THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 12 - DECEMBER 2004
New Recommendations for Concussion Management
Healthcare professionals who work with athletes often struggle with concussion management decisions, because symptoms vary so widely and so little clinical research exists to guide treatment. A group of concussions experts, assembled by the National Athletic Trainers' Association (NATA), reviewed the latest findings in concussion research and recently issued a position statement that suggests new concussion management recommendations.1
The NATA statement seeks to change the public perception of concussions by advising healthcare professionals and coaches to avoid using the word "ding" when referring to sports-related concussions. The position statement proposes that the term diminishes the seriousness of the injury and that "the athlete has, at the very least, sustained a mild concussion and should be treated for a concussion."1
Breaking new ground, the NATA statement is the first to recommend that clinicians use neuropsychological and postural-stability tests to assist diagnosis and treatment. The authors urge baseline testing for athletes in high-risk sports, and that all athletes who sustain head injuries undergo serial neuropsychological and postural-stability testing along with a thorough clinical evaluation.
The statement advises clinicians to monitor the severity and persistence of all signs and symptoms, and it proposes a systematic approach to evaluation with a graded symptom checklist. To assist athletic trainers, the statement contains a physician referral checklist and home-care instructions for the patient. The position statement and the checklists are available online at https://www.nata.org/publicinformation/files/concussion.pdf.
Neuropsychological Testing Draws Debate
Neuropsychological testing, once only available to elite athletes, has become more accessible to mainstream sports medicine, thanks to the wide availability of reasonably priced computerized testing programs such as CogSport, Headminder, and ImPACT. Though many sports medicine physicians and athletic trainers routinely use the computerized neuropsychological testing programs, some physicians say it's too soon for such testing to be recommended by sports medicine organizations, because such recognition may imply that neuropsychological testing is a standard of care. Some physicians also worry that if healthcare practitioners depend too much on a computerized tool to manage concussions, patient care may suffer.
Michael A. Yorio, MD, a team physician and internist at the University of Maryland in College Park, says the teams he works with are using a computerized neuropsychological testing product for the first time this year. He says the sports medicine team is very happy with the program, because it helps them discuss risks with athletes and provides objective data. However, he says he has concerns about such testing being considered a standard of care. "When I think of the words 'standard of care,' I think of something that has been extensively studied, validated by independent researchers, peer reviewed, and accepted in the medical community as the expected level of care," Yorio says, adding, "I don't think we are there yet in concussion management with standard neuropsychological testing and certainly not with computerized neuropsych testing."
As an athletic trainer who currently uses one of the computerized testing programs for the high school team he covers, Scott Andrews, MS, LATC, supervisor of athletic training services for HealthSouth in Massachusetts and head athletic trainer at Whitman-Hanson Regional School in Whitman, Massachusetts, says that though he understands the hesitations in considering neuropsychological testing the standard of care, the computerized results from the programs have the potential to assist the clinical assessment. "I believe these programs help control the subjective reporting of symptoms by the athlete," Andrews says.
Scott H. Grindel, MD, a team physician for Ferris State University in Big Rapids, Michigan, and the author of several publications on concussion and neuropsychological testing, says healthcare practitioners should keep in mind that neuropsychological testing has not been validated for the diagnosis of concussion and is still in the research phase for gauging resolution. He notes that cognitive deficits noted on testing that are followed by normal results don't always correlate to concussion recovery and safe return to play.2 "Having objective data is nice to evaluate individual concussions," he says; however, "putting it in the hands of irresponsible team physicians and nonphysicians who do not know how to properly evaluate concussion or fail to evaluate patients face to face scares me."
Some physicians fear that their medical liability may be influenced when national medical groups endorse neuropsychological testing. "Neuropsychological testing, at this point in time, does not remove any liability from the physician or medical professional, so we certainly should not be doing it for this reason," Grindel says. "It may, however, increase your liability if you return an athlete based solely on these tests and they end up with postconcussion syndrome or worse."
Kevin M. Guskiewicz, PhD, lead author of the NATA concussion position statement, counters that the recommendations clearly state that a thorough clinical evaluation should accompany use of neuropsychological testing. Guskiewicz, who is a professor and director of the Sports Medicine Research Laboratory in the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hill, also notes that many of the validation questions regarding neuropsychological testing after concussion have been answered. "Most of the batteries used in the sports setting have been found to be sensitive for detecting cognitive deficits during the initial 5 to 10 days after injury," Guskiewicz says.
The most practical use of the tests is to begin serial testing once the injured athlete is asymptomatic, Guskiewicz says. Comparing these postconcussion tests with baseline scores then allows athletic trainers and physicians to make return-to-play decisions, he adds. "It is important to recognize that neuropsychological testing represents only one piece of the concussion puzzle," Guskiewicz says.
Christopher Madden, MD, a family physician at Longs Peak Sports and Family Medicine in Longmont, Colorado, acknowledges that the computerized neuropsychological tests would benefit from the same long-term validation as older methods. "But we have to start somewhere. Anecdotal evidence fuels research that contributes to our quality evidence base," he says.
Though neuropsychological testing requires further study, Madden says using it now, carefully and appropriately, may assist in the management of athletes who have head injuries. "We are the gold standards, not neuropsych testing. If we keep this in mind while using the tests in combination with other clinical parameters, we will continue to deliver cautious and careful quality head injury care," he says.
A Role for Postural-Stability Testing
Postural-stability testing is another objective assessment method recommended in the NATA position statement. Concussions appear to disrupt sensory interaction, which can produce measurable changes in balance. Monitoring postural stability in athletes who have had head injuries is important, not just for tracking injury recovery, but also because athletes require a good sense of balance to avoid injury on the playing field. As with its recommendation for neuropsychological testing, the NATA statement recommends obtaining a baseline test once athletes are asymptomatic.
Research to determine how long postural stability problems persist is ongoing, Guskiewicz says. "Some studies suggest that sensory interaction problems can exist for up to 5 days postinjury," he says. "In many cases, it is believed that the vestibular mechanisms are temporarily disrupted."
The Romberg test and the stork-stand test are simple balance tests that have been used on the sidelines in the past; however, the Balance Error Scoring System (BESS)3,4 is a more sophisticated, yet practical, test that can be used in the office or on the sidelines. The BESS tests three stances on both a firm and foam surface (6- to 8-cm thick, medium density) with the eyes closed. Performance is scored by adding 1 point for each error. To maximize the usefulness of postural-stability tests, researchers continue to study the optimal timing as well as serial testing sequence for the test. A recent study5 found that the BESS should be performed 20 minutes after exertion to avoid the confounding effects of fatigue.
Computerized postural-stability testing systems that use force plates to measure the patient's reactions to balance challenges are also available, such as the NeuroCom Smart Balance Master System (NeuroCom International, Inc, Clackamas, Oregon).
More Guidance on the Horizon
Another group of concussion experts is expected to release a consensus statement in 2022. In early November, the second International Symposium on Concussion in Sport was held in Prague.
The last time the group met, in 2001, it published an agreement statement6 that proposed a revised concussion definition, issued a symptom scale for use in assessing concussion severity, and offered return-to-play guidance. The statement also summarized the latest findings in concussion-related research on topics.
Some of the topics that were on the scientific program for this year's symposium included neuroimaging, neuropsychological testing, medicolegal concerns, return-to-play issues, rehabilitation, special pediatric issues, and discussion of the importance of various symptoms such as loss of consciousness and postconcussion headache.
Does the Weather Affect Joint Pain?
Many patients who have arthritis say their symptoms are worse when the weather is cold and unsettled. Researchers who compared two sets of independently collected data have substantiated patient suspicions, according to research presented in October at the annual meeting of the American College of Rheumatology in San Antonio.
To evaluate a possible connection between environmental conditions and arthritis pain, researchers merged data collected from a large study of glucosamine treatment with data from the National Oceanic and Atmospheric Administration (NOAA). The glucosamine trial was conducted in 41 states between 2000 and 2002 and tracked 205 arthritis patients in 3-month randomized controlled trials. Researchers didn't decide to evaluate weather influences until the glucosamine trial was completed.
To explore the possibility of any effect, they identified the nearest weather station for each study participant, then they merged daily NOAA weather parameters for each day of the subject's 3-month study interval. Average values were computed over 1, 3, and 7 days before each participant's report of pain; the change in the weather values were also computed for the 24 hours before the pain reports.
The researchers found that changes in barometric pressure were strongly associated with increases in knee pain. Cooler temperatures were consistently, but weakly, associated with increased pain. Neither dew point nor precipitation was associated with pain.
Previous studies of weather influences on rheumatic symptoms have been inconsistent. Timothy E. McAlindon, MD, MPH, lead author of the study and chief of the Center for Arthritis and Rheumatic Diseases at Tufts-New England Medical Center in Boston said in a press release from the American College of Rheumatology that people have such strong convictions about the influence of weather on arthritis that studies can lead to bias on either side. "By merging two data sets that were obtained completely independently on each subject, we were able to conduct a robust study that really does suggest an association of weather with aches and pains," he said.