Concussions- question your surroundings

This blog post is a challenge to you to enhance your practice of evidence based medicine and learn to question your surroundings-
Unlike most sports injuries, concussion are often referred to as an invisible injury1. Concussions are defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces2. An estimated 300,000 sports related concussions occur annually in the United States, which is nearly 20% of the 1.5 million head injuries recorded3. This invisible injury can occur with several symptoms, many that are subjective in nature. Typical symptoms of a concussion may include somatic complaints (e.g., headache, dizziness, and fatigue), neurocognitive deficits (e.g., concentration and attention problems, information processing, and memory dysfunction), and emotional signs and symptoms (irritability, anxiety, low motivation).4,5 The presentation of concussion symptoms varies considerably patient to patient and without a formal way to identify the patient reported symptoms clinicians are unable to treat the patient accordingly6.
In recognition of the need for better concussion management strategies, the International Ice Hockey Federation (IIHF), in conjunction with the International Olympic Committee (IOC) and the Federation Internationale de Football Association (FIFA), convened in Vienna in October of 2001 to evaluate the current status of concussion management guidelines and to draft practical recommendations for making return-to-play decisions (Aubry et al., 2002). It was during this conference that the recognition of utilizing a symptoms scale during return to play protocols and the importance of documenting the self-reporting symptoms of the concussion patient became evident. It became clear that symptom reporting scales where important in treating the patient and that several scales addressed the same symptoms, but there was not one scale that was viewed as the golden standard. To identify these symptoms the post-concussion symptom scale (PCSS) was developed to provide a formal method of documenting post-concussion symptoms, as perceived and reported by the patient7. The PCS scale items were constructed to reflect actual player reports rather than medical jargon7. The PCS scale measures the severity of patient reported concussion symptoms on a 0-6 Likert scale, while providing the clinician a formal way of documenting these post-concussion symptoms8-10. The PCSS includes the following 22 items: headache, nausea, vomiting, balance problems, dizziness, fatigue, trouble falling asleep, sleeping more than usual, sleeping less than usual, drowsiness, sensitivity to light, sensitivity to noise, irritability, sadness, nervous, feeling more emotional, numbness or tingling, feeling slowed down, feeling foggy, difficulty concentrating, difficulty remembering, and visual problems. The PCSS was developed to provide an adjunct to other tools, such as neuropsychological testing, and is commonly found within on-field concussion assessment tools (e.g., Sport Concussion Assessment Tool 2 [SCAT2]) and post-acute computerized neurocognitive tests (e.g., Immediate Post-concussion Assessment and Cognitive Test [ImPACT], CogSport)6.
The PCSS is found to be broken into four factors: seven cognitive symptom factors (e.g., concentration, attention, memory and reaction time), three sleep disturbance symptom factors (e.g., sleeping more or less than usual) four emotional symptom factors (irritability, nervousness, sadness, more emotional than usual) and eight somatic symptom factors (e.g., headache, dizziness, fatigue, nausea)6. This scale is scored as a total overall score that includes all four of the factors. The instrument is documented as having a low score if the patient reports 0, a borderline normal score if the patient reports 1-5, a borderline score if the patient reports 6-12, a very high score if the patient reports 13-26 and extremely high if the patient reports 27+. It is not understood or well researched what these different scores mean or how they should be treated. Kontos 2006, reports that as clinicians we should
not only look at the total score of reporting symptoms but the individual score of each of the four factors2; this would allow clinicians a more in depth way of a multidisciplinary clinical management approach, rehabilitation treatments and return to play protocols6.
Researchers have found, through factor analysis of the PCSS scale and multiple other symptom scales, that the emergent four factors may reflect different subtypes of concussions6. Researchers report that, as clinicians, we should not only look at the total score of reporting symptoms but the individual score of each of the four factors. This would provide clinicians with a more in-depth approach of analyzing and controlling rehabilitation treatments and return to play (RTP) protocols6.
So…….… My question to my colleagues is this- Have you ever researched the tools given to you and may be required of you to use with your patients? Have you or do you understand the foundation of the numerous concussion scales, test or policies you are treating your patients with? I understand that concussions are a hot topic, however I feel this line of questioning should be utilized in all areas of athletic training. I know that being in the secondary setting myself we become comfortable and I find myself stuck, not able to explain a treatment method on a foundational scientific level or concussion scale with supporting research evidence. Once I realized this speed bump I began questioning everything, as I challenge you to do as well.
Which brings me back to the PCSS that I find absolutely fascinating. I have watched numerous sports medicine professionals ask the symptoms check-list and leave the patient with a mindset of “yes they have symptoms” or “no they do not have symptoms”. Did you ever stop to think what each of those symptoms mean or where those symptoms are located in the brain? Did you stop to think of what the difference of somatic and cognitive symptoms could mean for your patient? I know I didn’t at first and then it all became clear. These symptoms mean something and that something is crucial for their return to play or return to learn. So I CHALLENGE you to take a closer look at your patients symptoms and figure out what they truly MEAN.
~Cathlene Webb MS, ATC, LAT
University of Idaho Doctoral Student
1. Bloom GA, Horton AS, McCrory P, Johnston KM. Sport psychology and concussion: new impacts to explore. British Journal Of Sports Medicine. October 1, 2004 2004;38(5):519-521.
2. Meehan WP, d’Hemecourt P, Comstock RD. High School Concussions in the 2008-2009 Academic Year. The American Journal of Sports Medicine. December 1, 2010 2010;38(12):2405-2409.
3. Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubinstein D, Kleinschmidt-DeMasters BK. Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA : the journal of the American Medical Association. 1991;266(20):2867-2869.
4. Barr WB, McCrea M. Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion. Journal of Neurophysiology. 2001;7:693-702.
5. McCrea M, KM G, SW M. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA : The Journal of the American Medical Association. 2003;290:2556-2563.
6. Kontos AP, Elbin RJ, Schatz P, et al. A Revised Factor Structure for the Post-Concussion Symptom Scale: Baseline and Postconcussion Factors. American Journal of Sports Medicine. 2012;40(10):2375-2384.
7. Lovell M, Iverson G, Collins M, et al. Measurement of Symptoms Following Sports-Related Concussion: Reliability and Normative Data for the Post-Concussion Scale. Applied Neuropsychology. 2006;13(3):166-174.
8. Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Injury. 2004;18(5):433-443.
9. Echemendia RJ. Assessment and Management of Traumatic Brain Injury. Sports Neuropsychology. 2006.
10. Iverson GL, Lange RT. Examination of "Postconcussion-Like" Symptoms in a Healthy Sample. Applied Neuropsychology. 2003;10(3):137.