Concussion

Taking an Active Approach to Sports-related Concussion

Keeping the mind and body active are the two key management motivations at the helm of Axis Sports Concussion Clinic.

Since launching six months ago, Axis has seen over 270 new sports-related concussion patients walk through its doors. With a specific focus on concussion that has occurred within a two-week timeframe, our clinic has a collaborative approach – physical and physiological - for the acute assessment and management of injuries, referencing over a decade of major advances in evaluation and unique treatment protocols.

Past studies have been plentiful but knowledge gaps have remained. Recently, the Berlin Concussion Statement highlighted key findings which has shifted attitudes towards management options.

Sports-related concussion has many complexities – making it difficult to diagnose, assess and manage. However, the data we’ve already collected from our new sports-related concussion patients, has opened doors for further study on prognostic indicators and streamlined our management into areas that make a difference.

What we understand more of now, is the role exercise plays in the management of a symptomatic patient – it has altered the ‘rest is best’ anecdote of old. We know – thanks to accumulative research – that psychological factors have a huge role to play in symptom recovery – mood and behavioural patterns. We also know that careful management of the upper cervical spine and vestibular systems is critical to patient recovery and limiting concurrent injury.

Based on the sports-related concussion patients we have seen to-date, 75% of these patients improved within the traditional time frames – 10-14 days for adults, and four weeks for children – and on average we’re seeing patients 1.35 times prior to clearance before a return to sport. What this demonstrates is that early management revolves around education from a physical and cognitive load perspective.

In the past, there was more emphasis on post-injury neurophysiological testing, which was traditionally carried out on asymptomatic patients to determine their readiness to return to sport. However, thanks to research advances, the importance of neurophysiological testing in the early stage after injury has become an essential clinical evaluation tool. Although cognitive symptoms can present before or after physical symptoms resolve, it’s particularly important to overall sports-related return-to-play assessment.

The importance of cognitive load priority for education, above non-educational use of electronic devices, is also a constant theme delivered to patients – and is often met with a sigh of relief from frustrated parents.

How this works is patients are presented with a graduated return-to-play schedule – with a time difference based on their age – and factors a progression from heart rate increase, to movement, to skills-based exercise requiring coordination and increased cognition.

Taking an active rehabilitation approach with patients who are still symptomatic at two weeks post-injury is also a key focus for us. This involves patients undergoing a modified Balke treadmill-based testing regimen and cervico-vestibular screening as part of their individual treatment plan.

Current studies have highlighted the effectiveness of cervico-rehabilitation in patients with post-concussion syndrome. For example, a recent randomised controlled trial with 15 post-concussion patients in each arm, revealed individuals in the treatment group were 3.91 times (95%CI 1.34 to 11.34) more likely to be medically cleared by eight weeks.

Our initial data set highlights the added value initial presentation symptom scores and symptom severity have following a new assessment regime, whilst Standardised Assessment of Concussion scores show minimal change over a treatment course. Currently, we’re exploring further prognostic measured analysis around balance assessment scores and predominant symptoms.

References: Schneider K, Meeuwisse W, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial Br J Sports Med 2014;48:1294-8.