Injury specialist, Dr. Alexander Jimenez looks at the latest study about concussion in sports, especially regarding early/on-field assessment and diagnosis of this condition.
The proper medical definition of concussion is: a clinical syndrome characterized by immediate and transient change in brain function, including alteration of mental illness and level of consciousness, resulting from mechanical pressure or injury. But, it is more commonly described as an injury to the brain caused by a blow to the head (eg an uppercut in boxing, a clash of heads in soccer or a fisherman moving over the handlebars on the ground etc), which leads to temporary loss of normal brain function, including disturbances in memory, judgment, reflexes, speech, balance and muscle coordination. A less obvious cause is an indirect blow where the force is transmitted up to the head from a different portion of the body — for example when a stationary rugby player is tackled from behind causing his head to abruptly flick back, with a number of the force of the tackle passing through his brain; the participant may end up concussed without ever taking a direct blow to the head.
While bruises and cuts might be present on your face or head as a consequence of this blow, in most cases a person with a concussion never loses consciousness. Because of this, less experienced coaches and sports physicians may not immediately assume concussion, or if they do they presume that it’s unlikely to be a cause for concern. But, though some concussions are less severe than others, there’s absolutely no such thing as a ‘minor concussion’; while a single concussion should not result in permanent damage, another concussion shortly after the initial one doesn’t have to be very powerful for its consequences to be fatal or permanently disabling. Animal and human studies support the concept of this so-called ‘post-concussive vulnerability’, showing that a second blow before the mind has regained results in worsening metabolic changes within the cell(1). This explains the crucial importance of correctly and immediately identifying when a concussion has occurred because it affords the opportunity of this athlete to be taken out of the field of play, thereby ensuring a second concussion cannot happen.
Initial Diagnosis Of Concussion
As soon as an athlete suffers a blow to the head, the first priority should be that someone qualified is available to assess whether concussion has occurred. In an ideal world, this assessment could always be performed by a physician specifically trained in this area. In many sporting events (eg a small league football game), it is unlikely that such a individual will be there standing on the sidelines. However, as stated by the America Medical Society for Sports Medicine (AMSSM), the competence to execute this assessment also needs to be decided by training and experience and not purely dictated by specialty(1). To put it differently, with the right training and expertise, coaches, trainers and health care professionals are more than capable to perform a concussion examination.
The AMSSM additionally points out that the identification of concussion is ideally created by a healthcare provider who is not only knowledgeable in the recognition and analysis of concussion but also familiar with the person concerned. The reason for this is that while standardized sideline tests are a useful framework for making an appraisal, the validity and reliability of these tests are greatly reduced without some type of individual baseline test result with which to compare, and some other baseline rating will vary based on the individual athlete concerned.
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AMSSM New Guidelines
The primary recommendations were assembled by reviewing the evidence over a number of years and are summarized as follows:
- Any athlete suspected of having a concussion should be stopped from playing and assessed by a qualified healthcare provider trained in the evaluation and management of concussion and ideally someone who is familiar with the athlete (for the reasons given above). The recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (which should include orientation, past and immediate memory, new learning and concentration), balance tests and further neurological and physical examination.
- Coaches/physicians/healthcare providers should take note that while balance disturbance is a specific indication of a concussion, it isn’t very sensitive. In particular, performing equilibrium testing about the touchline may yield substantially different results than baseline evaluations simply because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injuries that might have also happened during the episode involving the head injury.
Any athlete suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status. Importantly, there should be NO same day return to play for an athlete diagnosed with a concussion injury. Meanwhile, imaging should be reserved for athletes where intracerebral bleeding is suspected.
- Even though most concussions can be managed appropriately without the use of neuropsychological (NP) testing, those with athletes in their maintenance ought to bear in mind that NP evaluations are an objective measure of brain- behavior relationships and, as such, are somewhat more sensitive for subtle cognitive impairment than a straightforward clinical examination. However, NP testing should be used only as part of a extensive concussion management plan and should not be utilized in isolation. Also, the ideal timing, frequency and type of NP testing have not been completely ascertained.
- Computerized NP testing should be translated by health care professionals educated and comfortable with the type of test and also the individual test limitations. Paper and pencil NP evaluations are both valuable and are able to test different domain names and assess for different conditions, which may masquerade as or reevaluate evaluation of concussion.
- Concussion symptoms must be resolved before returning to perform with (RTP) and RTP after concussion should happen just with medical clearance from an experienced health-care supplier trained in the analysis and management of concussions — see Box 2. An RTP progression entails a gradual, step-wise increase in bodily demands, sports-specific activities and the danger of contact. If any signs recur using action, the progression ought to be stopped and resumed in the previous symptom-free step. In the brief term, the principal concern with early RTP is diminished reaction time resulting in an increased risk of a repeat concussion or additional injury and prolongation of symptoms. In the long run, there’s a growing concern that head impact exposure and recurrent concussions can contribute to long-term neurological complications and a number of studies have indicated an association between previous concussions and chronic cognitive impairment.
- Physicians should be prepared to offer counseling regarding potential long-term consequences of a concussion and continuing concussions. However, there are currently no evidence-based guidelines for disqualifying/retiring an athlete from a game after a concussion. More commonly, greater efforts are needed to educate involved parties, such as athletes, parents, coaches, officials and school administrators and health care providers to boost concussion recognition, prevention and management.
Recent Findings: On-Field & Same Day Assessment
Make no mistake, but the first assessment of concussion in the mature athlete is tough, given that the elusiveness of harm, the sensitivity and specificity of their sideline assessment tools along with the evolving nature of concussive injury. A very current (2013) review newspaper systematically examined the evidence related to on-field concussion assessment and considered questions related to same day return to play, what to do if no doctor is available onsite, as well as the benefit of distant notification of future concussive events(3). It concluded that the on-field test of sport-related concussion is often a challenge, especially given the elusiveness and variability of presentation, the strain to create a quick diagnosis (as an instance, in the middle of an important match in which the concussed athlete was making a significant contribution), the specificity and sensitivity (or rather lack of) of this on-field assessment tools, along with the dependence on symptom presentation.
However, they cautioned that a range of assessments over a brief time period tend to be necessary and, since signs and symptoms may be postponed, erring on the side of caution (ie maintaining an athlete from participation whenever there’s a distress for harm) is important. In addition, they concluded that although a standardized evaluation of concussion is beneficial in the evaluation of the athlete with suspected concussion, it should NOT take the place of the clinician’s conclusion.
These findings have been very much in agreement with another 2013 review research on instruments currently utilized in the evaluation of sport-related concussion on the day of injury — consequently ‘same day’ assessment tools(4). In this review, a total of 41 research on sports concussion were pooled and their findings analyzed. The authors concluded that several well- supported tests are acceptable to be used in the evaluation of acute concussion from the athletic athletic environment and that these evaluations can provide significant data on the symptoms and functional impairments that clinicians can integrate in their diagnostic formula. But they also cautioned that such tests should not solely be used to diagnose concussion.
SCAT3 Assessment Tool
As mentioned above, the first evaluation of an injured athlete with suspected concussion remains predominant in determining subsequent action. There are a number of diagnostic tools available, but undoubtedly among the most admired is when there is no one with medical training available to tend to an injured athlete, it is recommended that the ‘Sport Concussion Recognition Tool’ be used instead (seeBox 3). The SCAT3 assessment tool can be downloaded here: http://bjsm. bmj.com/content/47/5/263.full.pdf. The SCAT3 is a standardized instrument for evaluating injured athletes for concussion, and is intended for use by medical professionals. SCAT3 supersedes the first SCAT and SCAT2 published in 2005 and 2009 respectively. Importantly, baseline testing together with the SCAT3 can be beneficial for translating post-injury test scores at a later date. The SCAT3 evaluation tool can be downloaded here: http://bjsm. bmj.com/content/47/5/263.full.pdf
SCAT3 is a detailed tool that assesses the following areas: background, symptom evaluation, cognitive and physical function, neck trauma, balance and coordination. According to the SCAT guidelines, the first indications through a sideline evaluation are critical and any of the following warrants triggering emergency procedures and barbarous transport to the nearest hospital:
- a Glasgow Coma score of less than 15 (see Box 4)
- deteriorating mental status
- potential spinal injury
- progressive, worsening symptoms or new neurologic signs.
It is important to highlight, but that scoring on the SCAT3 shouldn’t be utilized as a stand-alone process to diagnose concussion, quantify recovery or make conclusions regarding an athlete’s readiness to come back to competition after concussion. Additionally, since signs and symptoms can evolve over time, it’s very important to consider repeat evaluation from the acute evaluation of concussion. Finally, it needs to be stressed that the identification of a concussion is a medical judgment, ideally created by a medical professional. The SCAT3 shouldn’t therefore be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete could have a concussion even if their SCAT3 score is ‘normal’.
1. Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941
2. Am J Sports Med. 2012 Apr;40(4):747-55
3. Br J Sports Med. 2013 Apr;47(5):285-8
4. Br J Sports Med. 2013 Apr;47(5):272-84
5. Br J Sports Med 2013 47: 259
6. downloadable from: http://bjsm.bmj.com/content/47/5/267.full.pdf
These canons of professional ethics are based upon fundamental principles of moral and professional behavior and recommended for all doctors of chiropractic and chiropractic assistants. The following basic principles should be guiding factors in the practice of chiropractic and upheld at all times:
Consider the well-being of the patient. The primary effort and ultimate goal is for the greatest good of our patients.
- Dr. Alexander D. Jimenez D.C., C.C.S.TChief Clinical DirectorPhone: 9155408444Email: firstname.lastname@example.org
Specializing in Severe Pain: Sciatica, Neck-Back Pain, Whiplash, Headaches, Knee Injuries, Sport Injuries, Dizziness, Poor Sleep, Arthritis. We use advanced proven therapies focused on optimal mobility, health, fitness, and structural conditioning. We use Patient Focused Diet Plans, Specialized Chiropractic Techniques, Mobility-Agility Training, Cross-Fit Protocols and the "PUSH System" to treat patients suffering from various injuries and health problems.
Message from: Dr. Alex Jimenez D.C., C.C.S.T
( Biography and my promise to you )
My name is Dr. Alex Jimenez, I am Chiropractic Doctor specializing in advanced therapies focused on total joint health, strength training and complete fitness conditioning. We use patient Focused Diet Plans, Advanced Chiropractic Techniques, Agility Training, Cross-Fit and the PUSH System to treat patients suffering from various injuries and health problems. Our goal too is to help your body heal itself naturally. When your body is truly healthy, you will arrive at your fitness level and proper weight efforlessly. We want to help educate you on how to live a new and improved lifestyle. Our doctors have spent over 25+ years researching and testing methods with thousands of patients. We strive to create fitness and better the body through researched methods and total programs...
My goal too is to help the body heal itself naturally. When your body is truly healthy and balanced, you will move pain free and ultimatly arrive at your optimal fitness levels and proper weight effortlessly. We want to help educate you on how to live a new and improved lifestyle. Our doctors have spent over 25 years researching and testing methods with thousands of patients. We strive to create fitness and better the body through researched methods and total programs. These programs are natural, and use the body's own ability to achieve goals of improvement, rather than introducing harmful chemicals, controversial hormone replacement, surgery, or addictive drugs. We want you to live a life that is fulfilled with more energy, positive attitude, better sleep, less pain, proper body weight and educated on how to maintain this way of life.
The focus on spinal and skeletal adjustments is what makes doctors of chiropractic unique in their approach to treating patients with spinal complaints. This hallmark chiropractic adjustment, however, is not the only procedure a chiropractor may employ in managing a patient's care. I am very proud to bring my patients a variety of treatment options beyond the typical scope of care. With the advances in physical therapies and modalities we bring El Paso option that better aid in the rehabilitation process. Tissue healing is a wonderful process that begins the moment an injury occurs. How the injury is managed determine the final outcome in terms of healing. It is critical we implement immediate procedures as soon as we can in order to gain optimal recovery. The old day of let it rest until it gets better is not the only option.
Letting it rest may even be an irresponsible approach considering what we now know. The implementation of active and movement based treatments have clearly shown increased and improved outcomes in many instances.
As a doctors focused on the greater good for a patient, we must assess each patient individually and apply the appropriate protocols. It is also very important to denote, that El Paso has fine doctors in many specialties of healing and repair. The direct relationship we have with specialist of these disciplines is clearly what allows us to bring the highest quality of care to our patients.
My promise to my patients is clear for all to read here. I, with Gods help, will do what ever it takes to assist you in your recovery. I too will draw upon all the specialist in this town to find you the collaborative care that is required with the disorders being tended to.
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Big Mike was born and raised in El Paso and is an excellent personal trainer and CrossFit coach. Mike works hand in hand with each patient’s clinical care plan in order to achieve optimal outcomes. A trusted clinical representative of the PUSHasRx System along with his advance protocols. Mike not only trains the injured and recovering. Mike is a sincere human that has great talent of brining out the best in every individual he works with. He will never admit it, but we will share with you a secret. He with his God given talents trains the greatest athletes and champions in El Paso. Many champions in our community know of his commitment. As a youth, he also played football (wide receiver), basketball, and track at Bel Air High School. Educated in Clinical Human Kinesiology at UTEP and loves playing football and basketball with his little nephews in his free time. Mike has three sisters and one brother, most of which live nearby in El Paso. When he’s not watching the Cowboys or Spurs play, he’s usually lifting, sleeping or watching movies. We are blessed to have this soul on our team.Read moreRead less
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Ethan was born and raised in El Paso and is one of our most outgoing and friendly coaches. Ethan earned his nickname “rampage Ethan” from his years at El Dorado High School, where he played inside linebacker. He has placed twice in the Strongman Competition and also recently competed in the Desert Games with his fellow PUSH Athletes as a team and placed 4th overall! Ethan is currently pursuing his Bachelor’s Degree in Kinesiology at UTEP. His focus on clients is obvious to all. Ethan is able to manage very large groups of individuals like no other. His awareness of the dangers while exercising is his greatest concern. When he’s not coaching or studying for class, he likes to spend time with his family (who are here in El Paso) or with his weimaraner puppy. Fun fact: Ethan loves any food with sprinkles (especially donuts with sprinkles) and is a diehard Seattle Seahawks fan.Read moreRead less
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ylene has been working with us for over 4 years. In her spare time she enjoys working out and running. She has 2 dogs and loves movies. Iylene is extremely aware of body mechanics and mindfully watches rehabilitation movements. She is always standing ready to assist and respond to client needs. Her commanding voice is always clear to all, no matter what floor you are on. Iylene is always ready and willing to answer any question you may have regarding fitness and recovery.Read moreRead less
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