Concussion concerns are growing
At least half of football players return too quickly after a concussion, according to research by UEFA, NRC Handelsblad reported on 13th of February. Other research shows that the number of elderly e-bikers is increasing and so is the number of older patients with brain damage. In this first newsletter in this new format, we will explore how to investigate whether someone has a concussion, when someone has recovered, and what we, as osteopaths, can do to diagnose and treat concussions.
Table of contents:
The number of elderly users of the electric bicycle will increase further in the coming years, and with it the number of elderly patients with brain damage. This is also reflected in the statement by the neurology department of UMC Utrecht.
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.
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.
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)
Original Title: A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes
Authors: Ellis, M.J., Leddy, J., Cordingley, D., Willer, B.
Published in: Frontiers in Neurology, www.frontiersin.org, December 1, 2018, Volume 9, Article 1115
Original title: Chiropractic and concussion in sport: a narrative review of the literature
Authors: Claire D. Johnson, C.D., Green, B.N., Nelson, R.C.
Published in: Journal of Chiropractic Medicine (2013) 12, 216–229
Original title: Make helmet mandatory for older e-bike cyclists. Elderly people on an electric bicycle have a high risk of skull brain damage with serious consequences.
Authors: Algra, A., Wokke, J.
Published in: February 26, 2015, Volkskrant
Osteopathy may assist in the recovery of certain types of concussions. However, the treatment effects and “significantly effective techniques” are still unclear.
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).
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.
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.
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 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)
Original Title: Osteopathic Manipulative Treatment Relieves Post-concussion Symptoms in a Case of Polytrauma
Authors: Baltazar G A, Kolwitz C, Petrone P, et al.
Published in: Cureus 12 (3): e7317, 2020.
Original title: The Molecular Pathophysiology of Concussive Brain Injury – an Update
Authors: Barkhoudarian, G., Hovda, D.A., & Giza, C. C.
Published in: Physical Medicine and Rehabilitation Clinics of North America, (2016), 27 (2), 373–393.
Original Title: Concussions and Osteopathic Manipulative Treatment: An Adolescent Case Presentation
Authors: Castillo, I., Wolf, K., & Rakowsky, A.
Published in: The Journal of the American Osteopathic Association (2016), 116 (3), 178.
Original Title: Effect of the Suboccipital Musculature on Symptom Severity and Recovery after Mild Traumatic Brain Injury
Authors: Fakhran, S., Qu, C., & Alhilali, L. M.
Published in: American Journal of Neuroradiology (2016), 37 (8), 1556–1560.
Original Title: Resolution of Concussion Symptoms After Osteopathic Manipulative Treatment: A Case Report
Authors: Guernsey, D. T., Leder, A., & Yao, S.
Published in: The Journal of the American Osteopathic Association (2016), 116 (3), e13.
Original Title: Effects of Osteopathic Manipulative Treatment on Sleep Quality in Student Athletes After Concussion: A Pilot Study
Authors: Mazzeo, S., Silverberg, C., Oommen, T., Moya, D., Angelo, N., Zwibel, H., Mancini, J., Leder, A., & Yao, S. C.
Published in: The Journal of the American Osteopathic Association (2020), 120 (9), 615.
Original Title: Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms
Authors: Yao, S. C., Zwibel, H., Angelo, N., Leder, A., & Mancini, J.
Published in: The Journal of the American Osteopathic Association (2020), 120 (9), 607.
The disease process of women with traumatic brain injury turns out to be different than in men. More studies are needed to better map this out, as the effects are still underexposed.
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.
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)
Original title: Female soccer players suffer the most concussions in high school sports
Authors: American Academy of Orthopedic Surgeons
Published in: Science Daily 2017, March 14
Original title: Women may be at higher risk for sports-related concussion than men
Authors: American Academy of Neurology
Published in: Science Daily 2017, March 1
Original title: Girl soccer players five times more likely than boys to return to play same day after concussion
Authors: American Academy of Pediatrics
Published in Science Daily 2017, September 15
Original title: Female athletes seek special care for concussion later than males
Authors: Children’s Hospital of Philadelphia
Published in Sciecne Daily 2019, September 17
Original title: No overall difference in concussion recovery time for male and female college athletes
Authors: Children’s Hospital of Philadelphia
Published in Sciecne Daily 2021, January 26
Original Title: Factors Affecting Recovery Trajectories in Pediatric Female Concussion
Authors: Desai N., Wiebe, D.J. et al
Published in: Clinical Journal of Sports Medicine, 2019; 29 (5) 361
Original title: Differences in sport-related concussion for female and male athletes in comparable collegiate sports: a study from the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium
Authors: Master, C.M., Katz, B.P. et al
Published in: British Journal of Sports Medicine, 2020; bjsports-2020-13316
Original Title: Understanding Traumatic Brain Injury in Females: A state-of-the-Art Summary and Future Directions
Authors: Valera, E.M., Joseph, A.C. et al
Appeared in: Journal Head Trauma Rehabilitation Vol. 36, No1 pp E1-E7, 2021
Original title: First-time sports-related concussion recovery revisited: management changes and impact on recovery
Authors: Neidecker, J.M. et al
Published in: Journal Osteopathic Medicine 2021; 121 (1): 49-56
This summary examines the possibilities of diagnosing a concussion as an osteopath.
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:
- Immediate Post Concussion Assessment and Cognitive Testing (ImPACT), which has a sensitivity of 81.9% and a specificity of 89.4%.
- Montreal Cognitive Assessment (MoCA), which is a general test of cognitive functions.
- SCAT5 Sports Concussion Assessment Tool version 5, is used in many clinics in the US.
- Post Concussion Symptom Scale (PCSS), which is especially for adolescents.
- Rivermead Post Concussion Questionnaire (RPQS), which is widely used in the Netherlands.
The physical exam also looks at cervical, cephalic, and overall physical mobility.
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.
In addition, the vital signs (increase in systolic pressure, increase in orthostatic intolerance and increase in heart rate) must be considered (Zwibel, 2018).
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.
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)
Original title: Pathophysiologic mechanisms of concussion, development of chronic traumatic encephalopathy, and emerging diagnostics: a narrative review
Authors: Berry, JA, Elia, C., Sweiss, R., Lawandy, S., Bowen, I., Zampella, B., … & Miulli, D.
Published in: The Journal of the American Osteopathic Association ( 2020), 120 (9), 583.
Original title: Safety of osteopathic cranial manipulative medicine as an adjunct to conventional postconcussion symptom management: a pilot study
Authors: Patel, K. G., & Sabini, R. C.
Published in: The Journal of the American Osteopathic Association (2018, 118 (6), 403.
Original title: Cranial strain patterns associated with concussions
Authors: Schwartzberg, L., Aslanyan, L., Angelo, N., Mancini, J., Kooyman, P. S., Abu-Sbaih, R., … & Yao, S. C.
Published in: The Journal of the American Osteopathic Association (2020), 120 (9), 601.
Original title: Concussion evaluation and management: an osteopathic perspective
Authors: Zwibel, H., Leder, A., Yao, S., & Finn, C.
Appeared in: J Am Osteopath Assoc (2018), 118 (10), 655.
When is an athlete allowed to train again after a concussion? And how do we as therapists help an athlete get back on their feet?
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):
- 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.
- Aerobic training
Continuation of cardiovascular exercises (20 min), the player may also do more dynamic stretching and balance training.
- 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).
- 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).
- 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).
Original title: Consensus statement on concussion in sport — the 5th international conference on concussion in sport held in Berlin, October 2016
Authors: McCrory, Paul, Willem Meeuwisse, Jiří Dvorak, Mark Aubry, Julian Bailes, Steven Broglio, Robert C. Cantu et al
Published in: British journal of sports medicine 51, no.11 (2017): 838-847
Original title: NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol
Published in: July 7, 2020. https://static.www.nfl.com/image/upload/v1597677293/league/dhfywrwelyfsivvia3ie.pdf
Original title: Return-to-Play After Concussion: Clinical Guidelines for Young Athletes
Authors: Berry, J.A.D. et al.
Published in: JAOA: Journal of the American Osteopathic Association. December 2019, Vol. 119