Concussion Assessment: Difference between revisions

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The test involves a systematic approach to dropping a weighted stick that is calibrated to reflect speed of reaction for catching it. The athlete holds his or her hand around, but not touching, a rubber piece at the bottom of the stick, then the physiotherapist drops the stick, and the athlete catches it on the way down. The physiotherapist marks where his hand lands, and this becomes a baseline measure of patient’s reaction time. Theoretically, should a player later be suspected of having sustained a concussion, the physiotherapist could pull out the dowel-puck, repeat the test, and, if the player’s reaction time were slower, conclude that he or she likely was concussed. RT appears sensitive to the effects of concussion and distinguished concussed and non-concussed athletes. The dowel-puck RT test is simple, low cost, and requires minimal time.<ref>Eckner JT, Kutcher JS, Richardson JK. Effect of concussion on clinically measured reaction time in nine NCAA Division I collegiate athletes: A preliminary study. PM & R. 2011b;3(3):212–218. </ref>
The test involves a systematic approach to dropping a weighted stick that is calibrated to reflect speed of reaction for catching it. The athlete holds his or her hand around, but not touching, a rubber piece at the bottom of the stick, then the physiotherapist drops the stick, and the athlete catches it on the way down. The physiotherapist marks where his hand lands, and this becomes a baseline measure of patient’s reaction time. Theoretically, should a player later be suspected of having sustained a concussion, the physiotherapist could pull out the dowel-puck, repeat the test, and, if the player’s reaction time were slower, conclude that he or she likely was concussed. RT appears sensitive to the effects of concussion and distinguished concussed and non-concussed athletes. The dowel-puck RT test is simple, low cost, and requires minimal time.<ref>Eckner JT, Kutcher JS, Richardson JK. Effect of concussion on clinically measured reaction time in nine NCAA Division I collegiate athletes: A preliminary study. PM & R. 2011b;3(3):212–218. </ref>


[[Image:Clinical Reaction Time Test.pdf]]




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Introduction[edit | edit source]

Concussion results in a constellation of physical, cognitive, visual, emotional, and sleep-related disturbances. Signs and symptoms are broad and include headache, dizziness, gait and balance disturbance, nausea, vomiting, photophobia, trouble focusing, and fatigue. A person with concussion may have slowed mental processing, concentration deficits, memory impairment, irritability, anxiety and depression. [1][2]

Emotional Assessment[edit | edit source]

An assessment to address emotional stability is beyond the scope of the physiotherapist.The gold standard for the diagnosis of mental disorders remains the structured clinical interview with a neuropsychologist. Self-report measures can play an important role in screening patients in the physiotherapy setting for referral to a Neuropsychologist/neuropsychiatrist. 

Research has shown that concussions can cause new anxiety, and they can worsen existing anxiety.[3][4] Individuals with a mental health history are at risk for greater depressive and anxiety symptoms post-injury[5] worsening of their pre-existing mental health condition[6] ), and development of a novel mental health condition.[7] Neurometabolic disturbance secondary to concussion exhibits a similar pattern of brain alterations as individuals diagnosed with clinical depression on advanced neuroimaging.[8] There is evidence of alterations in limbic-frontal circuitry after concussion that resembles the functional alterations seen in major depression.[9] Other neurochemical changes consistent between mood disorders and concussion are the presence of serotonin disturbance[10] and decreased dopamine in the prefrontal cortex and brainstem.[9][11]Organic brain changes may provide an explanation for mood and anxiety symptoms post-injury in the absence of pre-injury mental health conditions. Anxiety is often triggered by a vestibular event, though may be maintained by psychosomatic factors.[12] For instance, an athlete with a vestibular disturbance may experience dizziness and anxiety when running sprints at practice, and then begin avoiding any physical activity or movement of their head for fear of re-experiencing the dizziness. When conducting vestibular-oculomotor screening, clinicians should be aware of signs of anxiety given the overlap in the symptoms of anxiety and vestibular dysfunction. If anxiety is not properly identified and addressed, it may interfere with the efficacy of treatment.[13]

Cognition[edit | edit source]

Clinical Reaction Time[edit | edit source]

Impaired reaction time (RT) is one of the most common cognitive sequelae of concussion. It represents one of the most sensitive indices of cognitive change following concussion[14] and has prognostic value in predicting time to recovery.[15] Reaction time is typically prolonged immediately after injury with a gradual return to baseline.[16][17] Impaired RT generally parallels the presence of other self-reported concussion symptoms[18][19] but in some athletes RT remains impaired even after the athlete has become asymptomatic.[20][21][19]  RT is an important component of the physiotherapist’s concussion assessment toolkit that can increase the sensitivity of the clinical examination for detecting the effects of concussion.

Test Procedure[edit | edit source]

The test involves a systematic approach to dropping a weighted stick that is calibrated to reflect speed of reaction for catching it. The athlete holds his or her hand around, but not touching, a rubber piece at the bottom of the stick, then the physiotherapist drops the stick, and the athlete catches it on the way down. The physiotherapist marks where his hand lands, and this becomes a baseline measure of patient’s reaction time. Theoretically, should a player later be suspected of having sustained a concussion, the physiotherapist could pull out the dowel-puck, repeat the test, and, if the player’s reaction time were slower, conclude that he or she likely was concussed. RT appears sensitive to the effects of concussion and distinguished concussed and non-concussed athletes. The dowel-puck RT test is simple, low cost, and requires minimal time.[22]


Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Kushner D. Mild traumatic brain injury: toward understanding manifestations and treatment. Arch Intern Med. 1998 Aug 10-24;158(15):1617-24.
  2. ↑ Alexander MP. In the pursuit of proof of brain damage after whiplash injury.Neurology Editorials 1998: 51 (2) DOI: https://doi.org/10.1212/WNL.51.2.336
  3. ↑ Broshek DK, De Marco AP, Freeman JR. A review of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228-37. doi: 10.3109/02699052.2014.974674. Epub 2014 Nov 10.
  4. ↑ Clement D, Granquist MD, Arvinen-Barrow MM. Psychosocial aspects of athletic injuries as perceived by athletic trainers. J Athl Train. 2013 Jul-Aug;48(4):512-21. doi: 10.4085/1062-6050-48.3.21. Epub 2013 May 31.
  5. ↑ McCauley SR, Wilde EA, Miller ER, Frisby ML, Garza HM, Varghese R, McCarthy JJ (2013). Preinjury resilience and mood as predictors of early outcome following mild traumatic brain injury. Journal of neurotrauma. 30(8):642–652.
  6. ↑ Bombardier CH, Fann JR, Temkin NR, Esselman PC, Barber J, Dikmen SS. Rates of major depressive disorder and clinical outcomes following traumatic brain injury.2010 Jama 303(19):1938–1945.
  7. ↑ Ellis MJ, Ritchie LJ, Koltek M, Hosain S, Cordingley D, Chu S, Russell K (2015b). Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics16(6):709–718.
  8. ↑ Barkhoudarian G, Hovda DA, Giza CC (2011). The molecular pathophysiology of concussive brain injury. Clinics in sports medicine 30(1):33–48.
  9. ↑ 9.0 9.1 Chen J-K, Johnston KM, Petrides M, Ptito A. Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion symptoms. Archives of General Psychiatry. 2008:65(1):81–89.
  10. ↑ Smyth K, Sandhu SS, Crawford S, Dewey D, Parboosingh J, Barlow KM (2014). The role of serotonin receptor alleles and environmental stressors in the development of post‐concussive symptoms after pediatric mild traumatic brain injury. Developmental Medicine & Child Neurology. 56(1):73–77. 
  11. ↑ Venzala E, Garcia-Garcia A, Elizalde N, Tordera R. Social vs. environmental stress models of depression from a behavioural and neurochemical approach. EuropeanNeuropsychopharmacology. 2013:23(7):697–708.
  12. ↑ (Edelman, Mahoney, & Cremer, 2012
  13. ↑ (Kontos, Deitrick, & Reynolds, 2015).
  14. ↑ Erlanger D, Feldman D, Kutner K, Kaushik T, Kroger H, Festa J, Barth J, Freeman J, Broshek D. Development and validation of a web-based neuropsychological test protocol for sports-related return-to-play decision-making. Archives of Clinical Neuropsychology. 2003;18(3):293–316.
  15. ↑ Lau et al, 2009
  16. ↑ Collie et al (2006)
  17. ↑ McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, Onate JA, Yang J, Kelly JP. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003.19;290(19):2556-63.
  18. ↑ Collins et al, (2006)
  19. ↑ 19.0 19.1 Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R. Testretest reliability of computerized concussion assessment programs. Journal of Athletic Training. 2007;42(4):509–514.
  20. ↑ Warden DL, Bleiberg J, Cameron KL, et al (2001). Persistent prolongation of simple reaction time in sports concussion. Neurology. 57(3):524–526.
  21. ↑ Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: Markers of severity and implications for management. American Journal of Sports Medicine. 2010;38(3):464–471.
  22. ↑ Eckner JT, Kutcher JS, Richardson JK. Effect of concussion on clinically measured reaction time in nine NCAA Division I collegiate athletes: A preliminary study. PM & R. 2011b;3(3):212–218.
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