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From PEKN 1P93 Winter 2014: Group 06: Cognitive Development, Concussions
A concussion is a mild brain injury which results in temporary loss of brain function. Concussion is a term derived from the Latin words concutere or concussus, respectively meaning "to shake violently", or "action of striking together". Concussions are usually brought on because of a blow to the head. The actual cause of a concussion is rapid shaking of the brain inside the containment of the skull. The brain bounces of the inner walls of the skull. This trauma can lead to various physical, cognitive, and emotional symptoms. Symptoms can sometimes go undetected when a concussion takes place. An important fact to know about receiving a concussion is that the victim does not necessarily need to go unconscious for concussion to be sustained.(Kissick, 2005). This is a common misconception among the sporting world which leads to ignorance of a serious, and potentially fatal injury. If regular physical activity is continued with an unknown concussion, serious, long-lasting repercussions may develop.
The following video gives a brief overview of a concussion, its symptoms and how to act upon it. It reiterates the importance of the three "R's" (recognize, report and rest), moreover, it provides additional information on future implications if left untreated
Concussions are currently the most common mild traumatic brain injury among the world. Current data estimates the incidences of concussion to be about 3.8 million annual cases in the U.S. alone. As concussion awareness becomes more popular, the amount of reported concussions are increasing, which suggests this number is even higher (Harmon,et Al. 2013). Due to these rising numbers of occurrences, concussions have become a hot topic among society, especially in regards to sport. The reason that concussions are such a detrimental injury is because of the large potential for various long lasting effects.
Concussion symptoms include various forms of cognitive related problems. Symptoms vary for each patient, and also change day to day. The early symptoms of a concussion include vertigo, dizziness, and imbalance (Gurley, et Al. 2013). Patients may also exhibit loss of focus, as well as taking more time than usual to understand information. These symptoms usually last for several weeks before they subside, however sometimes these symptoms do not go away, and further complications arise. Concussions cause physiological and metabolic changes within the body, not only within the brain, but consequentially to other organs and systems. This is the reason for the negative symptoms associated with concussions. When at least three of these symptoms persist for an extended period of time, the ailment becomes known as Post-Concussion Syndrome (PCS) ( Leddya, et Al. 2007).
Concussions from sports are becoming a large problem, for athletes in later years. As this has become a hot topic for health research in recent years, it has been discovered that multiple concussions throughout an athletes career are effecting his/her motor skills and cognitive function later on in life. Studies on former university-level athletes who had sustained concussions suggest that brain performance is impaired permanently due to concussions at a young age. It was found that sequence specific learning, as well as motor sequence learning was negatively affected by concussions when compared with the test results from subjects who had no history of concussions. Furthermore, it shows that as the number of concussions increase, the level of permanent brain impairment also increases (Beaumont, Tremblay, Henry, Poirier, Lassonde, Théoret, 2013). This discovery has lead to a movement towards concussion awareness in sports for youth and adults.
Concussions have only recently received much attention in sports. In past years the ability to identify and treat concussions of varying degrees was sub-par and as a result, many athletes suffered. Not only this, but there was, and to a point still is, a stigma around concussions in relation to toughness. Because of these factors, concussions and the treatment of them was not as high of a concern.
Concussions are not diagnosed with a strict set of symptoms, rather a scale with varying degrees. In the times of sport before medical technology, concussions were diagnosed purely on observation of an individual doctor. In more recent times concussions are diagnosed with a series of computerized and clinical tests (McCrae, Guskiewicz & Marshall, 2003). Because these tests were not around in the mid-late 20th century concussions were difficult to be properly diagnosed and athletes would then play before their brain was ready for it.
The attitude of sports like football and hockey are tough and encourage athletes to play through pain. This resulted in players hiding injuries and coaches expecting players to play through injury. Old school athletes considered ‘getting your bell rung’ something that passes quickly and is gone. However, research has shown that every time you feel the symptoms of having your bell rung you are actually suffering a minor concussion (McCrae, Guskiewicz & Marshall, 2003). Retired football players were tested for brain function and it was found that those who suffered several concussions were at a higher risk for dementia related syndromes because of ignored brain injuries during their careers (Guskiewicz, Marshall, Bailes & McCrae, 2005).
A lack of treatment for concussions used to be a serious problem. In 1980, suggested treatment for a patient who experienced a mild concussion was to give “information, explanation, and encouragement” (Minderhoud, Boelens, Huizenga & Saan, 1980). No part of the treatment for a concussion included a rest period with no physical activity. Once it was more universally known that rest was needed, activity was used as a tool to speed recovery once you rested for enough time for your brain to heal (Mittenberg & Burton, 1994).
Activity and sport can be beneficial in the recovery from a concussion, but only recently have we learned when this point is and the appropriate way to ease back in. In the past, activity was used to soon with little or no rest after a concussion and as a result players experienced negative long term effects and improper cognitive development.
 Target Audience
Concussions are a very serious injury and can occur at any moment in life, just at the snap of a finger. More specifically concussions can occur to any male or female at any given age. However the target audience for cognitive development relating to concussions would be adolescents, students or professional athletes due to the constant physical contact during sports or physical activities. Pellman (2004), stated that through 1996 to 2001 there was 787 game-related cases of concussions in the NFL due to the physical contact among players, 67.7% because of helmet on helmet contact.
As kids get older and bigger, the physical contact becomes much stronger as competition and competitiveness increases. Particularly high school students is where concussions mostly start to occur as kids compete harder and the physical contact increases. It doesn't help that many sports these days include physical contact such as hockey and football. A study showed that out of 183 high school students, 54 were diagnosed with concussion like symptoms due to sport activities (Field, 2002). It also explained that high school students take a longer time to recover from concussions as the consequences and symptoms from concussions at this age can be very serious and lead to improper cognitive development (Field, 2002).
Boriboon (2013) stated, more then 5-10% of athletes will experience a concussion in any given sport. Many major sports leagues have made started to make the effects of concussions aware and have helped change the way many sport coaches and athletes think about concussions and the risks. Many retired football players from the NFL now are faced with side effects of having to many concussions. The NFL made a new rule, the "madden rule" which makes it so if any player is suspected of a concussion they must be removed from play and off the field and escorted to the locker room where they will be examined by the trainer or paramedics (Smith, 2011). http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?sid=f11a8e6f-641d-414c-8884-ab51dca10486%40sessionmgr114&vid=15&hid=109
Rest is proven to be the best form of treatment to help recover from a concussion, proven in an experiment done by (Moser, et Al. 2012). High school students and collegiate athletes went through post- concussion assessments and cognitive tests before and after the rest period, 1-31 plus days. The athletes were showing great improvement, as the study showed that cognitive and physical rest is a useful way of treating concussion symptoms, which worked faster primarily right after a concussion but still could help reduce symptoms weeks or months later. http://journals1.scholarsportal.info/pdf/00223476/v161i0005/922_eoiadcrftosc.xml
Chronic Traumatic Encephalopathy is a brain disease that can occur after having multiple concussions. In recent studies, it is said that CTE has many of the same side effects that a concussion would have, such as decline of memory, depression, poor impulse control and improper cognitive development (Stern, et Al. 2011). After findings of connection of Chronic Traumatic Encephalopathy a brain disease caused by concussions was found in a NFL players and high school football players the awareness on concussion prevention has never been more important Moser, Schatz (2012).http://www.ncbi.nlm.nih.gov/pubmed/22035690
Many traumatic brain injuries are due from recreational activates. Sport-related concussions (SRC) are a health issue for children and schools because of it there has been more caution while playing spots and recreational activates. The Concussion in Sport Group emphasized the cautions and what could happen when the children return to the playing field. Athletes after SRC are more sensitive and have to be more careful while playing sports and should wait till they are fully recovered to return. Zuckerman, Scott, Young, Mitchell, Odom, Gary, Solomon, Jonathan, Forbes, Allen (2012) performed the study on young adults athletes who experienced SRC, they where put into two age categories and completed a baseline and post concussion test. In Result, the younger ages of the two categories of athlete’s baseline were greater than the older age athletes. Therefore, the results show younger athletes with SCR take longer to recover.http://eds.a.ebscohost.com/eds/detail?vid=8&sid=4ff10d9c-9c74-4590-87af-f28f802cef26%40sessionmgr4005&hid=4103&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=a9h&AN=83406201
Beaumont et Al. (2013), conducted a test that will prove that age and remote concussion will induce functional and metabolic alterations of the motor system. Former university athletes were selected for the experiment between ages of 51-75. Results showed that the participants who were older and had more concussions showed reduced glutamate/H2O ratio, which correlated with motor learning skills (Beaumont et al. 2013). The results showed that concussion in the long-term result in declining test results. Therefore having multiple of concussions through out your life can have a drastic effect as you age.http://www.biomedcentral.com/1471-2377/13/109
 Existing Physical Activity Programs
 Shift Concussion Management Program
Shift Concussion Management (SCM) strives to provide the best possible care for athletes, whether it be injury management, concussion education, pre-season testing, or general support. First -rate therapists recognize the complex needs of patients and work hard to help them return safely to sport, school and most importantly, daily life activities. SCM is the only clinic to carry the "Clinical Accreditation Program", a specific post-injury assessment and rehabilitation program.Additionally, the program offers concussion management training, clinical support, and training workshops. http://www.shiftconcussion.ca
 Accelerated Rehabilitation Centres
Accelerated Physical Therapy is one of the leading methods of concussion diagnosis and management for all athletes, various ages ranging from from youth to adults. According to researchers at the centre, more than 3.8 million athletes are expected to sustain concussions this year alone, as well as more than one million youth. There is a dedicated concussion management program in place, led by Paul Schroed and Tim Rylander, both specially trained physical therapists. The two types of concussed athletes that the program focuses on are asymptomatic (seeking a return-to-play protocol)and symtptomatic (those with symptoms after three weeks).Each patient receives his or her own customized protocol based on condition and symptoms. Depending on the patient's evaluation, therapists may use one of three techniques for treatment: Manual Therapy,Vestibular Rehabilitation Exercises or Neuromuscular Re-education Strategies. ImPACT tests are given to patients once they are able to show that they are symptom free. http://acceleratedrehab.com/index.cfm
In the following video, trained physical therapist Tim Rylander from Accelerated Rehabilitation Centres addresses symptoms that someone with a concussion may face. He also talks about concussion prevention and the importance of wearing a helmet.
 NeuroKinetics Health Services
NeuroKinetics Health Services allows patients to Restore and preserve their functional capacity and stay relatively active during the course of treatment. After a few weeks of treatment, patients were cleared for return to play and back to their sporting activities, and soon enough to be against all medical expectation. After a three step assessment, specific non-invasive stimulations can be designed to reset and support the patient's brain's own healing mechanisms so you can feel and function better faster. Often, the rapid functional recovery allows safe, speedy return to play and fully restored performance. http://www.neurokinetics.com
 SVA Concussion Clinic
The SVA Concussion Clinic provides collaborative assessment, diagnosis, and treatment of both concussions and treatment of mild traumatic brain injury, as well as post-concussive syndrome in children, teens, adults and seniors. Services include psychology, neurology, and neuropsychology. The psychology service uses science theory as well as clinical knowledge in order to understand and prevent psychologically-based distress. Psychologists have expertise in cognitive functions,brain injury and developmental abilities of the patient. Neuropsychologists are professional psychologists who perform tasks such as diagnosing brain disorders, and offering psychological treatment to those with brain damage. http://www.svapsych.ca/index.html
 Think First
Think First is a national non-profit organization dedicated to the prevention of brain and spinal chord injury. The program teaches children and youth how to participate in activities that they enjoy while remaining safe. In 2004 Think First Canada had more than fifteen experts combine ideas and thoughts to create a concussion education resource. In order to get the information into the hands of worried parents, the committee provided the expert advice on the Think First website, as well as participating in workshops and seminars across Canada. Through this process, they have been able to greatly diminish the number of traumatic brain and spinal chord injuries in Canadian children. http://www.thinkfirst.ca/index.aspx
One of the ways Think First has advocated to prevent brain and spinal chord injury is the promotion of a "Smart Hockey" program. Smart Hockey is a program that Think First offers to young Canadians, teaching them how to play the game of hockey in an appropriate and safe manner, which ultimately limits the risk of any type of injury. The following video addresses what is dangerous on ice, led by Olympic Gold Medalist, Tessa Bonhomme. She further breaks down how to keep the most important part of the body (our brain), safer every time, through 12 quick on-ice tips:
 Best Practice Activity Suggestions
When recovering from a concussion it is quintessential that the patient follows some form of a gradual return-to-play guide. It is essential to abstain from any form of physical activity until the patient experiences no apparent symptoms. At this point, Lear (2012), states that physical activity should be added to the patients routine in stages, starting with light aerobic activity, and ending with full game activity.
Yoga is an activity which is great for concussion rehabilitation. It is very light aerobic activity with components of muscle strain, balance, breathing, and focus. Regaining balance is an important factor when recovering from a concussion. Yoga will help to practice these abilities in a low risk situation.
 Stress Reduction
Another key factor in recovering from any injury, especially concussions, is to reduce the amount of stress in one's life on a daily basis. Stress will only make symptoms worse and will put a further strain on the whole body (Burke, 2009). A healthy body environment is one with low stress, as it allows optimal hormone levels and proper bodily function. An excellent way to reduce stress is to participate in yoga.
Sleep is important for proper bodily function, and is detrimental in determining how recovery takes place. Sleeping is the time when the body does the majority of it's physical and mental recovering. Also, a regular and adequate sleeping schedule will reduce a person's stress, by optimizing their level of cortisol (NSF, 2010). As mentioned above, stress is one of the key factors on the road to recovery from a concussion.
The last factor to a speedy recovery from a concussion is a healthy diet. Proper nutrition will contribute to the patients ability to exercise and sleep. Furthermore, a diet consisting of an appropriate amount of unsaturated fats will contribute to optimal brain function. Proper brain function is the ultimate goal of a recover guide for a concussion.
The best way to participate in light aerobic activity is to simply go for a walk outside. This is ideal as it is low impact, low strain,and gives the patient some fresh air.
This video shows a physical activity developed to increase the speed of recovery after contracting a concussion.
 Future Directions
Sport related concussion has become an area of great concern, such that it surpasses all other sport injuries. According to McCrory (2011), "there is increasing engagement by mainstream neuroscientists in this field, which had previously been dominated by sports team physicians" this has allowed for more in depth research on the subject. In recent years due to public health initiatives, as well as legislation, there has been an ever growing recognition of sports related concussions. There has been a five-fold increase in the number of youth-athletes presenting for concussion at medical centers Dessy (2014). Due to the human brain's complexity, there are many variables to consider. In order to better recognize and correct concussions, scientists are assessing a greater number of variables. These variables include, but are not limited to gender, age, fitness level, test setting, learning disability, and medical history.
 External Links
Links to organizations who are raising awareness about concussions are listed below:
1. Think First http://www.thinkfirst.ca/index.aspx
2. Coaching Association of Canada http://www.coach.ca/concussion-awareness-s16361
4. Centres for Disease Control and Prevention http://www.cdc.gov/concussion/headsup/online_training.html
5. Stop Concussions Foundation http://www.stopconcussions.com/
 Changemakers Initiative
Austin, Brayden, Greg, Kurtis, and Sean have created an idea to make Canada healthier and have submitted it to the Changemakers Initiative website. The link to the idea is listed here: http://www.changemakers.com/project/healthy-eating-initiative
 Notes and References
Beaumont, L., Tremblay, S., Henry, L., Poirier, J., Lassonde, M., Théoret, H., (2013). Motor. System Alterations in Retired Former Athletes: The Role of Aging and Concussion History BMC Neurology. 13: 109. Retrieved from http://www.biomedcentral.com/1471-2377/13/109
Boriboon, K. (2013). Concussion Management In Football: Don’t Shake It Off. PT in motion, 5(1), 18-25.
Burke, H. (2009). Brain Injury: Traumatic Brain Injury; Post Concussion Syndrome Rehabilitation and Treatment. Brain Therapy Centre. Retrieved from http://www.brain-injury-therapy.com/articles/brain_injury.htm
Dessy, A. (2014). A review of modifying factors affecting usage of diagnostic rating scales in concussion management. Ichan School of Medicine: New York.
Field, Melvin., et Al. (2003). Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. The Journal of Pediatrics, 142(5), 546-553.
Gurley, J., Hujsak, B., Kelly., J., (2013). Vestibular Rehabilitation Following Mild Traumatic Brain Injury. IOS Press, NeuroRehabilitation (32), pp. 519-528. Retrieved from http://ejournals.ebsco.com/Direct.asp? AccessToken=6V2XLL989VKIZF9JKFKNZ93J9ZKI82KC9&Show=Object
Guskiewicz, K., Marshall, S., Bailes, J., & McCrae, M. (2005). Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Congress of Neurological Surgeons, 57(4), 719-726.
Harmon, K., Drezner, J., Gammons, M., Guskiewicz, K., Halstead, M., Herring, S., Kutcher, J., Pana, A., Putukian, M., Roberts, W., (2013). American Medical Society for Sports Medicine Position Statement: Concussion in Sport. BR J Sports Med. (47) p. 3. Retrieved From http://bjsm.bmj.com/content/47/1/15.full.pdf+html
Kissick, J., (2005). New Concussion Management Guidelines: Concussion Question and Answer Document for Physicians. Retrieved from http://www.thinkfirst.ca/downloads/concussion/concussion-Q%20and%20A%20physicians.pdf
Lear, A.M., (2012). Sports concussion: A return-to-play guide. The Journal of Family Practice. Retrieved from http://web.b.ebscohost.com.proxy.library.brocku.ca/ehost/pdfviewer/pdfviewer?sid=ec5d68b1-8183-4fd3-8c7f-62da1f03d9e3%40sessionmgr112&vid=2&hid=114
Leddya, J., Kozlowskib, K., Funga, M., Pendergasta, D., Willera, B., (2007). Regulatory and Autoregulatory Physiological Dysfunction as a Primary Characteristic of Post Concussion Syndrome: Implications for Treatment. IOS Press, NeurRehabilitation. (22) pp. 199-205.
McCrae, M., Guskiewicz, K., & Marshall, S. (2003). Acute effects and recovery time following concussion in collegiate football players. The Journal of the American Medical Association, 290(19).
McCrory, P. (2011). Future advances and areas of future focus in the treatment of sport-related concussion. Clin Sports Med, 30 (1), 201.
Minderhoud, J., Boelens, M., Huizenga, J., & Saan, R. (1980). Treatment of minor head injuries. 82(2), 127-140.
Mittenberg, W., & Burton, D. (1994). A survey of treatments for post-concussion syndrome. Informa Healthcare, 8(5), 429-437.
Moser, R., Glatts, C., & Schatz, P. (2012). Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. The Journal Of Pediatrics, 161(5), 922-926. doi:10.1016/j.jpeds.2012.04.012
Moser RS and Schatz P(2012) A Case for Mental and Physical Rest in Youth Sports Concussion: It’s Never Too Late. Front. Neur. 3:171. doi:10.3389/fneur .2012.00171
NSF, (2010). Sleep, Athletic Performance, and Recovery. National Sleep Foundation. Retrieved from http://sleepfoundation.org/sleep-news/sleep-athletic-performance-and-recovery
Pellman, Elliot., et Al. (2004). Concussion in Professional Football: Epidemiological Features of Game Injuries and Review of the Literature—Part 3. Neurosurgery, 54 (1), Pages 81-96, DOI: 10.1227/01.NEU.0000097267.54786.54
Smith, M. (2011). NFL to teams: Pull players if you even suspect a concussion. Retrieved March 22, 2014 From http://profootballtalk.nbcsports.com/2011/09/01/nfl-to-teams-pull-players-if-you-even-suspect-a-concussion/
Stern RA, Riley DO, Daneshvar DH, Nowinski CJ, Cantu RC, McKee AC. (2011). Long-term consequences of repetitive brain trauma: chronic encephalopathy. Physical Medicine and Rehabilitation, Oct;3(10Suppl 2):S460-7.