Concussion concerns are growing

A higher age leads to a worse prognosis after cranial brain injury, according to the CRASH database. This is an international database in which data is stored on several tens of thousands of victims of cranial brain injury. The prognosis is broken down by chance of recovery, admission to a nursing home or death. The starting point for calculating the prognosis is the severity of the cranial brain injury within eight hours after the accident and the abnormalities measured on the CT scan.

Risk

For example, the risk of death or serious sequelae six months after a brain injury is 18 percent for a 50-year-old. This risk increases to 47 percent for a 70-year-old and even to 64 percent for an 80-year-old. The speed one had when one fell, the reaction time and the age determine the prognosis. SWOV (Institute for Road Safety Research) will now be conducting further research into this in the near future. In an ongoing study she compares the reaction speed and eye movements in a group of subjects aged 65 and older, which consists of electric cyclists and self-peddlers.

Three goals

An important evaluation tool in sports is the SCAT5 for adults and children. Ellis et al (2018) promote a more physiological approach for the estimation and management of acute concussion in athletes. The initial medical assessment of athletes with a possible acute concussion has three goals: (1) provide a clear medical diagnosis of an acute concussion; (2) identify the clinical pathophysiological symptoms that pose a risk of delayed recovery to the athlete; and (3) establishing an individualized recovery program that addresses the pathophysiological causes of the symptoms.

The 2017 ‘5th International Consensus Statement on Concussion in Sport’ advocated a modified approach in which patients with acute concussion were first prescribed a short rest period (24–48 h) followed by symptom-limited activity with the aim of a graded reintroduction of school / sports / work activities.

(Author: Joppe ten Brink)

Literatuur

A concussion is a nasty condition and can lead to chronic and very disabling disabilities. It is caused by an acceleration-deceleration trauma of the neuronal structures, the brain, in the cranium. In 80% to 90% of patients spontaneous recovery occurs within ten days, but unfortunately this does not always happen (Castillo et al., 2015). Depending on the affected systems, a concussion can roughly lead to four types of conditions or a combination of these: 1) changes in the brain’s metabolism; 2) vestibulo-ocular problems; 3) a cervicogenic headache and 4) changes in cognitive functioning (Barkhoudarian et al., 2016).

Effect

Osteopathic manual therapy (OMT) has an effect on recovery time after concussion, research shows, but the findings are often not statistically significant. Yet patients experience less serious complaints after OMT (Castillo et al., 2015; Yao et al., 2019; Mazzeo et al., 2020; Baltazar et al., 2020; Guernsey et al., 2016). How can that be explained? Such a wide range of techniques are used in multiple body regions that it is no longer possible to trace which techniques are effective and which are not. The underlying mechanism of OMT is therefore unclear. Guernsey et al. (2016) suggests that it cannot be ruled out that there are other mechanisms that explain the treatment outcomes of OMT.

Scientific models have shown that cerebral blood flow (CBF) varies after a concussion. This will increase in the acute phase and decrease in the sub-acute phase. The CBF thus adapts to the prevailing vascular resistance. Improving the blood circulation in the skull and the metabolism in the brain could hypothetically help to alleviate the symptoms.

Headache

The literal shaking of the brain in the hard skull causes trauma to the neuronal structures. These same neuronal structures are very closely linked to the myodural bridge (MDB) in their structure at the level of the neck-brainstem and cerebellum-occiput. There are a lot of muscle spindles in the muscles of the suboccipital region, more than elsewhere in your body. The suboccipital region is therefore important for overall proprioception and ocular integration.

The forces generated during the trauma could have an effect on the suboccipital muscles. In addition, they could also affect the tension of the dural system via the MDB and the neurological structures of the central nervous system in this region (Fakhran et al., 2016). An important neurological structure in this neck region is the trigeminocervical nucleus. In pain stimulation, this is linked to cervicogenic headaches.

Self-healing ability

The high neck-occiput region is also the main region for venous drainage from the head. Proper venous blood drainage leads to decreased intracranial pressure and an increase in CSF absorption. The venous drainage of the head is strongly influenced by our posture, breathing and (neck) movements. Neck movements can be problematic after an acceleration-deceleration trauma. Reduced mobility, changes in the position of the neck and hypertonia in this region can impede venous outflow. Good mobility of the upper cervical neck region is therefore crucial to influence the vestibular ocular, cervicogenic headache, venous drainage of the head and cognitive functioning. Based on physiology, a treatment of only the basicranium, the high cervical region and the connective tissue of the neck seems plausible to address the self-healing capacity.

Future

Future studies should focus on the added value of treatment of the neurocranium, sutures and extra-cranial fascia (with neuroreflective points) in concussions. In doing so, the various aspects of the existing complaint must be taken into account, in accordance with the five explanatory models of the Educational Council of Osteopathic Principles (ECOP). The added value of OMT for a multidisciplinary approach could also be investigated. This is partly because there are already many other manual therapies that focus on the treatment of the neck region and vestibular rehabilitation.

(Author: Joost Veldhuizen)

Literatuur

The Children’s Hospital of Philadelphia has investigated concussions in athletes. The “return-to-play” turned out to be 2 days longer for female contact sports. In the ages of 7-18 years, they also saw that female athletes report to the doctor later and had a markedly slower recovery. Recovery was slower in the following areas: neck musculature, hormonal, neurocognitive, visual and vestibular. Young athletes were also only able to fully exercise again after 119 days, in contrast to boys, who took 45 days to do so.

Twice as much

The American Academy of Pediatrics saw that after a concussion, soccer players of 14 years old were back on the field the same day in 52% of the cases, compared to only 17% of the boys. This can have major consequences for further recovery. A 2017 study of orthopedic surgeons found that girls are more likely to contract concussions than boys at soccer. Neurologists also saw twice as many concussions in female athletes in 2017. As a result, they saw more memory loss in men and more sleep disorders in women.

Shorter recovery

Valera et al show that even 24 years after the trauma there is often still dizziness and headache complaints. Women are also more likely to have dementia-related complaints. Neldecker et al showed in a recent study of 182 athletes (age 11-18 years) that early diagnosis and active rest after the first 24-48 hours is preferable to general rest. Increasing the physical and mental load gradually under supervision, in combination with reducing anxiety, leads to a shortening of the recovery in girls from 28 to 7 days and in boys from 11 to 5 days of recovery.

(Author: Liesbeth van den Berg – van Esch)

Literatuur

What are the explanatory models for complaints after a concussion?

1 Mechanical explanation

Accelerated rotational movement generates tensile forces throughout the brain, resulting in cavitations and cellular disturbances. Ventricles should absorb the forces. Substantia nigra and ventral tegmentum show cell damage with increased long-term parkinsonism (Berry, 2020).

2 Circulatory explanation

There is vasogenic edema and micro bleeding. The latter can only be detected via hemosiderin deposition after autopsy. The CNS’s ability to regulate blood circulation and dispose of waste products has been disrupted. The glymphatic system shows a reduced CSF discharge (Berry 2020).

3 Biochemical explanation

There is a disturbance in neurotransmitter release. Oligodendrocytes show impaired myelin production resulting in disturbances of the white tracts. Furthermore, the CT scan shows cytotoxic signs. An accumulation of beta amyloids occurs, which eventually leads to Dementia Pugilistica. This is seen in 20% of the former boxers. Two biomarkers can be seen in the blood: UCH-L1 and GFAP. The latter has the highest specificity (Berry 2020).

4 Neurological explanation

The EEG shows a disturbed sleep pattern and concentration problems (less alpha, more theta and delta activity).

What can be explored within these four explanatory models?

First of all, a questionnaire (PROMs) must be completed within a week. In the United States, this is often done by a neuropsychologist. These are the options:

1. Immediate Post Concussion Assessment and Cognitive Testing (ImPACT), which has a sensitivity of 81.9% and a specificity of 89.4%.
2. Montreal Cognitive Assessment (MoCA), which is a general test of cognitive functions.
3. SCAT5 Sports Concussion Assessment Tool version 5, is used in many clinics in the US.
4. Post Concussion Symptom Scale (PCSS), which is especially for adolescents.
5. Rivermead Post Concussion Questionnaire (RPQS), which is widely used in the Netherlands.

The physical exam also looks at cervical, cephalic, and overall physical mobility.

Skull examination

Schwartzberg (2020) distinguishes between physiological (SbRot and Torsion) and a-physiological (vertical / lateral strains and compression) cranial strains. Of the 19 people she studied, 11 have a-physiological and 6 with physiological strain patterns. These numbers are too small and there is no control group to speak of significant results.

Patel (2018) first performed and treated an occipital atlantal junction evaluation (6 people extension, 3 flexion dysfunction) in his procedure. He then went on to do the Cranial Vault Hold and the assessment and handling of the cranium. He indicates that there is a significant increase in the PCSS scores. However, no conclusion can be drawn, because a normal course of a concussion also shows a decrease in scores. The history is also important in assessing the severity of the symptomatology, it also determines the PCSS score.

Patel concludes that the normal shape of the skull has not been determined, so that normal and abnormal cannot be determined. In addition, he cannot establish the correlation between concussion and cranial dysfunction, as all 9 had a cranial “dysfunction”. The numbers are also too small in Patel’s research and no reference value has been established.

Circulatory investigation

In addition, the vital signs (increase in systolic pressure, increase in orthostatic intolerance and increase in heart rate) must be considered (Zwibel, 2018).

Neurological examination

Oculomotor (convergence insufficiency and accommodation dysfunction present at 65%), balance (67% disrupted), tests with Dix Hallpike maneuver, Romberg, BESS tests (Balance Error Scoring System) and gait observation, muscle strength tests, tendon reflexes and neuropsychological assessment.

Conclusion

The increase in the number of concussions, the lack of proper diagnostics and the often serious long-term consequences are reasons for osteopaths to pay more attention to concussions. For the time being, there is only evidence for the use of PROMs (questionnaires) and vascular and neurological tests. No evidence or validity has been demonstrated for palpatory testing of the cranium. It is therefore important to always use a combination of sources to arrive at a diagnosis. (Author: Sander Kales)

Literatuur

Recent research suggests that most concussion symptoms resolve within two weeks of injury. However, it has also been found that 10 to 30 percent of concussions among high school-aged athletes suffer from symptoms that last longer than 6 weeks (concussion legacy foundation). When is a player allowed to play sports again? Every player and every concussion is unique. Therefore, there is no fixed timetable for return, but there is a phased training program. Most guidelines follow a five-step plan (McCrory et al., 2017; Berry et al., 2019; NFL, 2020):

1. Symptom limited activities

The player is given rest and can do a limited stretching and balance training under the supervision of a therapist, which turns into light aerobic exercises (10 min), such as cycling or running on a treadmill if this is possible.

2. Aerobic training

Continuation of cardiovascular exercises (20 min), the player may also do more dynamic stretching and balance training.

3. Specific training

The player continues to do cardiovascular exercises that are increased and possibly simulate sport-specific activities. Strength training is done under supervision. The player may practice with the team for 30 minutes, only sport specific exercises (no contact moments).

4. Non-contact training

The player continues cardiovascular, strength and balance training. Team-based specific exercises can be picked up and the athlete participates in non-contact training activities with the team (e.g. catching, running, shooting or other function specific activities).

5. Resume complete training with team

If it is determined by a doctor or general practitioner that the concussion has been resolved, the player may participate in a complete training.

When a player suffers multiple concussions in a season, it will also ask for a longer recovery each time – sometimes even stopping the season for the player.

(Author: Nadi Blokhuis).

Literatuur