Douglas B. McKeag

Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

On-field predictors of neuropsychological and symptom deficit following sports-related concussion.

ObjectiveInvestigate the relationship between on-field markers of concussion severity and postinjury neuropsychological and symptom presentation in an athlete-specific population. DesignCase control study. SettingMulticenter analysis of high school and college athletes. ParticipantsA total of 78 athletes sustaining sports-related concussion were selected from a larger sample of 139 concussed athletes. Assessment of Predictor VariablesOn-field presence of disorientation, posttraumatic amnesia, retrograde amnesia, and loss of consciousness. Main Outcome MeasuresImPACT, a computerized neuropsychological test battery, was administered pre-season and, on average, 2 days postinjury. Good postinjury presentation (n = 44) was defined as no measurable change, relative to baseline, in terms of both ImPACT memory and symptom composite scores. Poor presentation (n = 34) was defined as a 10-point increase in symptom reporting and 10-point decrease in memory functioning (exceeding the 80% confidence interval for measurement error on ImPACT). Athletes failing to meet good or poor selection criteria (n = 61) were not included in the analysis. ResultsOdds ratios revealed that athletes demonstrating poor presentation at 2 days postinjury were over 10 times more likely (P < 0.001) to have exhibited retrograde amnesia following concussive injury when compared with athletes exhibiting good presentation. Similarly, athletes with poor presentation were over 4 times more likely (P < 0.013) to have exhibited posttraumatic amnesia and at least 5 minutes of mental status change. There were no differences between good and poor presentation groups in terms of on-field loss of consciousness. ConclusionsThe presence of amnesia, not loss of consciousness, appears predictive of symptom and neurocognitive deficits following concussion in athletes. Athletes presenting with on-field amnesia should undergo comprehensive and individualized assessment prior to returning to sport participation. Continued refinement of sports concussion grading scales is warranted in lieu of consistent findings that brief loss of consciousness is not predictive of concussion injury severity.

Does loss of consciousness predict neuropsychological decrements after concussion

OBJECTIVE To investigate the importance of loss of consciousness (LOC) in predicting neuropsychological test performance in a large sample of patients with head injury. DESIGN Retrospective comparison of neuropsychological test results for patients who suffered traumatic LOC, no LOC, or uncertain LOC. SETTING Allegheny General Hospital, Pittsburgh, Pennsylvania. PATIENTS The total number of patients included in this study was 383. MAIN OUTCOME MEASURES Neuropsychological test measures, including the visual reproduction, digit span, and logical memory subtests of the Wechsler memory scale (revised), the Trail Making test, Wisconsin Card Sorting test, Hopkins Verbal Learning test, Controlled Oral Word Association, and the Galveston Orientation and Amnesia test (GOAT). RESULTS No significant differences were found between the LOC, no LOC, or uncertain LOC groups for any of the neuropsychological measures used. Patients who had experienced traumatic LOC did not perform more poorly on neuropsychological testing than those with no LOC or uncertain LOC. All three groups demonstrated mildly decreased performance on formal tests of speed of information processing, attentional process, and memory. CONCLUSION The results of this study cast doubt on the importance of LOC as a predictor of neuropsychological test performance during the acute phase of recovery from mild traumatic brain injury. Neuropsychological testing procedures have been shown to be sensitive in measuring cognitive sequelae of mild traumatic brain injury (concussion) in athletes. The failure of this study to find any relationship between LOC and neuropsychological functioning in a large sample of patients with mild head trauma calls into question the assignment of primary importance to LOC in grading severity of concussion. This study also does not provide support for the use of guidelines that rely heavily on LOC in making return-to-play decisions. Continued research is necessary to determine the relative importance of markers of concussion in athletes.

Single leg balance test to identify risk of ankle sprains

Background: Ankle sprains are a common and potentially disabling injury. Successful prediction of susceptibility to ankle sprain injury with a simple test could allow ankle sprain prevention protocols to be initiated and help prevent disability in the athletic population. Objective: To investigate the ability of the single leg balance (SLB) test, carried out at preseason physical examination, to predict an ankle sprain during the autumn sports season. Design: Prospective cohort study Setting: High school varsity athletics and intercollegiate athletics. Main outcome measure: Ankle sprains in athletes with positive SLB tests. Results: The association between a positive SLB test and future ankle sprains was significant. Controlling for confounding variables, the relative risk for an ankle sprain with a positive SLB test was 2.54 (95% confidence interval, 1.02 to 6.03). Athletes with a positive SLB test who did not tape their ankles had an increased likelihood of developing ankle sprains. The relative risk for ankle sprain for a positive SLB test and negative taping was 8.82 (1.07 to 72.70). A history of previous ankle injury was not associated with future ankle sprains in this study. The κ value for interrater reliability for the SLB test was 0.898 (p<0.001). Conclusions: An association was demonstrated between a positive SLB test and ankle sprain. In athletes with a positive SLB test, not taping the ankle imposed an increased risk of sprain. The SLB test is a reliable and valid test for predicting ankle sprains.

Sport-related concussion: Factors associated with prolonged return to play

Objective:To assess predictive value of concussion signs and symptoms based on return-to-play timelines. Design:Physician practice study without diagnosis that includes presentation, initial and subsequent treatment, and management of concussion. Setting:National multisite primary care sports medicine provider locations. Participants:Twenty-two providers at 18 sites; 101 athletes (91 men, 10 women in the following sports: 73 football, 8 basketball, 8 soccer, 3 wrestling, 2 lacrosse, 2 skiing, 5 others; 51 college, 44 high school, 4 professional, and 2 recreational). Main Outcome Measurements:Duration of symptoms, presence of clinical signs, and time to return to play following concussion. Results:One hundred one concussions were analyzed. Pearson χ2 analysis of common early and late concussion symptoms revealed statistical significance (P < 0.05) of headache >3 hours, difficulty concentrating >3 hours, any retrograde amnesia or loss of consciousness, and return to play >7 days. There appeared to be a trend in patients with posttraumatic amnesia toward poor outcome, but this was not statistically significant. Conclusions:When evaluating concussion, symptoms of headache >3 hours, difficulty concentrating >3 hours, retrograde amnesia, or loss of consciousness may indicate a more severe injury or prolonged recovery; great caution should be exercised before returning these athletes to play.

Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement.

Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term “Team Physician” is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.

The physically-challenged athlete: Medical issues and assessment

AbstractThe rate and pattern of injuries is similar in both physically-challenged and able-bodied athletic participation. However, understanding of the unique medical issues faced by physically-challenged athletes is necessary in conducting appropriate pre-participation evaluations and developing strategies for injury prevention and medical management. Review of the literature provides insight for choosing relevant tests and interpreting components of the physical examination for this population. More research is needed in the management of medical problems specific to the physically-challenged athlete.

Traumatic deep vein thrombosis in a soccer player: A case study

A 42 year-old male former semi-professional soccer player sustained a right lower extremity popliteal contusion during a soccer game. He was clinically diagnosed with a possible traumatic deep vein thrombosis (DVT), and sent for confirmatory tests. A duplex doppler ultrasound was positive for DVT, and the patient was admitted to hospital for anticoagulation (unfractionated heparin, warfarin). Upon discharge from hospital the patient continued oral warfarin anticoagulation (six months), and the use of compression stockings (nine months). He followed up with his family doctor at regular intervals for serial coagulation measurements, and ultrasound examinations. The patients only identified major thrombotic risk factor was the traumatic injury. One year after the initial deep vein thrombosis (DVT) the patient returned to contact sport, however he continued to have intermittent symptoms of right lower leg pain and right knee effusion.Athletes can develop vascular injuries in a variety of contact and non-contact sports. Trauma is one of the most common causes of lower extremity deep vein thrombosis (DVT), however athletic injuries involving lower extremity traumatic DVT are seldom reported. This diagnosis and the associated risk factors must be considered during the initial physical examination. The primary method of radiological diagnosis of lower extremity DVT is a complete bilateral duplex sonography, which can be augmented by other methods such as evidence-based risk factor analysis. Antithrombotic medication is the current standard of treatment for DVT. Acute thrombolytic treatment has demonstrated an improved therapeutic efficacy, and a decrease in post-DVT symptoms.There is a lack of scientific literature concerning the return to sport protocol following a DVT event. Athletic individuals who desire to return to sport after a DVT need to be fully informed about their treatment and risk of reoccurrence, so that appropriate decisions can be made.

Medical students' experience with musculoskeletal diagnoses in a family medicine clerkship

Many US medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses the students experience. This study examines patients encountered with musculoskeletal diagnoses using quantitative data collected by family practice clerkship students. Over a two-year period, 445 students completed 7202 patient encounter forms for patients with a musculoskeletal diagnosis, noting their confidence level and responsibilities. Of the 78 854 diagnoses presented, 7850 were for musculoskeletal conditions. Students reported a lower level of confidence in diagnosing and treating musculoskeletal patients when compared with their confidence level in dealing with non-musculoskeletal patients. They are generally more actively involved with musculoskeletal patients by observing, seeing the patient before the preceptor, taking a history, suggesting treatment and discussing the case with the preceptor. At the study school, this fact may reflect that formal curricular teaching in orthopedics occurs in the fourth year, after students have completed their family medicine clerkship. It is concluded that by using a relatively simple computerized database, areas of need for curricular change can be identified. Our study verifies that additional training is needed in the area of musculoskeletal diagnoses.

Concussion consensus: raising the bar and filling in the gaps.

The 3 International Consensus Statement on Concussion in Sport was published in last month’s issue of CJSM; it was the product of a meeting held in Zurich, Switzerland, in October 2008. This meeting and the resulting publication were intended to build on the consensus statements produced from international conferences held in Vienna (2002) and Prague (2005). The organizers of the Zurich conference used the formalized consensusbuilding process described by the US National Institutes of Health. The outcome of the Zurich meeting represents another significant step forward in our understanding and approaches to the management of sports-related concussion. We support the consensus position that the classification of concussion into ‘‘simple’’ versus ‘‘complex’’ be abandoned. The collective clinical experience of sports medicine points to little practical value in making this distinction. We agree that in some sports, such as soccer and rugby, there exists a significant obstacle to providing appropriate medical care as the result of rules that do not allow for stoppage in play and timely evaluation of injured athletes on the field. We are pleased to see the concept of ‘‘special populations’’ reinforced, with recognition of the unique qualities of the pediatric population being especially noteworthy. Consensus statements, by their nature, suffer from a common malady: They are frequently products of compromise. They may reflect the ‘‘average’’ or agreed-upon thinking on a subject. As much as we would like such statements to be evidence based, they often wander into experiential thought and anecdote. Frequently, clinically relevant issues are not discussed at all because of a lack of background science, and if they are, the group’s ‘‘best guess’’ becomes consensus. Often, these factors combine to create a very real gap between a consensus statement and its true clinical applicability. Although we celebrate the achievement of the 3rd International Consensus Statement on Concussion in Sport, we wish to take this opportunity one step further. What follows is a discussion that not only highlights what we feel are the important givens contained in the statement, but also addresses gaps we feel were left unfilled. In the end, our goal is to provide the reader with a more clinically complete focused framework for concussion management.