficiency of a muscle. Improvement of circulation is also another short term benefit in which the contraction and relaxation of muscles aids in the pumping of blood and lymphatic vessels. Long term benefits include increases in bone mineral density, and prevention of falls through improved balance, postural control, and overall strength.
A study published this year investigated older persons (average age of 85 years) and the effects of WBV on mobility, balance and overall health status. Participants were assigned to either a "vibration group" or to an "exercise based" group. The frequency of the vibration platform ranged from 6 to 26 Hz and participants performed 4-5 repetitions of a 60 second exercise, 3-5 times weekly over the course of 8 weeks. The researchers found that knee extensor (quadriceps) strength, postural stability, and general health status (measured by a survey) showed greater improvements in the vibration group compared to those who performed general exercises only. Overall, the research in this study indicated that WBV performed by seniors is effective in improving mobility, strength, and balance.
Another study in 2013 also showed similar results in that quadriceps strength and total lean mass increased in participants (active adults) that were subjected to WBV, compared to those in a control group (no vibration training). In this study, participants who were assigned to the vibration group were required to stand on the platform in a semi-squat position for 60 second intervals. VBW was performed 2 days per week for 6 weeks.
Overall, the literature to date suggests that VBW may be beneficial in improving strength (especially quadriceps muscles), balance, circulation, and general conditioning and health.
Frozen shoulder, also known as adhesive capsulitis, is a condition of the glenohumeral (shoulder) joint that results in pain and restriction of range of motion (ROM). This condition affects 2% to 5% of the population and is more frequent in women than in men, often present between 40 to 60 years of age. Anatomically, frozen shoulder is characterized by the thickening and tightening of the joint capsule, a specific type of tissue surrounding the shoulder joint, which results in the restriction of motion. Over time, frozen shoulder often presents with painful, progressive loss of both active (movement is performed by the patient without any assistance) and passive (patient is assisted with movement) ROM. This decreased mobility often follows a particular pattern in which lateral rotation is most affected, followed by abduction (raising the arm out to the side), and then medial rotation. There are 4 stages of frozen shoulder, which are as follows:
1. Painful Stage: Symptoms include an aching pain of the shoulder and moderate limitation of ROM. Pain occurs at rest and is often bothersome at night. Pain is aggravated by movement of the shoulder. This stage often lasts for up to 3 months.
2. Freezing Stage: Symptoms include severe pain and significantly reduced ROM. Abduction, internal and external rotation are the most affected movements. This stage persists for 3 to 9 months after symptom onset.
3. Frozen Stage: Symptoms include stiffness and restriction of movement in every direction. Pain is minimal or only at extremes of ROM. This stage is often present 9 to 15 months after the onset of symptoms.
4. Thawing Stage: Pain has decreased and ROM begins to improve. This stage can persist from 15 to 24 months after onset of symptoms.
As you can see from the above stages, frozen shoulder can persist for up to 24 months from the initial onset of symptoms. There are many types of treatments that may be suggested by your physician, including physiotherapy, anti-inflammatory medications, injections, as well as surgical interventions. As a physiotherapist, two main principles for the treatment of frozen shoulder include restoring ROM and reducing pain. Physiotherapy techniques often used to treat frozen shoulder include modalities (laser, ultrasound, electrotherapy, hot/cold therapy), stretching, manual mobilization of the shoulder joint, and prescribed home exercise programs.
Please check with your primary health care provider to determine a diagnosis for your shoulder pain and if any of the above treatments may be of benefit to you.
Read more Physio Matters articles
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- Fall prevention Dec 19
- Benefits of pole walking Dec 5
- Low level laser therapy Nov 7
- Acupuncture 101 Oct 24
- Calcific tendonitis of the shoulder Oct 10
- Compartment syndrome of the thigh Sep 26
- Hockey injuries Sep 12
- What is Sciatica? Aug 29
- Whiplash Associated Disorders (WAD) Aug 15
- Choosing a walker to suit your needs Aug 1
- Meniscal injuries: Part 2 Jul 18
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