Authors: W. Meehan

Journal: Clinics in Sports Medicine

Date: 2011

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Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this “traumatic brain injury”, particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an “invisible injury”, Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan’s first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline – his preferred treatment) as well as the potential negative effects (“rebound”) of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan’s academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.

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This one’s for the manual therapists out there. A brief little review of 2 landmark papers pertaining to fact joint pain and referral patterns.

Part 1A:

CERVICAL ZYGAPOPHYSEAL JOINT PAIN PATTERNS I: A study in normal volunteers (Dwyer et. al., Spine, 1990)

A study determining whether or not pain from a given joint assumed a characteristic distribution…where the pain pattern in a given patient might be used as an accurate indicator for clinically diagnosing the symptomatic joint

4 asymptomatic subjects were used

A contrast medium was injected into the joints, acting in a prevocational matter (experimental stimulus). Subjects were then examined for tenderness in both the cervical and shoulder regions

The distributions of evoked pain were recorded and a visual analog scale was completed

The medial branches of the dorsal primary rami were also blocked

The pain felt was deep and achy in quality

Pain patterns:

• C2-3: into the head
• C3-4: (coinciding with the levator scapula) was more rostral than C4-5 (which concentrated by the angle formed by the shoulder and neck)
• C5-6: covered the top of the scapula and shoulder above the level of the scapular spine laterally
• C6-7: extended caudally to the inferior angle of the scapula

Following the analgesic blocks, the subjects unexpectedly demonstrated a slight hypesthesia over the area coinciding with the previous recorded area of invoked pain and tenderness

Concluded that the cervical z-joints can be sources of pain, including referred pain and that a physiological mechanism must exist whereby pain stemming from a z-joint can be referred into the related limb or limb girdle

Further, cervical z-joint pain is distributed in a pattern characteristic of its segmental origin

Click here for Part 1B

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For my first post, I would like to summarize the developments of the most recent symposium on concussion in sport. This was held in Zurich last year and brought together the “big dawgs” in sports concussion. Since this is merely a summary, I ask that you all read the original document in its entirety as well as my summary found at Research Review Service.

Here’s the summary:

The 3^rd and most recent symposium was based on the need to address issues pertaining to acute simple concussion, return-to-play, complex concussion and long-term issues, pediatric concussion, and future directions.  Additionally, this statement examined and addressed the management issues discussed in the first and second symposia.

• Updated classification of concussion in sport: The use of the terms “simple” and “complex” to classify concussion were abandoned at this symposium.
• Sideline evaluation of acute concussion: While the need for a thorough, post-injury evaluation was established since the first consensus statement, it was agreed that an appropriate medical assessment be performed in all cases and that rule modifications may be necessary in some sports in order for this to occur. Such modifications would enable a proper assessment to be performed without disrupting the game in play (e.g.. rugby) or punishing the team involved (e.g.. soccer).
• Concussion management and same-day return to play: It was recognized that certain settings in adult athletics may have experienced personnel, such as neuropsychologists, and resources (neuroimaging) at their immediate disposal. In such situations, return to play may follow a more rapid process based in part on evidence collected from research in professional football. However, was the conservative treatment of younger athletes (<18 yoa) was strongly suggested.
• Modifying factors: Identified at this symposium were a range of specific modifiers with the potential to complicate cases and therefore, warrant advanced care and attention. Prolonged LOC (> 1 minute) was an example of such a modifier. Gender on the other hand, was reported inconclusive as a modifier; however, sex was accepted as a potential risk factor and/or influence of injury severity. Further, the presence of immediate motor signs and/or convulsions were reported to warrant no more than standard concussion management.
• Children and adolescents: Updating from the previous developments of the Vienna and Prague statements was the statement that the standard evaluation and management recommendations be applicable only to those aged 10 and older. All assessments performed on younger athletes must include age-appropriate symptom checklists. In addition, cognitive testing was recommended to be developmentally sensitive, especially in those presenting with learning disorders and/or ADHD. A more conservative RTP approach was also reiterated in this population.
• Elite athletes: All organized high-risk sports should incorporate these formal baseline neuropsychological screening assessments regardless of age or level of play.
• The sport concussion assessment tool 2 (SCAT2): The original SCAT card was revised and includes a “pocket” SCAT2.

The SCAT2 now boasts four pages of examination resources to aid in the concussion assessment protocol. Specifically, the previously integrated evaluation components have been expanded to its original sources and the SCAT2 now incorporates the Glasgow Coma Scale (GCS), the Modified Maddocks Questionnaire and the Standardized Assessment of Concussion (SAC) as separate entities within. Identified in this tool is its potential use for baseline testing.  The quantification of injury evaluation plays a significant role in the updated SCAT2 and permits the tabulation of an “overall” test score. Unfortunately, however, a definitive “cut-off” score has yet to be determined. Useful though is the ability to isolate and quantify the SAC score for use in the management of a particular concussive event.

A section devoted to balance testing (based on the modified Balance Error Scoring System) was also incorporated. This protocol utilized the double leg, single leg, and tandem stances. A finger-to-nose task was also included to isolate upper limb coordination. Finally, a detachable section on the final page permits the provision of advice to those sustaining a concussive injury.

…well there you have it. Again, I advise you to read both the document in its entirety as well as my review posted on www.researchreviewservice.com

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