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Sports Concussions A Complete Guide to Recovery and Management Sports Concussions A Complete Guide to Recovery and Management Edited by Isabelle Gagnon Alain Ptito Cover art: Courtesy of Carolina Echeverria (www.carolinaecheverria.ca) CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4987-0162-4 (Hardback) This book contains information obtained from authentic and highly regarded sources Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents Editors ix Contributors xi Section I: What is a concussion? Chapter Introduction .3 Isabelle Gagnon, Scott A Holmes, and Alain Ptito Chapter Concussion revisited: A historical perspective: How has the focus on concussion evolved over the years? Paul McCrory Chapter Concussion incidence, risk factors, and prevention: What is the scope of the problem? .25 Amanda Black, Paul Eliason, Declan Patton, and Carolyn Emery Chapter Biomechanics of sports concussion: How sport concussions happen? 81 Blaine Hoshizaki, Anna Oeur, Andrew Post, David Koncan, Marshall Kendall, Clara Karton, and Philippe Rousseau Chapter Acute diagnosis of sports concussion: How we identify a concussion? 113 Roger Zemek and Josh Stanley Section II: Managing a concussion Chapter Rest and recovery from concussion: How should rest be used in concussion management? 131 Noah D Silverberg and Grant L Iverson Chapter Early management recommendations: What should be done now that we know it is a concussion? 149 Roger Zemek and Josh Stanley Chapter Physiotherapy and concussion: What can the physiotherapist do? 159 Kathryn J Schneider and Isabelle Gagnon v vi Contents Chapter Role of neuropsychology in sport concussion: What can the neuropsychologist do? 171 Vickie Plourde, Brian L Brooks, Michael W. Kirkwood, and Keith O Yeates Chapter 10 The role of the occupational therapist in concussion management: What can the occupational therapist do? 201 Carol DeMatteo, Nick Reed, and Kathy Stazyk Chapter 11 The role of the psychologist and psychiatrist in pediatric concussion management: What can they for me? 223 Michael Takagi, Emma Thompson, and Vicki Anderson Section III: Recovery and beyond Chapter 12 Return to school: When and how should return to school be organized after a concussion? 241 Gerard A Gioia Chapter 13 Return to work: When and how should I return to work after a concussion? 263 Michelle McKerral and Geneviève Léveillé Chapter 14 Return to sports: When and how should I return to sports after a concussion? 285 Ruben J Echemendia Chapter 15 How to manage persistent problems: What if I don’t recover as quickly as I expected from a concussion? .299 Isabelle Gagnon Chapter 16 When the effects of concussions endure: What are some of the longer term consequences? 315 Robin Green and Charles Tator Section IV: Additional considerations Chapter 17 Team and high risk sports: The baseline model: Is it useful to measure an athlete’s abilities before the sport season? .331 Gillian Hotz and Danielle Ransom Chapter 18 On-field diagnosis and management of concussion: What should be done while I am still on the field? 345 J Scott Delaney and Ammar Al-Kashmiri Chapter 19 Emerging diagnosis technology: What is coming up in terms of the use of biomarkers of concussion? .363 Linda Papa Contents vii Chapter 20 Emerging diagnosis technology: What is coming up in terms of the use of imaging technology in concussion care? 375 Rajeet Singh Saluja, Scott A Holmes, Jen-Kai Chen, and Guido Guberman Chapter 21 Emerging treatments: What is coming up in terms of the use of technology for treatment of concussion? 407 Lisa Koski Section V: Putting it all together: Complete concussion care Chapter 22 Putting it all together: The need for personalized care after concussion 431 Isabelle Gagnon and Alain Ptito Chapter 23 Complex case studies 435 Maude Laguë-Beauvais, Alain Ptito, and Isabelle Gagnon Index .447 Editors Dr Isabelle Gagnon is a pediatric physical therapist and clinical scientist at the trauma center of The Montreal Children’s Hospital, McGill University Health Center, and an associate professor in the School of Physical and Occupational Therapy of McGill University, Montreal, Quebec, Canada In both these roles, she has participated in changing the landscape of concussion assessment and care, as well as in the inclusion of concussion awareness in the curriculum of future physical therapists She leads an innovative research program, which focuses on the consequences and the management of mild traumatic brain injuries or concussions in the pediatric and adolescent population More specifically, she has investigated sensorimotor outcomes in children and adolescents, and how these can impact return to physical activities and self-confidence after traumatic injuries Her work has also examined intervention programs and service organization for children and adolescents after a traumatic injury As an author of several key publications in the field of pediatric concussions, she has participated in the creation of pediatric concussion management guidelines and in standardizing the assessment of children and teens who sustain concussions As it has been since the beginning of her career, her goal remains to contribute to the well-being of children after they sustain injuries, placing evidence-based management at the heart of her approach Dr Alain Ptito is professor of Neurology and Neurosurgery at McGill University He has worked as a neuropsychologist at the Montreal Neurological Institute and Hospital since 1983 and he is now the director of the Psychology Department at the McGill University Health Centre (MUHC) and a medical scientist at the Research Institute of the MUHC Dr A Ptito’s research program involves the investigation of the mechanisms involved in cerebral reorganization and plasticity in patient populations (hemispherectomy, callosotomy, Parkinson’s disease, stroke, and head injury) and his clinical work includes the neuropsychological assessment of these patients One of his principal research focuses has been the investigation of the residual visual abilities (blindsight) of patients following a rare procedure called hemispherectomy, the surgical removal or disconnection of a cerebral hemisphere Dr Ptito studied clinical psychology at the McGill University (1975) and obtained his postgraduate degrees in experimental psychology (1979) and neuropsychology (1986) from the Université de Montréal His doctoral thesis examined residual vision in the blind field of patients who underwent a hemispherectomy Dr Ptito now delivers lectures throughout the world on residual vision and on traumatic brain injury (TBI) He is a member of the Order of Psychologists of the Province of Quebec and of the Société des Experts en Evaluation Médicolégale du Québec Dr Ptito has been a member of several consensus panels on guidelines for TBI ix 442 Sports Concussions smoke She was independent in all instrumental activities of daily living, preinjury, and her home has 15 interior steps and exterior steps She is an avid horseback rider (rides 7 days per week) Mrs H was horseback riding when she fell from her horse, but she was wearing a helmet during the accident She was found two hours later, confused and disoriented walking along with her horse She probably lost consciousness and her post-traumatic amnesia lasted more than 24 hours but less than 48 hours Her Glasgow coma scale score varied between 13/15 and 15/15 when she was sent to a local hospital After her CT scan, she was transferred to a tertiary trauma center where she was admitted The CT scan that was done the same day revealed a left holohemispheric subdural hematoma, small bifrontal subdural hemorrhages, and inferior bifrontal subarachnoid foci She did not suffer from any other traumatic injuries During her hospital stay, once deemed safe by neurosurgery, she was followed by an multidisciplinary team, such as a physiotherapist, an occupational therapist, a speech language pathologist, a social worker, a physiatrist, and a neuropsychologist as well as a complete nursing team Patient’s complaints (multiple disciplines) At the moment of the assessment, the patient reported being agitated and feeling antsy She noticed that she had some difficulty in finding her words She admitted that she was feeling bored while being admitted to the hospital and having trouble doing nothing She first complained of severe left-sided headaches which subsided She denied vertigo, dizziness, and diplopia She denied noticing any problems with memory Clinical observations (multiple disciplines) Mrs H was alert and aware during the initial team multidisciplinary assessment Her social interactions were adequate: she was polite and maintained good visual contact She did not resist answering questions, and she collaborated well with testing She even tended to be overly jovial at times However, her symptom was generally anxious, and she became somewhat defensive when confronted with her difficulties Her anxiety was sometimes overwhelming, which seemed to cause a drop in her performance at times Thus, her testing results had to be interpreted with caution Moreover, some impulsivity was noted during the completion of tasks Her judgment and insight were affected Her overall difficulties are summarized as follows (detailed report is given in Section “Detailed reports and recommendations”): • • • • • • • • • Some confusion/impulsivity Moderate psychomotor slowness Mildly decreased balance in complex activities Requires supervision for ADLs (confusion, poor planning, poor judgment, and insight) Fluctuations while maintaining and manipulating verbal information Weakness in visual analysis/visual planning Impaired working memory Weakness in lexico-semantic access Mental rigidity/somewhat concrete thinking pattern Chapter twenty three: Complex case studies 443 Final discharge plan The patient refused in-patient rehabilitation categorically and threatened to leave against medical advice if she was sent to in-patient rehabilitation An out-patient service was, thus, organized as the patient was still considered competent She was able to resume all her pre-injury roles after discharge from rehabilitation services Detailed reports and recommendations Social work recommendation and intervention plan Patient will either require in- or out-patient rehabilitation She has strong support from husband and extended family and friends Mrs H expresses eagerness in returning home and may be minimizing the severity of her TBI condition Ongoing support counselling with patient and family will be of benefit to encourage accepting the treatment team’s rehabilitation recommendations Rehabilitation medicine assessment The patient was slow, somewhat confused, and was present with moderate psychomotor slowness The examination of the cranial nerves (nerves I to XII), reflexes, and senses is normal The patient shows no drift in her limbs The Dix–Hallpike test was deferred because there were no dizziness complaints Out-patient rehabilitation was recommended at first but was then changed to an in-patient rehabilitation recommendation following the TBI team’s advice Neurosurgery trauma assessment Acute but stable subdural hematoma was confirmed with no complications and increased alertness and orientation She tolerated oral feeding and remained hemodynamically stable throughout her hospitalization The patient was advised to go to in-patient rehabilitation several times, but she was discharged to home with out-patient rehabilitation Physiotherapy assessment Patient was moving all limbs She was cooperative and oriented to person and place She was able to roll in bed, sit up from lying, stand up from sitting, and was able to go from the bed to her chair independently Static and dynamic balances were good while sitting and standing Her score at the Berg balance scale was 54/56 She tolerated walking well for a distance of 100 m with supervision She was able to go up and down 20 steps using the railing by alternating her legs Her range of motion and her strength were normal In-patient rehabilitation was recommended due to her mental status and to further optimize her balance and functional independence Occupational therapy assessment Functional assessment: The patient showed that she was independent with modified structures for feeding and mobility transfers She needed supervision for grooming, bathing, dressing her upper and lower body, and transferring in and out of the tub As for instrumental activities of daily living, she required assistance for 444 Sports Concussions household chores, meal preparation, groceries, driving, transportation, and medication Finances could be done with some supervision Physical components: Her strength as measured by a dynamo was 20 kg on the right side and 23 kg on the left side She showed good finger to nose coordination Cognitive-perceptual components: Attention and scanning (Bells test) were slightly impaired The motor-free visual perception test (MVPT-III) showed a normal performance and verbal problem solving The patient had trouble in recalling her age, and her insight was poor Considering the severity of the TBI and her premorbid status, the patient was thought to have benefited from functional intensive rehabilitation to maximize her independence in instrumental and domestic activities of daily living and to help her return to baseline Speech-language pathology assessment Administered Tests: • Boston naming test (BNT)—short form • Selected subtests of the Boston diagnostic aphasia examination (BDAE) • Arizona battery for communication disorders of dementia (ABCD) • Detroit test of learning aptitude (DTLA) • Scales of cognitive ability for TBI (SCATBI) • Canadian adult achievement test (CAAT) • Protocole Montréal d’évaluation de la communication (MEC) There were no swallowing or hearing problems reported or observed Her voice quality was good, and there were no significant motor speech deficits noted Auditory comprehension: She missed a simple reasoning question and also did not understand inferential information from a short story (BDAE) Her score on the immediate recall in a story-telling subtest (ABCD) was poor, and she could not mention any of the elements of the story during a delayed recall She correctly explained verbal absurdities, except for one of six items (DTLA) Oral expression: Performance for confrontation naming on the BNT was adequate She obtained 11/13 on orientation questions from the mental status subtest of the ABCD, missing the current year and her age Semantic category naming (semantic verbal fluency) was below average for her age and level of education, whereas letter-category naming (lexical verbal fluency) was poor Procedural discourse for the recall task steps subtest of the SCATBI was accurate However, narrative discourse for the description of a sequential picture story with six images, although accurate, failed to include all salient details, and the patient omitted one image completely In spontaneous conversation, the patient adequately understood concrete information, but instructions for testing were needed to be repeated sometimes The discourse checklist of the MEC revealed that the patient was generally able to express her needs and discuss simple hospital-related topics adequately However, the content tended to reflect poor recall and occasional word-finding problems A mildly decreased verbal initiative was also noted as compared with norms Reading comprehension: The patient correctly answered all questions about a functional reading text of the reading comprehension subtest of the CAAT (grade 7 to 10 level), but she had significant difficulty for descriptive texts of a higher level, where she had difficulty in understanding and recalling the information read Chapter twenty three: Complex case studies 445 Clinical conclusions: Mrs H is present with moderate to severe cognitive-communication deficits in auditory recall, whereas moderate problems were noted in reading comprehension and organization of narrative discourse In addition, mild problems were found for verbal reasoning and production of conversational discourse She senses changes in cognitive functioning without being able to identify what problems are there and does not fully appreciate the impact on return to work Thus, a referral to a specialized in-patient rehabilitation center is recommended with intervention in speech-language pathology to improve cognitive-communication skills for optimal home and community reintegration Results of the brief neuropsychological assessment Administered Tests: • Clock drawing • Digit span (Wechsler adult intelligence scale IV) • Frontal assessment battery (FAB) • Gavelston orientation and amnesia test (GOAT) • Mental control (Wechsler memory scale III) • Similarities (Wechsler adult intelligence scale IV) • Trail-making test A and B • Repeatable battery for assessment of neuropsychological status (RBANS-A) Language: Oral comprehension is preserved Spontaneous discourse is coherent No word-finding difficulties are noted, but the denomination task (RBANS) is poor and reveals trouble with lexical access as the patient produces two semantic paraphasias (e.g., bugle for trumpet) Attention and working memory: Auditory selective attention is in the average range due to fluctuations in her performance because the length of the span is excellent (digit span forward = 9, RBANS-A) Moreover, Mrs H recites and manipulates overlearned information (e.g., reciting days of the week forward and backward, mental control— WMS-III) easily, and processing speed is adequate Working memory, without bonus points for speed, is in the high average range (digit span backward = 8, WAIS-IV), but some fluctuations are also noted Psychomotor speed is in the low average range as measured by the coding subtest (RBANS-A), in which the patient must write the right number associated with the right symbol As for visual selective attention, her performance was normal for time of completion on the trail-making test A, and she did not make any mistakes Although sustained attention was not formally assessed, Mrs H tolerated mental effort well, and the assessment was done in one session Overall, attentional abilities are characterized by a mild weakness in psychomotor speed and fluctuation in maintaining and manipulating verbal information Visuoperceptual and visuoconstructive abilities: The ability to recognize images during a denomination task is normal and does not attest to any visual agnosia However, a line orientation task (RBANS) reveals a performance in the low average range for visual analysis Furthermore, the copy of a geometric figure (RBANS) is in the borderline range The clock drawing test where the patient needs to draw a clock with all the numbers and the hands indicates 11:10 She produced many errors in organizing her numbers, and perseverations are observed She was also doing these tasks impulsively, which was detrimental to her score Learning and memory: Concerning verbal memory, Mrs H.’s learning curve of a 10-word list presented four times (RBANS-A) was somewhat weak (5–6/0 to 6–7/10) Moreover, 446 Sports Concussions the total amount of words recalled was in the low average range She cannot recall any of these words during the delayed recall and the recognition task is also poor, although she does not produce any false positive Mrs H also has trouble recalling a short story (RBANS) both at the immediate recall and the delayed recall However, she obtained an almost perfect score at the GOAT, which suggests that she is oriented in person, time, and place As for visual memory, her delayed recall is very poor that the patient is not reproducing any details, other than the figure’s contour Thus, a consolidation and retrieval of information deficits are observed, somewhat modulated by the patient’s performance anxiety, especially during the delayed recalls Executive functions: Frontal efficiency, as assessed by the FAB, is poor Verbal fluency under a semantic constraint (RBANS-A) was poor, given her age, whereas verbal fluency under a lexical constraint (FAB) was in the borderline range Performances to the inhibition and inhibitory control tasks (FAB) were normal She easily replicated the Luria motor sequence (FAB) while mirroring the assessor, but she could not maintain it alone However, she did not show any prehension behavior (FAB) Concerning mental flexibility, her performance on a task in which she must link in order and by switching two overlearned sets (trail making test B) was poor, and she made two sequencing mistakes Finally, her score on the similarities subtest (WAIS-IV), which measures verbal abstraction abilities, was in the low average range Consequently, a weakness in lexico-semantic access is noted, and trouble in maintaining motor programming, mental rigidity, and a somewhat concrete thinking pattern are noted Index Note: Page numbers followed by f and t refer to figures and tables respectively F-fluorodeoxyglucose (FDG), 389 18 A AAN (American Academy of Neurology), 20 AAP (American Academy of Pediatrics), 243, 246 ABCD (Arizona battery for communication disorders of dementia), 444 ABCDE assessment strategy, 347 Academic liaison role, 248 Academic management plan, 251–252 Academic monitoring tool, 259 Academic program monitor, 247 ACE See Acute concussion evaluation (ACE) Active treatment group, 134 Activity modification technique, 211 Activity plans, clinical practice, 140–141 Acute cognitive testing, 177 Acute concussion evaluation (ACE), 250 gradual return to school guide, 256 return to school letter, 255 Acute evaluation, RTP, 289–290 Acute period post-injury, 175, 177–181 assessment and management role, 178–180 interventions, 180–181 symptoms and neuropsychological effects, 175, 177–178 Acute phase post-injury, 431, 432f Adjustment disorder, 228 Advanced trauma life support (ATLS) program, 347 Aegrotat standing, 211 Aging process, 318 All-or-nothing behavior, 134 Alpha-II SBDPs, 367 Alpha waves, 417 American Academy of Neurology (AAN), 20 American Academy of Pediatrics (AAP), 243, 246 American football, 26, 30 Amyloid precursor protein (APP), 318 ANAM (Automated Neuropsychological Assessment Metrics), 338–339 Andrew, rugby player, 436 clinic initial assessment, 436 phone follow-up, 436 visiting clinic, 436–437 Anxiety disorders, 226–227, 231 APP (amyloid precursor protein), 318 Arizona battery for communication disorders of dementia (ABCD), 444 Arterial spin labeling (ASL), 386 Assessment of concussion, 348 athlete volunteering symptoms, 348–349 locations, 355–356, 356t methods, 350–351 assessment of symptoms, 351–352 mental status and neurocognitive testing, 352 physical examination, 352–353 questions, 351 situation, 353 final evaluation, 354 follow-up evaluation, 353–354 initial evaluation, 353 spotters and sideline video review, 349–350, 350t tools, 337–338 clinical reaction time test See Ruler-drop test KD test, 338 SAC, 337 SCAT5, 337–338 Astroglial injury, biomarkers GFAP, 365–366 S100β, 365 ATLS (advanced trauma life support) program, 347 Audience response system, 18 Australian Football League (AFL), 30 Automated Neuropsychological Assessment Metrics (ANAM), 338–339 Axon, 339 Axonal injury, biomarkers alpha-II SBDPs, 367 tau protein, 367–368 447 448 B Balance Error Scoring System (BESS), 340, 352 Balance/postural stability and visual system, 335, 340 Baseball, 30–31, 93–94, 100 Baseline data, 351 Baseline evaluation, 288–289 acute evaluation, 289–290 post-injury evaluation, 290 Baseline model, 332–333 balance/postural stability and visual system, 335 baseline test administration recommendations, 336–337 limitations, 335–336 measures in balance/postural stability, 340 computerized neuropsychological tests, 338–339 concussion assessment tools, 337–338 self-reported symptoms, 339–340 neuropsychological assessment, 333–334 overview, 331–332 ratings, 334 self-reported symptoms, 334 Baseline test administration, 336–337 Basketball, 31 BDAE (Boston diagnostic aphasia examination), 444 BDNF (brain-derived neurotrophic factor), 291, 306 Behavioral problems, post-mTBI, 229 Benign paroxysmal positional vertigo (BPPV), 161–162 Berlin, CISG guidelines, 17–18 BESS (Balance Error Scoring System), 340, 352 Beta-amyloid (Aβ), 318 Beta waves, 417 Biomarkers acute TBI, 363–364 features, 364 astroglial injury GFAP, 365–366 S100β, 365 axonal injury alpha-II SBDPs, 367 tau protein, 367–368 brain injury for mTBI, 364–365 concussion, 119 neuronal injury NSE, 366 UCH-L1, 366–367 Biomechanics of sports concussion, 81–102 brain trauma, measurement, 99–102 FE models, 89–92 head injury predictors, 82–86, 85f impact compliance, 86–88 injury events and concussion risk, 92–96 kinematic and MPS values, 95t linear and rotational acceleration curves, 94f tissue trauma and brain injury, 96–99 Blood oxygen level-dependent (BOLD), 379–380, 383 Index Boston diagnostic aphasia examination (BDAE), 444 Boston naming test (BNT), 444 BPPV (Benign paroxysmal positional vertigo), 161–162 Brain 101 Concussion Playbook program, 246–247 Brain commotion, 11 Brain-derived neurotrophic factor (BDNF), 291, 306 Brain imaging tools, 266 BrainSTEPS program, 247–248 Brainwaves, 417–418 Built-in detectors, fNIRS, 385 C Canadian adult achievement test (CAAT), 444 Canadian CT Head Rule (CCHR), 118, 356 Canadian Occupational Performance Measure (COPM), 203–204 Canadian Pediatric Society (CPS), 243, 246 CanChild guidelines, 208 CBT (cognitive behavioral therapy), 184, 187 CDRs (Clinical decision rules), 356–357 Central vision component, 163 Cerebrospinal fluid (CSF), 98, 367–368 Cerebrum commotum, 11 Cervical spine, 164–165 Cervicogenic dizziness, 161 Cheerleading, 31–32 Child and adolescent development, 206–207 Child SCAT5, 288, 338 Chronic period post-injury, 185–188 Chronic phase, 433, 433f Chronic traumatic encephalopathy (CTE), 97–98, 186, 319–321 CISG See Concussion In Sport Group (CISG) Client-centered rehabilitation goals, 203–204 Clinical decision rules (CDRs), 356–357 Clinical neuropsychologists, 171–172 Clinical reaction time test See Ruler-drop test Clinic initial assessment, post-injury, 436 CMS (Colorado Medical Society), 286–287 CN-NINM See Cranial nerve noninvasive neuromodulation (CN-NINM) Cognitive behavioral therapy (CBT), 184, 187 Cognitive function, 205 Cognitive rest, 132 Colorado Medical Society (CMS), 286–287 Commotio cerebri See Brain commotion Computed tomography (CT) scan, 266–267, 317, 364–365 guidelines in adults, 118t in children and adolescents, 120t–121t need for head, 115, 117–119 Computerized neuropsychological tests, 338–339 ANAM, 338–339 Axon, 339 ImPACT, 339 Concise intervention plan, 271 Index Concussion assessment See Assessment of concussion consensus and agreement statements conferences/position statements report, 21 formal meetings, 14–18 organization and institutional guidelines, 19–21 sport-specific meetings, 18 defined, 133 diagnosis, 113–123, 116f, 117f discharge planning, 119–123 need for CT scan and other investigations, 117–119 prediction algorithm, 123 diffuse axonal injury, grading scales, 13t guidelines mTBI and persistent symptoms, 268, 274 pre-1974, 11–12 severity grading scales and, 12–14 incidence, 26 management See Management of concussion neuroinflammatory, 4–5 neurophysiology, nonpharmacological interventions, 304–307 aerobic exercise, 305–306 types of exercises, 306 overview, 3–5 pathophysiology, persisting symptoms, 315–318 prevention, 44, 44t coach education, 46 encouraging safe behaviors, 47 neck strength, 46–47 nutritional interventions, 47 primary, 44 protective equipment uses, 44–45 rule changes and enforcement, 45–46 secondary, 47–48 stages, 44t tertiary, 48 vision enhancement training, 47 risk factors, 40 intrinsic and extrinsic, 41t–43t rotational acceleration thresholds, 88t signs and symptoms, 114t targeted evaluation and active management approach, 20–21 Concussion In Sport Group (CISG), 11, 14, 287 conference at, guidelines, 14–18 Berlin, 17–18 Prague, 15–16 Vienna, 15 Zurich, 16–17 meeting, 14 Concussion Symptom Inventory (CSI), 339 Control image, ASL, 386 Conversion disorder, 229–230 449 COPM (Canadian Occupational Performance Measure), 203–204 CPS (Canadian Pediatric Society), 243 Cranial nerve noninvasive neuromodulation (CN-NINM), 422 procedure, 421–422 reviews, 422–423, 422f CSF (cerebrospinal fluid), 98, 367–368 CSI (Concussion Symptom Inventory), 339 CTE See Chronic traumatic encephalopathy (CTE) CT scan See Computed tomography (CT) scan Culture/language factors, RTP, 290 Curriculum modifications technique, 211 D Default mode network (DMN), 383–384 Delta waves, 417 Dementia disease, 318–319 Detroit test of learning aptitude (DTLA), 444 DHA (docosahexanoic acid) supplementation, 47 Diffusion tensor imaging (DTI), 98–99, 317, 377–378, 383–384 Diffusion-weighted imaging (DWI), 376–378 Disposition decisions, 356 emergency department, 356–358 Dizziness, 160 BPPV, 161–162 central vestibular disorders, 163 cervicogenic, 161 duration, 161 nature, 160 peripheral vestibular hypofunction, 162 VOR, 162 DMN (default mode network), 383–384 Docosahexanoic acid (DHA) supplementation, 47 Dorsolateral prefrontal cortex (DLPFC), 380, 414 DTI (diffusion tensor imaging), 98–99, 317, 377–378, 383–384 DTLA (Detroit test of learning aptitude), 444 DWI (diffusion-weighted imaging), 376–378 E Early management recommendations, 149–155 anticipatory guidance, 150–153 avoidance of reinjury, alcohol, recreational drugs, and driving, 152 expected recovery and return to activities, 150–151 high-risk pediatric and adult patients, prediction algorithm, 123 physical and cognitive rest, 153 positive behaviors to promote recovery, 151 overview, 149–150 pharmacological and nonpharmacological treatments, 153–155 fatigue and sleep disturbances, 154–155 headaches, 153–154 450 EDH (epidural hemorrhage), 356–357 Electroencephalogram (EEG), 317, 417 Electroencephalography (EEG), 386–388 EP, 387 ERP, 386–387 graph theory, 387 Emergency medical services (EMS), 346 Environment adaptation technique, 211 EP (Evoked potentials), 387 Epidural hemorrhage (EDH), 356–357 ERPs (Event-related potentials), 386–387 Error-related negativity (ERN), 387 ERT (extension rotation test), 165 Event-related fields (ERFs), 388 Event-related potentials (ERPs), 386–387 Evoked potentials (EP), 387 Extension rotation test (ERT), 165 Index H FA (fractional anisotropy), 377 FAB (Frontal assessment battery), 445–446 FFR (frequency-following response), 387 Field hockey, 32–33 Finite element (FE) models, 89–92, 91t fMRI (functional magnetic resonance imaging), 119, 379–383, 382f, 415 fNIRS (Functional near-infrared spectroscopy), 385 Fractional anisotropy (FA), 377 Frequency-following response (FFR), 387 Frontal assessment battery (FAB), 445–446 Functional magnetic resonance imaging (fMRI), 119, 379–383, 382f, 415 Functional near-infrared spectroscopy (fNIRS), 385 Functional neuroimaging, 379 ASL, 386 EEG, 386–388 fNIRS, 385 MEG, 388–389 MRS, 390–391, 390f, 390t neuroimaging and metabolomics, 389 PET, 389–390 rs-fMRI, 383–385, 384f task-based fMRI, 379–383 Hallpike–Dix test, 162 HDFT (High definition fiber tracking), 378 Head acceleration, 82 Head injury criterion (HIC), 83 Head injury predictors, 82–86, 85f Heads Up toolkit, 243 Health-care provider role, 248 Health risk management approach, 267 Helmet-to-helmet contact mechanism, 30 HIC (head injury criterion), 83 High definition fiber tracking (HDFT), 378 Historical perspective, consussion, 9–21 CISG guidelines, 14 formal consensus meetings, 14 guidelines 1974–2001, 12–14 2001-present, 14–21 pre-1974, 11–12 key elements, 10–11 organization and institutional guidelines, 19–21 overview, 9–10 position statements, 21 sport-specific meetings, 18 Horseback riding, 441–442 clinical observations, 442 The Dix–Hallpike test, 443 final discharge plan, 443 patient’s complaints, 442 reports and recommendations neuropsychological assessment result, 445–446 neurosurgery trauma assessment, 443 OT assessment, 443–444 physiotherapy assessment, 443 rehabilitation medicine assessment, 443 social work recommendation and intervention plan, 443 speech-language pathology assessment, 444–445 Hyperactivation (n-back), 380–381 Hypoactivation (Petrides task), 380–381 G I Gadd severity index (GSI), 83, 87 Gamma-frequency tACS, 419 Gamma waves, 417 Gavelston orientation and amnesia test (GOAT), 445 Glasgow Coma Scale (GCS) score, 364, 378 Glial fibrillary acidic protein (GFAP), 365–366 GOAT (Gavelston orientation and amnesia test), 445 Good old days bias, 316 Graph theory technique, 384, 387 GSI (Gadd severity index), 83, 87 Gymnastics, 33 Ice hockey, 18, 32–34, 86, 88, 99 ICF (International Classification of Functioning), 300–301, 300f, 301f, 304 Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), 179, 289, 339 Injury events and concussion risk, 92–96 Insulin-like growth factor (IGF), 291 Interdisciplinary rehabilitation program, 274 International Classification of Functioning (ICF), 300–301, 300f, 301f, 304 Intervention process, 276–277 F Index K Kinesiology, 275 King Devick (KD) test, 338 Knockout (KO), concussion in MMA, 35 L Lacrosse, 34–35 Lasers/light emitting diodes (LED), 385 Lightheadedness, 160 Loss of consciousness (LOC), 10, 81, 113–117, 131–133, 166, 181–183, 228, 242, 250, 286 Low-level laser light/LED light therapy (LLLD/LED therapy), 420 for neurologic conditions, 420–421 procedure, 420 for TBI, 421 M Machine learning method, 391–392, 392f, 392t Magnetic resonance imaging (MRI), 89, 266, 371, 376 Magnetic resonance spectroscopy (MRS), 390–391, 390f, 390t Magnetocencephalography (MEG), 388–389 ERFs/spectral analysis, 388 network based analyses, 388 Malingering/symptom exaggeration/noncredible effort, 228–229 Management of concussion in acute phase, 432f algorithm for, 434f in chronic phase, 433f consensus guidelines on sport, 174–175 on-field diagnosis and concussion assessment, 348–356 disposition, 356–358 initial assessment of injured athlete, 347–348 overview, 345–346 preseason and pre-event preparation and preparedness, 346 standardized concussion evaluation, 346–347 OT role in activity planning, 208–209 adaptation techniques, 211 approach, 203, 203f case study, 215–217 evaluation, 203–207 four P’s, 213 intervention, 207–208 overview, 201–203 prevention, 214 process, 207 rehabilitation, 214 research, 214–215 school planning, 209–214, 212f 451 psychologist and psychiatrist role in pediatric See also Psychological and mental health factors case study, 232–234 common difficulties, 225–230 definitions, 224–225 factors, 230–232 in subacute phase, 432f Manual spinal examination (MSE) test, 165 Mayo-Portland Adaptability Inventory–MPAI-4, 273 M-BESS (modified version of the balance error scoring system), 352–353 MEC (Protocole Montréal d′évaluation de la communication), 444 Medical/symptom monitor and liaison role, 247–248 MEG See Magnetocencephalography (MEG) Mild traumatic brain injury (mTBI), 10, 215, 241, 263, 268, 316 clinical complexity, 272t improving systems, 246–247 education and training, 247 policies and procedures, 246 neighborhood, care, 242–243 recovering, 272t school learning and performance, 243–246 school management pathway, 249, 249f components, 247–248 implementation, 249–253 in working-age adults, 264 Mixed martial arts (MMA), 35–36, 93 Modified version of the balance error scoring system (M-BESS), 352–353 Mood disorders, 165, 321–322, 378, 393 Mouthguards, fitting equipment, 44–45 MRI (magnetic resonance imaging), 89, 266, 371, 376 MRS See Magnetic resonance spectroscopy (MRS) MSE (manual spinal examination) test, 165 mTBI See Mild traumatic brain injury (mTBI) N N-acetylaspartate (NAA), 391 National Academy of Neuropsychology (NAN), 171 National athletic trainers’ association, 19 National Collaborative on Childhood Brain Injury (NCCBI), 246 National Federation of State High School Associations (NFHS), 32 National Football League (NFL), 30 National Operating Committee on Standards for Athletic Equipment (NOCSAE), 83 n-back task, 380 NCCBI (National Collaborative on Childhood Brain Injury), 246 Near-infrared light, 385 Neck pain and headaches, 164–166 452 Neurodegeneration multiple concussion, 319–320 single concussion, 318–319 Neurofilament light polypeptide (NFL), 99 Neuroimaging techniques, 317 in diagnosis, 391 machine learning, 391–392, 392f, 392t functional, 379 ASL, 386 EEG, 386–388 fNIRS, 385 MEG, 388–389 MRS, 390–391, 390f neuroimaging and metabolomics, 389 PET, 389–390 rs-fMRI, 383–385 task-based fMRI, 379–383 future directions, 394–396 high magnetic fields, 393 pediatrics, 393 sample variance, 393 structural, 376 DWI, 376–378 SWI, 378–379 and symptoms, discordance between, 394 Neuroinflammation, 319, 321, 363 Neurological injuries, 96 Neuronal injury, biomarkers NSE, 366 UCH-L1, 366–367 Neuronal network, 391, 392f Neuron specific enolase (NSE), 366 Neurophysiology, Neuropsychological assessment, 333–334, 439–440 administered tests, 445 attention and working memory, 441, 445 clinical observations, 440 executive functions, 441, 446 intellectual functioning estimate, 441 language, 441, 445 learning and memory, 441, 445–446 test in, 445 visuoperceptual and visuoconstructive abilities, 445 Neuropsychology, 171, 275 assessment, 172, 172t–174t overview, 171–174 roles, 174–175, 176f SRC, 175–188 Neurorehabilitation considerations, 321–322 Neurosurgery trauma assessment, 443 Neurotransmitter GABA, 390, 390f New Orleans Criteria (NOC), 118 NEXUS (National Emergency X-Radiography Utilization Study) criteria, 357 NFHS (National Federation of State High School Associations), 32 Index NOC (New Orleans Criteria), 118 NOCSAE (National Operating Committee on Standards for Athletic Equipment), 83 NSE (Neuron specific enolase), 366 Nutrition, 213 O Occupational therapy (OT), 201, 275 activity planning, 208–209 adaptation techniques, 211 approach, 203, 203f assessment cognitive-perceptual components, 444 functional assessment, 443 physical components, 444 case study, 215–217 evaluation child and adolescent development, 206–207 client-centered rehabilitation goals, development, 203–204 cognitive function, 205 exertion challenge, 204–205 mood, risk for depression/anxiety, 205–206 sensory challenges, 204 symptoms, 204 four P’s, 213 intervention, 207–208 overview, 201–203 prevention, 214 process, 207 rehabilitation, 214 research, 214–215 school planning, 209–214, 212f “Rest” and energy conservation, 212–214 Oculomotor system, 162–164 Ontario Neurotrauma Foundation (ONF), 117, 268, 274 Open-label trial, 415–416 OT See Occupational therapy (OT) Overlapping concussions, 133 P Palpation for segmental tenderness (PST) test, 165 Pathophysiology, Patrick, outdoor hockey player, 437 follow-up visit, 438 phone follow-up, 438 visiting clinic follow-up, 437 initial, 437 PCS (post-concussion syndrome), 315–317, 320 PCSI (Post-Concussion Symptom Inventory), 339 PCSS (Post-Concussion Symptom Scale), 339–340 Peak acceleration values, 95–96 Peripheral vision component, 163 Index Persistent problems, post-concussion in body functions, activities, and participation, 302–304 deficits observed and assessed, 303–304, 304t self-reported problems, 303, 303t body structures/pathophysiology symptoms, 302 nonpharmacological interventions, 304–307 aerobic exercise, 305–306 types of exercises, 306 overview, 299–302 PET (Positron emission tomography), 321, 389–390 The Petrides task, 381 Pharmacological and nonpharmacological treatments, 153 fatigue and sleep disturbances, 154–155 headaches, 153–154 Physical and cognitive rest, 153 Physical versus physiological recovery, 290–291 Physician, 275 Physiotherapy, 160 assessment, 443 dizziness, 160–163 BPPV, 161–162 central vestibular disorders, 163 cervicogenic, 161 duration, 161 nature, 160 peripheral vestibular hypofunction, 162 VOR, 162 neck pain and headaches, 164–166 visual impairments, 163–164 Placebo/sham stimulation procedure, 414 Portable neuromodulation stimulator (PoNS) device, 422–423 Positron emission tomography (PET), 321, 389–390 Post-Concussion Symptom Inventory (PCSI), 339 Post-Concussion Symptom Scale (PCSS), 339–340 Post-concussion syndrome (PCS), 315–317, 320 Post-injury evaluation, 290 Post-traumatic stress disorder (PTSD), 114, 227–228, 317 Prague, CISG guidelines, 15–16 Pre- and post-intervention social participation outcomes, 273, 273f Pre-/post-injury assessment model, 336 Preseason and pre-event preparation and preparedness, 346 Protocole Montréal d′évaluation de la communication (MEC), 444 Proton-MRS (1H-MRS), 390–391 PST (palpation for segmental tenderness) test, 165 Psychological and mental health factors, 224–234 common difficulties, 225–230 adjustment disorder, 228 anxiety disorders, 226–227 behavioral problems, 229 conversion disorder, 229–230 malingering/symptom exaggeration/ noncredible effort, 228–229 453 mood disorders, 225–226 PTSD, 227–228 definitions, 224–225 factors, 230–232 age, 230 family dynamics, 231 parental mental health, 231–232 personality traits, 230–231 sex, 230 subclinical mental health, 232 PTSD (Post-traumatic stress disorder), 114, 227–228, 317 R RBANS-A (Repeatable battery for assessment of neuropsychological status), 445–446 Recreational synchronized skater, 438 initial intake clinic, 438 neuropsychological assessment, 439–441 rehabilitation medicine assessment, 439 follow-up, 439–440 Relaxation training, 213 Remote effects of concussion, 318 neurodegeneration multiple concussion, 319–320 single concussion, 318–319 Repeatable battery for assessment of neuropsychological status (RBANS-A), 445–446 Repetitive transcranial magnetic stimulation (rTMS), 408 research on, 415 sham, 414 stimulation patterns, 408, 414 Rest and recovery from concussion, 131–141 contemporary clinical practice, 137–138 effects and activity restriction, 136–137 evidence, 133–136 evolution, 131–133 implementation, 139–141 knowledge-practice gap, 138–139 overview, 131 rationale treatment, 133 Resting-state functional MRI (rs-fMRI), 383–385, 384f Retinal slip component, 163 Return to play (RTP), 285 assessment, 288 baseline evaluation, 288–289 acute evaluation, 289–290 post-injury evaluation, 290 contemporary approaches, 287–288 culture/language factors, 290 historical approaches, 286–287 overview, 285–286 physical versus physiological recovery, 290–291 post-injury evaluation, 290 retirement, 292–293 role of exercise/active rehabilitation, 291–292 Return to school (RTS) protocol, 211–212 454 Return to work, 263–281 atypically recovering, specialized intervention, 270–274, 272t guiding interventions algorithm, 269f head injury mTBI in working-age adults, 264 prognostic models and outcomes, 265–267, 266t symptom and cognitive recovery, 265 planning and self-assessment tools, 280–281 practice guidelines, 268–270, 270t specialized interdisciplinary interventions, case study, 274–279 structured interventions framework, 270, 271t Rodeo, 36 Romberg test, 352 rs-fMRI (Resting-state functional MRI), 383–385, 384f rTMS See Repetitive transcranial magnetic stimulation (rTMS) RTP See Return to play (RTP) RTS (return to school) protocol, 211–212 Rugby league, 36–37 Rugby sevens, 37 Rugby union, 37–38 Ruler-drop test, 338 S S100β protein, 365 SAC See Standardized Assessment of Concussion (SAC) SAH (subarachnoid hemorrhage), 356 SBDPs (spectrin breakdown products), 367 Scales of cognitive ability for TBI (SCATBI), 444 SCAT (sport concussion assessment tool), 178, 288, 351–352 SCAT5 (Sport Concussion Assessment Tool-5), 288–289, 337–338 SCC (semicircular canal), 161 School mTBI management pathway, 249, 249f components, 247–248 health-care provider role, 248 school personnel role, 248 implementation, 249–253 academic management plan, 251–252 full academic participation, recovery/return, 253 health-care provider communication/return to school letter, 250–251 notification, 250 progress monitoring, 252–253 return to school, 252 SDH (subdural hemorrhage), 86, 356 Self-management tools, 213–214 Self-reported pattern, 134 Self-reported symptoms, 334, 339–340 CSI, 339 PCSI, 339 PCSS, 339–340 Semicircular canal (SCC), 161 Index Sham-controlled trial, 414–415 Sham rTMS, 414 Sham stimulation procedure, 416 Shoulder charge, 37 Single-photon emission computed tomography (SPECT), 389 Skull fracture, 82–83, 102, 149, 365, 376 Sleep hygiene, 213 Soccer, 38–39, 39f, 90, 100, 352 Softball, 39–40 SORT (strength of recommendation taxonomy), 19–20 Spectrin breakdown products (SBDPs), 367 Speech-language pathology assessment auditory comprehension, 444 oral expression, 444 reading comprehension, 444 test in, 444 Sport concussion assessment test (SCAT), 178, 288, 351–352 Sport Concussion Assessment Tool-5 (SCAT5), 288–289, 337–338 Sport-related concussion (SRC), 11, 174–175, 243, 285–286 neuropsychological care, 175 acute period post-injury, 175, 177–181 chronic period post-injury, 185–188 subacute period post-injury, 181–185 Sports Neuropsychology Society, 175 STAMP (symptom-targeted academic management plan), 251–252, 257 Standardized Assessment of Concussion (SAC), 115, 177, 337, 351 Standardized concussion evaluation, 346–347 Strength of recommendation taxonomy (SORT), 19–20 Structural neuroimaging, 376 DWI, 376–378 SWI, 378–379 Subacute period post-injury, 181–185 assessment and management, 182–184 interventions, 184–185 symptoms and neuropsychological effects, 181–182 Subacute phase, 431, 432f Subarachnoid hemorrhage (SAH), 86, 356 Subdural hematoma, 83 Subdural hemorrhage (SDH), 356 Susceptibility weighted imaging (SWI), 378–379 Symptom monitoring log, 258 Symptom/performance validity, 316 Symptom-targeted academic management plan (STAMP), 251–252, 257 T tACS See Transcranial alternating current stimulation (tACS) Tactile Communication and Neurorehabilitation Lab (TCNL), 422 Tag image (or flow image), ASL, 386 Index Take CARe (Concussion Assessment and Recovery Research), 224–225, 227, 231 Task-based fMRI, 379–383 Tau protein, 367–368 TBI See Traumatic brain injury (TBI) tDCS See Transcranial direct current stimulation (tDCS) Technical knockout (TKO), 35–36 Thalamus, 383, 386, 389 Theta waves, 417 TIPC (trauma-induced protein changes), 96–97 Tissue magnetic susceptibility, 378 Tissue trauma and brain injury, 96–99 TKO (technical knockout), 35–36 TMS See Transcranial magnetic stimulation (TMS) Total tau (T-Tau), 368 Tractography, 377 Transcranial alternating current stimulation (tACS), 417 gamma-frequency, 419 in healthy human brain, 418–419 in neurologic conditions, 419–420 procedure, 417–418 stimulation frequency, 418 treatment of TBI, 420 Transcranial direct current stimulation (tDCS), 408, 416 in TBI effects, 412t–413t, 416–417 procedure, 416 research on, 417 Transcranial light therapy, 420–421, 423 Transcranial magnetic stimulation (TMS), 408 procedure, 408, 414 research on rTMS, 415 on TBI, repetitive effects of, 414–415 Transcranial random noise stimulation (tRNS), 420 Translocator protein (TSPO), 389 Trauma-induced protein changes (TIPC), 96–97 Traumatic brain injury (TBI), 83, 241–242, 363, 408 biomarker, 364 455 LLLD/LED therapy, 421 tACS for treatment, 420 tDCS studies in, 416–417 in TMS, 409t–411t effects of, 414–415 tRNS (Transcranial random noise stimulation), 420 TSPO (translocator protein), 389 U Ubiquitin C-terminal Hydrolase-L1 (UCH-L1), 366–367 United Fighting League (UFC), 35 V Vascular endothelial growth factor (VEGF), 291 Vertigo symptom, 160 Vestibular rehabilitation, 163 Vestibulo-ocular reflex (VOR), 162 Vienna, CISG guidelines, 15 Visible signs (VS), 349, 350t Vision therapy, 164 Visual impairments, 163–164 oculomotor system, 164 perception, 164 Visuoperceptual and visuoconstructive abilities, 445 Volleyball, 40 W Wayne state tolerance curve (WSTC), 83, 86 White matter tract, 377–378, 377f Working memory task, 380–381 Wrestling, 40 Z Zurich, CISG guidelines, 16–17 .. .Sports Concussions A Complete Guide to Recovery and Management Sports Concussions A Complete Guide to Recovery and Management Edited... sports concussion: How sport concussions happen? 81 Blaine Hoshizaki, Anna Oeur, Andrew Post, David Koncan, Marshall Kendall, Clara Karton, and Philippe Rousseau Chapter Acute diagnosis of sports. .. Chronic Traumatic Sports Concussions Encephalopathy (Jordan et al 1995; McKee et al 2009; see also the review by Seifert and Shipman (2015) on the pathophysiology of sport-related concussions) Neurophysiologically,

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