ISSUE 6 l DECEMBER 2013
BULLETIN FEATURE TOPIC: Concussion www.spnz.org.nz
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In this Edition: EDITORIAL: It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss About? By Dr Tony Schneiders
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EDITORIAL IT ’ S JUST A HEAD KNOCK AND PART OF THE GAME. CONCUSSION: WHAT ’ S ALL THE FUSS ABOUT? By Dr Tony Schneiders
Concussion has been around since the beginning of
Chronic Traumatic Encephalopathy (CTE), formerly
civilisation but it has recently come to the forefront of
known as athletica pugilistica (punch-drunk syndrome).
societal debate via the media for all the right, and maybe the wrong, reasons. While as a health-conscious society we see participation in activity and exercise as synonymous with health and well-being, it must be accepted that sport and recreational pursuits also expose participants to significant risks, with one of them being the possibility of head injury, particularly in contact and collision sports.
This condition has been in the media ever since former Chicago Bears NFL player Dave Duerson tragically committed suicide in 2011 and donated his brain to Boston University who confirmed CTE on autopsy. The Sports Legacy Institute at Boston University accepts donations of brain tissue from deceased sporting and military personal and cites that the brain tissue of 18 of 19 deceased former NFL players have tested positive
Sport-related concussion is a transient functional injury
for CTE. Since this revelation, there has been a proces-
to the brain and considered a sub-category of mild trau-
sion of ex-football stars lining up to report to their attor-
matic brain injury (mTBI) . Concussion is considered to
neys a long list of neurological mediated signs and
be among the more difficult injuries in sports medicine
symptoms that include forgetfulness, short temper, apa-
to diagnose and manage, with a myriad of mechanisms,
thy and depression which has resulted in multiple class-
presentations, manifestations, and resolutions which
action lawsuits being filed against the NFL. The cynics
are most often individualized to the specific athlete.
amongst you, especially those that have been married
There is no doubt that the science behind concussion
to men in their 5th decade, might suggest a likely cause
assessment continues to evolve and that management
for these symptoms as being the medical condition an-
principles should be based on sound clinical judgement
dropause, colloquially known as Irritable Male Syn-
underpinned by an evidence based approach. There is
drome (IMS) or grumpy man syndrome. This alternate
currently no single “gold standard” for diagnosing con-
view may also hold some credence given last year’s
cussion and multiple assessment domains are utilised
tragic suicide by ex-San Diego Charger Junior Seau
by health professionals in order to make a diagnosis
(also a claimant in the NFL law suit) who apparently
which is fundamentally clinical in nature.
had no reported medical history of sustaining a concus-
While the majority of sports concussions resolve within
sion during his entire football career.
7-10 days, symptoms can become chronic in some
Additionally, at this point in time we must consider the
people especially those with anxiety or other mental
best evidence available to determine whether CTE ac-
health comorbidities, and repeated concussions are
tually occurs as a result of repeated concussions in
also now considered to put the athlete at risk of long
sport. It was recently agreed by the Concussion in
Sport Group in the latest Consensus Statement on
One recently identified medical condition considered to be associated with repeated exposure to concussion is
Concussion in Sport4 that CTE was not related to concussions alone, or simple exposure to “contact sports”,
CONTINUED ON NEXT PAGE.
It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss About? cont’d ….. CONTINUED FROM PREVIOUS PAGE. and that due to the limited published research “the
staff to be appropriately educated on concussion in or-
der to manage high school athletes in at-risk sporting
codes. As it currently stands, education and law chang-
However, this has not stopped the NFL recently pro-
es have been the most successful intervention strate-
posing to settle out of court with former players to the
gies to date. Closer to home the ACC RugbySmart pro-
tune of 765 million dollars.
gramme has led to a reduction in reported concussions
concussive impacts causes CTE remains unproven”.
Closer to home we have had a number of high profile head injuries from our national game, rugby. Most will remember Steve Devine’s public battle with repeated concussions that eventually ended his career, Darryl Sabin’s ill-informed decision to return to rugby which lead to his permanent disability, and earlier this year the tragic death of Takapuna Rugby Club player Willie Halaifonua. It must be remembered that acute traumatic brain injury (TBI) is a continuum with concussion at one end and severe TBI, that occurred in the latter two examples, at the other. In fact it seems that some people appear to be more susceptible to catastrophic head injury in the form of subdural haematomas than others. Why is this the case? Well, one area worth investigating from my perspective might be the presence of a congenital arachnoid cyst in these players. The incidence of this developmental anomaly is around 1-2% in the normal population and the condition is up to 4 times higher in males than females. These usually benign
since its inception so perhaps the message is getting through to match officials and coaches that a head injury can have serious consequences. However at the top level of the game poor examples of concussion assessment and management are still being displayed. We all saw the Australian loose forward George Smith’s sickening head clash with the British Lions hooker earlier this year when he fell to the ground unconscious. He was clearly concussed but put back on the field 5 minutes later. What signal does this send to young players? In the NRL, teams are also getting around the concussion regulations by not having players assessed by the doctor. As concussion is a medical diagnosis, if the doctor doesn’t attend the injury, then they can’t diagnose a concussion and the player returns to the field of play. Obviously we still have some way to go in the education of our sports teams and administrators regarding the assessment and management of concussion.
cysts torsion the bridging veins in the brain making
Given the current discussion and debate around head
them more likely to rupture in the event of a head
injury in sport this issue of the SPNZ Bulletin therefore
knock. A question here that we may need to consider is
focuses on the most recent and up to date information
should we be screening for these anomalies using MRI
available from the consensus statement on concussion
in young males taking up collision sports?
in sport following the meeting in Zurich late last year. If
This also begs the question, are we doing enough to prevent concussions and other related head injuries in sport? America now has the Lystedt law, the first law ever to cover a medical condition, and one which has been invoked by nearly all the states across the USA. This legislation requires athletes, coaching and training
you work with sports teams or individuals at risk of head injury the summaries presented in this newsletter are a must read. I am sure you will find them informative and I thank the special projects team who took the time to summarise the best information available at present on this topic. CONTINUED ON NEXT PAGE.
It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss About? cont’d …..
CONTINUED FROM PREVIOUS PAGE.
Finally, on behalf of the SPNZ executive, I would like to wish you all a very happy Christmas and a profitable and (head) injury free New Year. I look forward to further discussing concussion with you at the SPNZ Symposium in March. See you there. Ka kite ano Dr Tony Schneiders
References: McCrory, P., Meeuwisse, W. H., Echemendia, R. J., Iverson, G. L., Dvořák, J., & Kutcher, J. S. (2013). What is the lowest threshold to make a diagnosis of concussion?. British Journal of Sports Medicine, 47(5), 268-271. Schneiders, A.G. (2013). A heads-up on what's new in sports-related concussion assessment and management. Physical Therapy in Sport; 14 (2), Pages 75-76. Guskiewicz, K. M., Register-Mihalik, J., McCrory, P., McCrea, M., Johnston, K., Makdissi, M., & Meeuwisse, W. (2013). Evidence-based approach to revising the SCAT2: introducing the SCAT3. British Journal of Sports Medicine,47(5), 289-293. McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, R. C., Dvorák, J., Echemendia, R. J., ... & Turner, M. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012. Journal of athletic training, 48(4), 554-575.
Dr Tony Schneiders is currently senior lecturer at the University of Otago and has been actively researching concussion in sport for the last 10 years. His work on the sideline assessment of sports concussion appears in the last two versions of the Sports Concussion Assessment Tool (SCAT). Tony is on the executive of the International Federation of Sports Physical Therapy and the Associate Editor for Australasia of the journal Physical Therapy in Sport. Early next year he will be taking up the role of Discipline Leader Physiotherapy and Professor at the University of Central Queensland.
SPNZ SYMPOSIUM 2014
SPNZ Symposium Rotorua 15-16 March 2014 SPORT AND EXERCISE ACROSS THE LIFESPAN
Confirmed Key Note Speakers: Professor Craig Purdam Mary Magarey Free Workshops:
Head of Physiotherapy Australian Institute of Sport
Specialist APA Sports & Musculoskeletal Physiotherapist
Craig Purdam – Hamstring Injuries
Mary Magarey – Shoulder Injuries
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Other Great Speakers Include: Dr Ben Speedy - Exercise and the older person Dr Nic Gill - All Blacks Trainer Dr Erica Hinckson - Exercise in children
Mr Andy Stokes - Shoulder surgery through the ages Dr Tony Schneiders - Concussion Dr Lynley Anderson - Sports ethics
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CLINICAL SECTION ARTICLE REVIEW Day of Injury Assessment of Sport-related Concussion
McCrea M, Iverson G, Echemendia R, Makdissi M, Raftery M (2013), Day of injury assessment of sport-related concussion. British Journal of Sports Medicine 47:272-284. doi 10.1136/bjsport-2013-092145.
Clinicians consider that concussion is among the most complex injuries in sports medicine to diagnose, assess and manage. It is a clinical diagnosis based largely on the observed injury mechanism, signs and symptoms. Sportsrelated concussion is not necessarily synonymous with loss of consciousness or frank neurological signs. Mild concussion may induce slight confusion without clearly identifiable retrograde or post-traumatic amnesia. It also cannot be diagnosed by neuroimaging (CT or MRI). A standardisation movement of identifying concussion will ensure that athletes and clinicians (to name a few) are able to recognise the signs and symptoms that indicate possible concussion. Performance-based assessment measures may be superior to an athlete’s reporting of symptoms which might be unreliable due to the athletes’ tendency to under-report or fail to recognise their symptoms. Standardised tests have been devised to provide a more objective performance based method of measuring post injury recovery and determining an athlete’s fitness to return to play. The aim of the article was to review whether the existing tests and measures currently used are sensitive enough and reliable enough on the day of injury to assist clinicians in accurately evaluating sports-related concussion. The authors conducted a thorough search of the literature of the main databases for relevant sub-headings relevant to sports-related concussion. Articles looking at the assessment or diagnosis data collected within 24 hours of the injury were analysed. Of the original 577 articles a total of 41 qualified for the review. Symptom Rating Scale Most common and consistently reported acute symptoms across the studies are headaches, dizziness and some form of mental state disturbance such as mental clouding, confusion or a slowing down feeling. Other acute symptoms include visual problems, fatigue and nausea. Some observational signs included a dazed facial expression and unsteady gait.
Post Concussion Scale; 0.88-0.94 internal consistency in college students and 0.92-0.93 in concussed athletes.
SCAT2; includes symptom ratings, balance testing and cognitive screening. Normative values available, but data not available on large samples of concussed athletes.
Concussion Symptom Inventory (CSI); 12 item scale that was developed using samples from 16,000 noninjured athletes and 600 concussed athletes.
Neurocognitive Tests Most studies used brief cognitive screening tests intended for rapid assessment, side-line or rink side. Few studies used conventional paper and pen neuropsychological testing within 24 hours of injury. Neuropsychological tests can detect changes across multiple domains of cognitive function that are susceptible to the acute effects of concussion such as cognitive processing speed, working memory, attention and concentration, new learning and memory and executive functioning. A high percentage of symptomatic athletes exhibited a significant decline in both computerised and conventional neuropsychological testing on the day of injury. The studies illustrated significant decline in cognitive functioning compared with an athlete’s individual pre-injury baseline performance, relative to the performance of non-injured control athletes.
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CLINICAL SECTION ARTICLE REVIEW CONTINUED... CONTINUED FROM PREVIOUS PAGE. Postural stability/balance tests
Numerous studies illustrate that balance is typically affected in concussed athletes in the early post-injury stage. The majority of studies examine group data in concussed athletes compared with their own baseline and/or compared with uninjured controls. Most, but not all, concussed athletes had significant balance deficits following injury. Balance is an important component of the sideline assessment. Electrophysiological Tests These are used to examine athletes and non-athletes following concussion; only recently have these been used during the acute phase of injury. Studies have reported significant differences using qEEG between mild-moderate concussion and control groups. CONCLUSION This review illustrates that concussion produces an excess of self-reported symptoms and impairments in cognitive functioning, balance and other functional capacities during the acute (24 hour) initial phase. These tests do not diagnose if concussion has occurred, they provide data on the physiological, psychological and behavioural changes associated with the injury. These aid the clinician in the overall diagnosis, injury severity, assessing clinical recovery and determining return to play. The literature highlights the use of symptoms scales combined with functional tests. The concussed athlete can display a complex set of symptoms and therefore a multidimensional approach that integrates assessment of self-reported symptoms and other functional domains (cognitive function and balance) is recommended to maximise the sensitivity of clinical evaluation on the day of injury.
Reviewed by Charlotte Raynor MPhty, BSc(Hons), NZRP, MNZSP
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Sports Concussion - Assessment and Prevention www.sportsphysiotherapy.org.nz/resources
Onfield assessment of concussion in the adult athlete Putukian M, Raftery M, Guskiewicz K et al (2013). Onfield assessment of concussion in the adult athlete. British Journal of Sports Medicine 47:285-288. Article Summary This article is systematic review investigating onfield concussion assessment and management. A search was conducted in the PubMed, MEDLINE, Psych Info and Cochrane Library databases using a variety of associated keywords. Inclusion/exclusion criteria were then applied to get the final number of articles. These articles were then reviewed by the authors with the objective of reviewing the evidence for what is ‘best practice’ for evaluating the adult athlete on the sports field. Additionally they also looked at whether an athlete with concussion should return to play on the same day, what to do for situations in the community when no doctor is available, and the benefits of remote notification of potential concussive events on the playing field. Prior consensus statements and sideline assessment tools were also reviewed. This article suggests that the onfield assessment of an athlete is geared towards excluding cervical spine injury and serious brain injury, while evaluating the general disposition of the athlete. If signs and symptoms of concussion are noted the athlete should be removed from play and evaluated on the sideline. The sideline concussion test should include a symptom checklist, balance assessment, and cognitive assessment such as the SCAT3 or another standardised sideline assessment tool. But clinical suspicion should overrule a negative SCAT3 or other sideline assessment. The research indicated a ‘no return to play in the same game or same day’. This was due to the fact that symptoms may be delayed and not be present at initial assessment. In the event that no doctor is present at a sporting event when a possibility of a concussion exists, the player should be removed from the field. The player should be observed by a responsible adult, and transported to medical care by ambulance if there is concern. Medical evaluation is recommended prior to return to practice or play. The benefits of remote notification of potential concussive events appears unclear. Clinical Applications This article was very clinically relevant and provided quite clear guidelines for the assessment and management of concussion. It highlighted the need for the use of a standardised assessment such as the SCAT3. So it is important to be familiar with such tools and be comfortable using them. But it also noted that clinical suspicion overruled a ‘negative’ SCAT3. This was really important and emphasised the need to back our own clinical assessment and if concussion was still suspected then the athlete should not return to the field of play. The guidelines for ‘return to play’ and ‘if no Doctor is present’ are also quite useful and should aid the decision making process in this event.
Reviewed by Greg Usherwood MPhty, BPhEd
For more information about SCAT3 click here
Sports Concussion - Assessment and Prevention continued…….. www.sportsphysiotherapy.org.nz/resources
What are the most effective risk-reduction strategies in sport concussion? Benson BW, McIntosh AS, Maddocks D et.al. (2013). British Journal of Sports Medicine 47:321-326. Article Summary This was a review paper, looking at the effectiveness of protective equipment (head gear and mouth guards), rule changes (in ice hockey), neck strength and legislation in reducing the risk of concussion. They looked at a variety of studies covering rugby, American and Australian football, and ice hockey. “Concussion may be caused either by a direct blow to the head or an indirect blow elsewhere to the body that creates an ‘impulsive’ force that is transmitted to the head.” The best treatment for concussion appears to be prevention, but what are the best ways to prevent it. This appears to be a little hard to answer, with most of the studies looked at in this review showing little conclusive evidence in reducing the incidence of concussion. Three studies looking at protective equipment were reviewed, two showed some minor reductions in concussion, one for a customised mouthguard in American Football, and the other in standard head gear in amateur Australian Rugby players, however both studies had limitations which called into question the validity of the results. The third study looked at headgear in New Zealand Youth Rugby. This showed no difference between no headgear, standard thickness and increased thickness. Again the study had limitations which needed to be considered along with the results. Neck strength is another factor thought to have a role in concussion, but studies were of limited clinical value, as they did not look at reduction of concussion on the field. So no meaningful, practical conclusions could be drawn in regards to neck strength and reduction in concussion. The last variable looked at was rule and legislation changes. It seemed that these things may have the most potential for concussion reduction; however there was a paucity of studies looking into this. The Rugby Smart programme in New Zealand has shown a reduction in claims for concussion and brain injury since its introduction.
Clinical Applications Clinically it seems all of the above measures may have some merit, and shouldn’t be “thrown out” because none of them showed an increase in concussion rates and further studies of better quality may still show that they are effective. Mouthguards have also been shown in other studies to be of great benefit in reducing dental injuries. Programmes for coaches and referees have great potential but need to be run regularly so that as coaches move on new coaches are kept up-to-date with best practice guidelines. The authors state that: ’’From a biomechanical perspective, the most effective method to prevent concussion is to minimise the likelihood and/or severity of a head impact” however “sport-governing bodies need to carefully consider potential injury trade-offs associated with the implementation of injury-prevention strategies.” In conclusion it appears that more high-quality research is needed to determine which factors are most effective in reducing the incidence of concussion.
Reviewed by Karen Carmichael BSc, BPhty, M(SportsPhysio)
Sports Concussion - Assessment and Prevention continued…….. www.sportsphysiotherapy.org.nz/resources
What is the lowest threshold to make a diagnosis of concussion? McCrory, P., Meeuwisse, W. H., Echemendia, R. J., Iverson, G. L., Dvořák, J., & Kutcher J. S. (2013).
What is the
lowest threshold to make a diagnosis of concussion? British Journal of Sports Medicine, 47, 268–271. doi:10.1136/ bjsports-2013-092247
Article Review This systematic review looks at the evidence for diagnosing a sports-related concussion. The majority of concussions occur without loss of consciousness or neurological signs and most cannot be diagnosed with neuroimaging. There is no one reliable test or symptom that clinicians can use to diagnose concussion in the sporting environment. Therapists can face significant pressures to make a rapid assessment of an athlete to return them to play. Concussion results in a variety of somatic, cognitive and neurobehavioral symptoms that are typically the most severe during the first 24–48 hours and lessen over several days to weeks. When obvious signs exist (i.e. loss of consciousness or concussive convulsions) the diagnosis is relatively straightforward; however, there may be difficulty when symptoms and/or cognitive disturbance are delayed or the signs are less clear. Some of the characteristic signs of concussion include mental confusion, memory and balance disturbance. Over the course of the first 24 hours, the most common symptoms include headache, nausea, dizziness and balance problems, visual disturbances, confusion, memory loss and fatigue. The pathophysiology of sports concussion remains poorly understood. There appears to be a period of vulnerability following concussion where brain metabolism and function are altered. During this time even a mild second concussive episode may cause significant additional and/or dramatic brain damage. Athletes suspected of concussion should be removed from play and evaluated thoroughly. Studies show cognitive impairments associated with the time period of glucose metabolic dysfunction lasting about 7–10 days in adult rats. The Concussion in Sport Group defines concussion as, ‘a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces’ that ‘may be caused by a direct blow to the head, face, neck or elsewhere in the body with an impulsive force transmitted to the head’. The mechanism of injury includes linear acceleration or rotational shearing forces transmitted to the brain. The terms mild traumatic brain injury (mTBI) and concussion are often used interchangeably. An mTBI however, is part of a spectrum of injury severity that reflects a pathological injury, whereas a concussion is more transient. An athlete who has any one or more of the following, needs to be removed from play with a suspected concussion and then assessed in a thorough manner. 1. Initial obvious physical signs consistent with concussion (eg, loss of consciousness, convulsion or gait unsteadiness). 2. Teammates, trainer or coaching staff observe cognitive or behavioural changes in functioning [eg, mental confusion (often manifest as slowness to answer questions and follow directions, being easily distracted, has poor concentration, vacant stare/glassy eyed or inappropriate playing behaviour) or emotional lability]. 3. The athlete reports any concussive symptoms. 4. Abnormal neurocognitive and/or balance examination (eg amnesia, confusion or other neurological abnormalities).
Reviewed by Monique Baigent BHsc (Physiotherapy)
Sports Concussion - Assessment and Prevention continued…….. www.sportsphysiotherapy.org.nz/resources
Evidence-based approach to revising the SCAT 2: Introducing the SCAT 3. Guskiewicz KM, Register-Mihalik J, Mc Crory P, et al Br J Sports Med 2013; 47: 289-293 Article Summary This article reviews the Sport Concussion Assessment Tool 2 (SCAT2); outlining the shortcomings identified, when trialled over a 4 year period. The purpose of the review is to identify the most sensitive and reliable assessment components for concussion management for inclusion in a revised version-SCAT3. There is no single ‘gold’ standard for assessing and diagnosing concussion. Concussion is still considered a functional injury, based on a combination of symptoms, physical signs, and impairment in cognitive function which cannot be structurally identified on imaging. In 2004 the Sport Concussion Assessment Tool (SCAT) was proposed by the Concussion in Sports Group (CISG) in an attempt to standardise the assessment internationally. In 2008 this tool was modified by the CISG and the SCAT2 was introduced. The purpose of this review was to search current evidence based literature to introduce a more sensitive and reliable concussion assessment and present a revised version- the SCAT3. Although to date, no studies have been conducted on the factors that may affect the SCAT2 as a whole, various studies have addressed factors that may affect the components of the SCAT2. Specifically, base rates for many symptoms are relatively high among healthy, non-concussed athletes. Factors such as gender, dehydration and oral contraceptive use in women may play a role in symptom reports. Mode of administration of the symptom checklist also may be a factor. Concerning balance, the Balance Error Scoring System (BESS), it is suggested that training fatigue, number of administrations, ankle injury, sport played, and testing environment, can have significant effect on the number of errors. Gender and order effects single leg stance and tandem gait tasks. Age and environmental factors may also complicate the concussion assessment and medical management. Some sports have attempted to modify the SCAT2 for their specific needs, eg Bull Riding. Other authors have queried specific aspects of scoring and/or the serial assessment template. The authors recommend the use of a modified tool for conducting serial assessments but conclude the need for validation. Results published on baseline values in the original SCAT, highlight the need to consider post injury results in context to an athlete’s own baseline.
Clinical Implications Based on the available evidence and practical consideration, the SCAT2 is a useful and practical concussion assessment tool. However, several modifications should be considered for refinement and inclusion in the SCAT3. There is no evidence to support the use of a composite score, however, there is great evidence to support the use of several components scored independently, in the SCAT3. Important clinical information can be ascertained through a multimodal assessment and diagnostic tool such as the SCAT3, when managing concussion.
Reviewed by Pip Sail
For more information about SCAT3 click here
Sports Concussion - Assessment and Prevention continued…….. www.sportsphysiotherapy.org.nz/resources What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Kutcher JS, McCroy P, Davis G, Ptito A, Meeuwisse WH, Broglio SP (2013). What Evidence Exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery?, British Journal of Sports
Medicine 47: 299-303. Article Summary At present there is an absence of objective tests that can confirm the presence of concussion or mild traumatic brain injury (mTBI) and diagnosis and management relies largely on subjective clinical decision making processes. It has hoped that newer diagnostic technologies will be of greater clinical use with regards to concussion diagnosis, as well as guiding treatment and recovery. This article reviewed the current literature regarding the newer diagnostic topics and/or technologies such as functional neuroimaging, Quantitative EEG (qEEG), head impact sensors, telemedicine and mobile devices/applications. Quantitative EEG qEEG is a technique that involves the computer-aided analysis of electroenceohalographic data and in contrast to standard EEG, qEEG allows for identification of subtle changes and patterns in source data. Four studies were identified which showed the ability of the technology to document physiological dysfunction in the setting of concussion and may act as a useful measure of tracking recovery if evaluated in future prospective studies. At present there is no data which analyses the ability of qEEG to provide distinguishing features of concussion and as the observed changes are non specific to the cause there is limited clinical utility of the technology. Functional Neuroimaging CT and standard MRI is of little clinical use in the diagnosis of sports related concussion, however, CT does have an important role in screening for potential bleeding or identification of skull fracture. MRI may be of benefit in monitoring of structural changes over time or evaluating concurrent pathology that complicate concussion. Functional neuroimaging refers to a subset of technologies that provide an estimating of function hence generating interest in those investigating concussion. Functional MRI (fMRI) is based on the relationship between blood flow and neuronal metabolism. It takes advantage of the different magnetic states between oxygen rich and poor blood through the use of blood –oxygen-leveldependent (BOLD) contrast technique. Advantages to using fMRI is that there is no contrast media or radiation exposure and it can be used with other measures of brain pathology. Three studies found that there were differences in the BOLD signal pattern between matched control groups and the symptomatic concussed group. There were no differences between controls and asymptomatic concussion subject. One study (Talavage et al) of American college football players found differences pre and post season in 11 subjects however only 4 had sustained a recognised concussion. Megnetoencephalography (MEG) is a brain mapping technique that records the magnetic fields produced by the brains electrical activity. It has a higher degree of temporal resolution than fMRI and readings are less distorted by the skull and scalp than EEG. There were no studies identified that used MEG in sports related concussion. It has been shown to be sensitive to mTBI in those sustaining injuries from blast and nonblast causes. Near-infrared spectroscopy (NIRS) detects changes in haemoglobin concentrations via measurement of the nearinfrared (800-2500mm) region of the electromagnetic spectrum. It is more portable than other functional neuroimaging devices and can be used on moving subjects however it only detects changes in surface tissue and not deeper brain structures. There have been no studies found using the NIRS in sports related concussion. CONTINUED ON NEXT PAGE.
Sports Concussion - Assessment and Prevention continuedâ€Śâ€Ś.. www.sportsphysiotherapy.org.nz/resources
Position emission tomography (PET) uses a biologically active molecule to introduce a positron emitting radionuclide. It has been used in military personnel with persistent concussion symptoms but there were no studies reporting its use in sports related concussion. It has been show to be sensitive to metabolic changes seen in the diagnosis mild cognitive impairments therefore PET may be used a tool for demonstrating the metabolic changes in longer term symptoms following concussion. Single photon emission CT (SPECT) uses a radioactive tracer like PET but is significantly cheaper. There were no identified studies using SPECT in sports related concussion. Head Impact Sensors Head impact sensors allow for the monitoring of impacts throughout an athletic even in the hope of providing a threshold for injury but no threshold has been discovered. Although the onboard accelerometer may not be able to accurately predict injury it may act as a screen device to alert sideline personnel that an impact has occurred. Telemedicine There is clear mismatch between the number of athletes who experience a sports-related concussion and the number of licensed health care providers who possess training in diagnosis and management of the injury. There have been no studies using telemedicine in concussion. Telemedicine has been used successful in other neurological diagnoses such as stroke where a well studied, validated and reproducible measurement tool is used. However considering concussion symptoms are much more subtle establishing techniques for remote diagnosis and management of concussion may be more difficult. Mobile Devices Mobile devices are uniquely placed to address gaps in concussion management and diagnosis. There is a need to educate all participants in sports concussion care and mobile devices provide the opportunity to download educational materials quickly. It can also be used to organise information on injury demographics, symptom timing and recovery milestones. Diagnostic screening tools such as the SCAT2 can be employed over any computing platform. There have been no studies using mobile devices for sports concussion diagnosis or management however the study found 17 applications created for sports concussion diagnosis, management or education.
Clinical Implications At present may of the newer technologies have yet to prove to have clinical utility where they can provide distinguishing features of a concussion and thus should be used with caution. Many of the technologies are expensive and impractical to administer in the general population. The use of mobile applications for concussion may be of benefit for physiotherapists involved in sport as they have instant access to education and measurement tools that can be employed easily and wherever it is needed.
Reviewed by Louise Turner B App Science (Physiotherapy), Masters of Health Practice (Musculoskeletal Physiotherapy)
JOSPT www.jospt.org JOSPT ACCESS All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at firstname.lastname@example.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the “Forgotten your password” link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.
Current Issue December 2013 CASE REPORT Varied Response to Mirror Gait Retraining of Gluteus Medius Control, Hip Kinematics, Pain, and Function in Two Female Runners With Patellofemoral Pain
CLINICAL COMMENTARY The Modified Sleeper Stretch and Modified Cross-body Stretch to Increase Shoulder Internal Rotation Range of Motion in the Overhead Throwing Athlete
MUSCULOSKELETAL IMAGING Acute Exertional Rhabdomyolysis Fracture of the Lateral Femoral Condyle
RESEARCH REPORT Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound Quadriceps and Hamstrings Morphology Is Related to Walking Mechanics and Knee Cartilage MRI Relaxation Times in Young Adults RESEARCH REPORT Arthritis Self-Efficacy Scale Scores in Knee Osteoarthritis: A Systematic Review and Meta-analysis Comparing Arthritis Self-Management Education With or Without Exercise Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the Ankle The Effect of Burst-Duty-Cycle Parameters of Medium-Frequency Alternating Current on Maximum Electrically Induced Torque of the Quadriceps Femoris, Discomfort, and Tolerated Current Amplitude in Professional Soccer Players Variability in Diaphragm Motion During Normal Breathing, Assessed With B-Mode Ultrasound
CRICKET SHOES: FROM THE GROUND UP, NO SHORTCUTS cont... The Cricket category has always been an excellent way for ASICS to demonstrate its commitment not only to investing in a diverse range of sports but also creating well thought out, high quality products exclusively for the passions and interests of the Australian/New Zealand population. I’m sure I have previously mentioned that ASICS is a unique company in that it allows us to design and develop shoes here that are relevant specifically to the Australian and New Zealand market. We are fortunate in this regard as some of the sports we love dearly are quite small when you look at them from a global perspective. Because of the limited population in our region, south the equator, it is common for footwear brands to take shoes designed for use in the Northern Hemisphere, tweak them slightly and then distribute them down here saying: “Here you go sell this as a cricket shoe”. Instead, by allowing us to build our own shoes, despite how expensive or time consuming they are to research and construct, they make our shoes more technical and better suited to the sports they are being marketed for. The ASICS Cricket range is a very good example of the diligent attitude displayed by our parent company in Japan with respect to the sports we love. Cricket shoes are highly specialized. They are not like running shoes, cross trainers or even netball shoes that can at a push be worn for multiple sports. They have been purpose built exclusively for one use: Cricket. Because the spread of numbers sold is limited and production numbers are small (from a global perspective) it means in some cases it can literally take us years to recoup the money spent on midsole/ outsole tooling expenses. Furthermore, cricket shoes are one of, if not, the most complicated shoes to put together from a tooling perspective at the factory level. They have internal spike plates, midsoles that need to withstand an immense amount of stress, wear and tear and uppers that need to do the same…Fast bowlers for example are tremendously hard on their shoes and also require high levels of protection. This is why I take so much pride in the fact that ASICS cricket shoes are not rehashed nor altered shoes but rather unique shoes designed and built from the ground up for this sport in particular. The humble cricket shoe has in fact evolved significantly from the early cricket shoes that ASICS once sold. Originally, they were constructed using golf plates which were quite rigid and helped the wearer to get a firmer grip on the ground when batting. Unfortunately they were not so crash hot to walk around in. Funnily, the advances that we have made in cricket shoe design are now influencing the golfing industry as golfers now strive for the grip and flexibility demonstrated by the flexible PU plate we embed into our current cricket shoes. Once we had researched and produced a few ranges it became apparent to us that there was a need to provide different shoes for different aspects of the game. The GEL Strike Rate is an interesting development in that it was designed to act just like a running shoe and provide incredible forefoot
flexibility and rearfoot cushioning. The main inspiration for its design was the batsmen and fielders in the 20/20 circuit. To achieved the desired flexibility and reduce weight whilst still providing outstanding grip special inserts were used with an integrated pin system, similar to that used in track and field events but specifically positioned for the requirements of cricket. Additionally, these pins were bound by PU strips to prevent them from being pulled out during play. The underfoot feel of this shoe is amazing. Subsequently, all the research and development being done so successfully here at home has led other countries like England and India to approach us for the supply of their cricket shoes. As a matter of fact, while I sit here and write this I am in India, on the final leg of my tour, showing the range for the back half of 2014 to our distributors in Bangalore, Mumbai and Delhi. India is an amazing country that has both a passion for cricket and a desire for access to better quality, higher performing product. As a result our high end cricket shoes are booming here. Simply put, they too have noticed that ASICS built shoes that work better. According to one distributor; Indian consumers are like Australian consumers in that they value quality product and don’t get sucked in too much with gimmicks and hype. We have been lucky enough in India to have many of the national players wearing our shoes. Most of these players have been recommended our shoes by others on the international circuit, predominantly health professionals. At ASICS we are so grateful for the support and trust of the medical fraternity here in Australia. During my trips to India I have been lucky enough to have met some of the most revered names in Indian cricket; some current and some retired. These players have nothing but praise and thanks for the ASICS shoes they had worn during their careers or are currently wearing. That is quite a buzz knowing that it all started here in Australia. Now all we have to do is win the Ashes back and I will be a happy man! Participation in off road running events is increasing as elite and recreational runners alike are taking a break from the pavement and flocking to the mud, rock and dirt of a good trail. The hard surfaces and repetitive stressors associated with road running and the increased demand on the bones and muscles are physiologically taxing. Trail running on the other hand unloads the impact on the body which acts to prevent injury while maintaining high mileage training for aerobic endurance. With this in mind the new ASICS Fuji Sensor was created; a high performance trail shoe built on a stable base with superior cushioning. Regards, Mark Doherty GM Product
SEPTEMBER 2013 FORERUNNER
SPNZ SYMPOSIUM 2014 ACRS THE
SPNZ Symposium Rotorua 15-16 March 2014 SPORT AND EXERCISE ACROSS THE LIFESPAN Key Note Speakers: Professor Craig Purdam (Australia) HEAD OF PHYSIOTHERAPY, AUSTRALIAN INSTITUTE OF SPORT Craig Purdam is the Head of Physical Therapies at the Australian Institute of Sport. He has worked as a clinician in elite sport for over 30 years and has been a physiotherapist at five Olympic Games (1984-2000) and a longstanding physiotherapist to the Australian National Men’s Basketball team over that period. He has also had other associations with the Australian national swimming, track and field and rowing teams. He was awarded the Australian Sports medal in 2000 and in 2009 was appointed an adjunct Professor to the University of Canberra. His undergraduate qualification was gained in 1975, a postgraduate diploma in Sports in 1992, a Masters in Sports in 2000. He was awarded specialist status in Sports Physiotherapy through Fellowship of the Australian College of Physiotherapists in 2009.
Mary Magarey (Australia) SPECIALIST PHYSIOTHERAPIST APA SPORTS AND MUSCULOSKELETAL PHYSIOTHERAPIST Mary is a Fellow of the Australian College of Physiotherapists as a Specialist Musculoskeletal and Sports Physiotherapist, the only Fellow in Australia in two areas of specialty. She also has a Doctorate (PhD) in Physiotherapy. Her area of particular specialty is the shoulder but she is also passionate about injury prevention, particularly for those athletes in throwing sports. Mary has over 20 years experience examining and managing complex shoulder problems, in particular problems with shoulders of athletes who throw. She has been teaching physiotherapy at the University of South Australia for over 30 years.
For speakers’ profiles and provisional programme check out the Symposium website.
CONTINUING EDUCATION CALENDAR
Upcoming courses and conferences in New Zealand and overseas in 2013 & 2014. For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/
LOCAL COURSES & CONFERENCES When?
15-16 March 2014
3rd SPNZ Symposium
1 February 2014
University of Otago - Postgraduate Study - Introduction - Supporting Healthier Lifestyles
21-22 February 2014
Mulligan Concept - Update with Brian Mulligan
1-2 March 2014
Mulligan Concept Functional Treatment of the SIJ and Pubic Symphysis
4 April 2014
Optimising 3D Biomechanics, The Pelvic and Lumbar Spine - Assessment & Treatment
4 April 2014
Retraining Optimal Dynamic Function of the Hip Region
APA CPD EVENT FINDER SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and conferences at APA member rates. This includes all webinars and podcasts (no travel required!). To see a full list visit the APA and SPA Events Calendar Course
Sports Level 1
8-9 Feb 2014
Sports Level 1
Kent Town, SA
15-16 Feb 2014
Hamstring Assessment, Prevention and Rehabilitation
St Leonards, NSW
16 Feb 2014
Sports Level 1
22-23 Feb 2014
24 Feb, 24 Mar 2014
Tendinopathy Pain, Pathology and Management
5 Mar 2014
Sports Level 1
Warners Bay, NSW
8-9 Mar 2014
North Ryde, NSW
8 Mar 2014
The Sporting Elbow, Wrist and Hand
Woodville South, SA
15 Mar 2014
Sports Level 2
28-30 Mar 2014
SPNZ Bulletin December 2013