There's much to see here. So, take your time, look around, and learn all there is to know about concussion assessment and how we are advancing your recovery.
A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head. Or a hit to the body that causes the head and brain to move rapidly back and forth.
Anyone can be injured; during a fall, car accident, rollercoaster or any other activity where your head and brain are jarred. Sports such as; football, lacrosse, soccer, hockey or any sport that may involve contact with your head can result in a concussive event. Concussions do not necessarily involve a loss of consciousness and they are usually not life-threatening, but they can cause serious symptoms that may require medical treatment and can have long lasting implications. That is why they are such a silent, overlooked and underestimated problem in our society.
Post - Concussion Syndrome refers to the set of symptoms that may accompany a concussion. These symptoms may linger for weeks, months or even years after the initial injury.The brain is cushioned inside the skull by the surrounding cerebrospinal fluid, but despite this, in the event of a blow to the head or rapid deceleration, it can cause the brain to contact the inside of the skull and then "bounce back" striking the other side of the skull as well, This type of injury is often referred to as a Coup and Contra Coup. There is potential for tearing of blood vessels, pulling of nerve fibers and even bruising of the brain tissue.
Sometimes this damage is microscopic and not even visible by CT scan. In severe cases, brain tissue can swell within the rigid confines of the skull resulting in compression of the brain and its blood vessels. Brain swelling after a concussion has the potential to increase the severity of the injury.
Post - Concussion Syndrome refers to the set of symptoms that may accompany a concussion. These symptoms may linger for weeks, months or even years after the initial injury.
We offer a comprehensive approach to rehabilitation after concussion. There are multiple aspects to our treatment protocol to facilitate recovery. Manual Therapeutic interventions are extremely helpful in facilitating the recovery of musculosketal injuries that may accompany the concussion. As well as facilitating neuro-plasticity and thus neuro-cognitive recovery.
Testing is a vital part of the rehabilitation process. It helps determine the stages of recovery and when an individual is ready to return to work, academics and sports.
Hyperbaric Oxygen Therapy increases oxygen perfusion intra-cellularly. Accelerating the healing and detoxification processes.
Decreasing Inflammation and creating the relaxation and healing brain wave patterns.
Learn how SportGait supports Athletes, Families, Medical Professionals, Coaches and Teams.
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Concussion is a diffuse injury to the brain affecting numerous brain functions, including both neurocognitive processes and motor control (Broglio & Puetz, 2008; Parker et al., 2006). Failure to assess, or ignoring, either of these domains will weaken the sensitivity of any assessment. Therefore, it is important to measure neurocognitive and neuromotor functioning with the best instruments available. To select the best measures to support diagnostic decisions, it is important to consider:
1) Reliability, which is the consistency of a test, and
2) Validity, which is the extent to which the test measures what it is supposed to measure.
Reliability and validity are related because a test can only be valid if it is first shown to be reliable.
As an illustration, imagine you have a blood pressure measure that provides the following readings three times over the span of 10 minutes; 120/80, 90/40, and 175/145. Assuming the machine was used correctly, the readings suggest that the machine is not producing consistent/reliable scores. When reliability is poor, the values do not inform us of the individual’s BP (i.e., no validity). Moreover, when a test has low test-retest reliability (as would be the case in this illustration), knowing their score at one point in time (e.g., 120/80) would not provide any information about what their score might be the next time it is measured (potentially ranging from 90/40 to 175/145). Thus, the measure is not clinically useful, as one would not intervene or make clinical decisions based on these unreliable estimates of blood pressure. The same would be true for any test purporting to assess the consequences of a head injury.
Unfortunately, some of the most commonly used measures to assess sport concussions suffer from low reliability.
For example, ImPACT is highly variable in terms of its reliability, as most
studies found values well below .7, which is considered the minimum accepted value
(some as low as .15 to .22; e.g., Broglio et al., 2007; Bruce et al., 2014). Poor
reliability will undermine validity, and this is consistent with the fact that ImPACT
has very high misclassification rates (anywhere from 1 in 4 to almost 1 in 2 healthy
individuals misclassified as concussed; e.g., Resch et al., 2013), ImPACT scores fail
to predict performance on well-validated instruments assessing the same constructs
(e.g., Svhatz & Pulz, 2006), and ImPACT scores do not relate to concussion history
(e.g., Broglio et al., 2006). Given these problems, it is not surprising that researchers
have concluded that ImPACT does not have enough accuracy to help guide
important medical decisions, such as return-to-play (e.g., Mayers & Redick, 2012).
The graph to the right illustrates how poor reliability (r = .22) results in large error bars (dashed lines) around the actual score (solid line). Poor reliability undermines the ability to differentiate a concussed from a non-concussed performance.
The Sport Concussion Assessment Tool (SCAT3) is typically better than ImPACT with respect to reliability, but even its values are suboptimal (topping out at .55; e.g., Hänninen et al., 2016). To again illustrate the cost associated with having suboptimal reliability, consider that the SCAT3 does show sensitivity to the incidence of concussion at 24 hours, but it does not show sensitivity after 8 and 15 days (Chin et al., 2016). Thus, the SCAT’s sensitivity appears to be limited to 24- hours post injury, when symptoms are most pronounced, and much less so when symptoms are subtler (see also meta-analysis by
Broglio & Puetz, 2008).
Giventhese findings, medical professionals should be using other more reliable and
validated tests. The graph to the left shows how a reliability of .55 is still not effective at differentiating a concussed from non-concussed performance.
For neurocognitive symptoms, one of the most reliable (.92 for internal
reliability and > .82 for test retest reliability; e.g., Riccio & Reynolds, 2003) and
sensitive measures is the Connors’ Continuous Performance Test (CPT). This test has
been used by neuropsychologists and medical professionals for years to help diagnose
neurocognitive deficits. The CPT provides information regarding speed of mental
processing, attention/inattention, response inhibition, and impulsivity (errors of
omission and commission). Recent research has shown the CPT to relate to measures
assessing the presence of a concussion in adolescents (O’Neill et al., 2015), it captures
remediation in adolescents with TBI (Galbiati et al., 2009), and is associated with
improved scores as a function of time following mild head trauma (Naunheim et al.,
2008). Thus, the CPT is not only reliable, but valid. The graph to the right illustrates
how a reliability of .88 can allow one to differentiate a concussed from a non-concussed performance.
Neuromotor functioning that supports postural control can be assessed in the form of balance, and this can capture the consequences of a concussion and inform return to play decisions (e.g., Howell et al., 2016). In fact, best-practice statements have recommended that balance testing is a critical component in the clinical examination of concussion (Harmon et al., 2013; McCrory et al., 2013), and a validated neuromotor assessment such as the BESS (Balance Error Scoring System) is therefore an important component of a valid assessment of functioning. Using the full BESS, reliability is .65 and this can still provide useful information to differentiate a concussed from a non-concussed performance. (see graph to the left).
Neuromotor functioning can also be evaluated using gait analysis, as the NIH 4-meter gait test consistently yields some of the highest reliability coefficients, with values of .97 (Peters et al., 2013). Individuals with concussions have shorter stride length while walking, as well as slower gait velocity relative to normal controls, and gait slowing has been reported to persist for 28-days post-concussion (Cantena et al., 2007, 2009; Parker et al., 2008). Additionally, slower walking speeds and shorter stride lengths are evident in concussed participants evaluated up to 1 year after injury (Chou, et al. 2004). With a reliability of .97, the NIH 4-meter gait test has some of the best validity and is very effective at differentiating a concussed from a non-concussed performance (see graph to the right).
Broglio SP, Puetz TW. The effect of sport concussion on neuro- cognitive function, self-report symptoms, and postural control: a meta-analysis. Sports Med 2008;38:53-67.
McCrea M, Guskiewicz KM, Marshall SW, et al.(2003). Acute effects and recovery time following concussion in collegiate football players: The NCAA Concussion Study. Journal of the American Medical Association. 290, 2556-63.
Parker TM, Osternig LR, van Donkelaar P, Chou LS. (2006). Gait stability after a concussion. Med and Sci in Sports & Exer.. 38, 1031-1040.
Cantena RD, van Donkelaar P, Chou LS. (2007a). Altered balance control following concussion is better detected with an attention test during gait. Gait & Posture. 25, 406-411.
Cantena RD, van Donkelaar P, Chou LS. (2007b) Cognitive task effects on gait stability following concussion. Exp. Brain Res.,176, 23-31.
Cantena RD, van Donkelaar P, Chou LS. (2009). Different gait tasks distinguish immediate vs. long- term effects of concussion on balance control. J of euroEngin & Rehabil. 2009. 6(25).
Parker TM, Osternig LR, van Donkelaar P, Chou LS. (2008). Balance control during gait in athletes and non-athletes following concussion. Med Eng & Phys., 12, 1360-8.
Chou LS, Kaufman KR, Walker-Rabatin AE, Brey RH, Basford JR. (2004). Dynamic instability during obstacle crossing following traumatic brain injury. Gait Posture, 20, 245-54.
DM Peters et al. (2013). Assessing the Reliability and Validity of a Shorter Walk Test Compared With the 10-Meter Walk Test for Measurements of Gait Speed in Healthy, Older Adults. J Geriatr Phys Ther 36 (1), 24-30.
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