Playing it Safe
Monday January 23, 2012
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Baseline neurological tests administered by PTs can help monitor youth athletes for concussions and inform back-to-play recovery strategies. "Neurocognitive baseline tests should be part of every youth athlete's checkup along with pre-participation physicals that make sure the heart, lungs and joints are functioning properly," said Jennifer Christie, PT, DPT, clinic director of Texas Physical Therapy Specialists in San Antonio.
Computer testing to establish a baseline of a healthy student athlete's normal problem-solving abilities, verbal and visual memory and reaction times for certain functions can help determine later whether a concussion has occurred on the playing field, said Christie, who helped initiate a screening program in central Texas.
Under the initiative, hundreds of local school athletes are required to take a 20-minute test called ImPACT — Immediate Post-Concussion and Cognitive Testing — a baseline computerized neurocognitive exam used to help protect players in 24 National Football League teams and other sports leagues, according to ImPACT Applications Inc., based in Pittsburgh (ImpactTest.com). The original software was launched in the early 1990s.
Christie said she became aware of ImPACT when Sports Training Physical Therapy clinic network in New Jersey offered online neurocognitive testing for $20. Maureen Wilhelm, PT, DPT, started the service to make it easier for concerned parents, coaches or health professionals to familiarize themselves with the test that incorporates a symptom scale to measure post-concussive severity ranging from zero (none) to six (severe) for about 20 symptoms, including headache, dizziness, fatigue, numbness and irritability.
"At the forefront of concussion management is the implementation of baseline and post-injury neurocognitive testing," Wilhelm said. "The test takes approximately 20 minutes and measures multiple aspects of cognitive functioning." These include:
• Attention span
• Working memory
• Sustained and selective attention time
• Response variability
• Nonverbal problem solving
• Reaction time
Christie said licensing ImPACT testing technology in a community can be cost-prohibitive, a barrier that can be overcome by forming partnerships with schools, athletic clubs or healthcare facilities. Several Texas PTS clinics administer group neurological testing of athletes at school computer labs with a portion of software costs paid by student athletic fees or private donations, she said.
Hospitals, schools and athletic organizations can purchase ImPACT on a yearly subscription basis with packages that include technical support and software updates, a company spokesman said. These range from $350 annually for 75 baseline and 10 post-injury exams to $750 for 500 baseline and 50 post-injury tests, and additional tests can be purchased as needed ($10 baseline; $20 post-injury).
A lot of athletes start playing sports at a very young age and recall "having their bell rung" by frequent hits to the head, so it is likely a large number of concussions go undiagnosed, Christie said. Educating parents about the need to monitor a young athlete's head injuries is a big part of sports therapy, she said.
Making brain tests mandatory
Sports concussion is a hot button topic that has resulted in wide support for the ImPACT program, especially in the wake of studies warning about dangers of a second-impact syndrome, said Jonathan Sams, PT, DPT, a certified orthopedic, sports and strength/conditioning specialist at a Texas PTS clinic in Belvedere, 15 minutes north of San Antonio.
"If a player returns too early from a concussion, usually within 14 days, another blow to the head — even a normal hit that's not very traumatic — can result in significant swelling of the brain," Sams said. "There have been sudden deaths due to this syndrome."
Second-impact syndrome is a rare but often fatal event that is preventable by removing concussed athletes from practice or play until they can be cleared by a health professional. The syndrome causes brain swelling and bleeding that can cause death or permanent disability and can show up weeks after a first concussion is diagnosed.
An analysis of sudden death in young athletes between 1980-2009 found 261 of 1,827 deaths of athletes age 21 or younger were caused by trauma-related injuries, usually involving the head and/or neck in 22 sports. The study was published in the July 1, 2011, issue of Pediatrics. The largest number of deaths during the 30-year period were in football (148), including 17 high school athletes who sustained concussions shortly before fatal head trauma, or second-impact syndrome.
Sams conducts ImPACT tests in a partnership with Bracken Christian School. "Bracken doesn't have the resources some of the larger schools have, such as athletic trainers or team doctors," Sams said. "We offered a sharing deal to purchase the baseline tests needed and split the costs."
Sams oversees the majority of some 250 initial baseline tests at the school's computer lab across the street from his clinic. "School officials made baseline neurocognitive testing mandatory for athletes as part of an annual physical exam," Sams said. "Students won't be cleared to compete in middle school or high school high-contact sports until they take the ImPACT test."'
For high school athletes, the baseline tests are given in the freshman year and repeated in the junior year because student brains are developing and changing, said Sams.
After his son suffered a concussion playing youth football, Gino Brunello, PT, CKTP, owner of Sims Physical Therapy Clinic in Santa Maria, Calif., also led an effort to bring ImPACT testing to local schools. The clinic's athletic trainers administer the baseline tests to about 2,500 athletes at four high schools and a junior college.
The tests are given to all football, basketball, soccer and wrestling athletes preseason at school computer labs using ImPACT software purchased by the regional Marian Medical Center, where neurology experts can interpret post-injury tests for concussions and provide specialty care and recovery management.
"If a head injury occurs, we retest the athlete within the first 48 hours and if the results deviate from baseline, we send them to a doctor with the exam results for a medical evaluation," Brunello said.
Smartphones allow sideline assessment
Short of being knocked unconscious, some brain trauma can be hard to detect in the heat of a game — a situation where a smartphone application comes in handy, Sams said. A parent or coach on the sidelines can use a free app developed by ImPACT to field a short list of questions that help determine whether a concussion has occurred.
"This action triggers the next step, deciding whether to seek immediate care for the player or wait and repeat the test within 42 to 72 hours," Sams said. "If scores deviate from the normal baseline, it raises a red flag that the individual needs a more definitive diagnosis and it is in their best interest to see a neuropsychologist or other medical doctor who handles concussions."
The tool, called ImCAT (ImPACT Concussion Awareness Tool), and available for both the iPhone and Android, is designed to be used immediately after a head injury. A GPS feature records where the incident took place, a camera feature photographs the injured player and documentation is emailed to healthcare providers. ImCAT also offers home symptom monitoring for post-injury follow-up and a five-step return-to-play tiered workout schedule.
Return to play process
Sams said if medical care is recommended by a follow-up ImPACT test, the athlete is told to avoid any activity for a few days. A clinic PT also may contact the school nurse and make recommendations regarding the demands of homework, classroom events and other activities. "It's vital to not tax a developing young brain after a concussion because it can delay the healing process," Sams said. "We would also coordinate care with the school's athletic training staff and coaching staff as needed."
The student should not resume normal activities until follow-up test results return to baseline levels, Sams said. Therapists and trainers do not interpret test results because deviations in scores must be evaluated carefully by a concussion specialist, usually an MD, DO or PhD.
Once medically cleared to play again, athletes treated for concussions don't go back onto the field immediately, Sams said. Instead, they progress from light to moderate exercises to test their physical tolerance and to make sure neurological symptoms are gone.
"We help oversee some post-concussion retraining and work with school coaches to make sure it is safe for a youngster to again compete," Sams said. "As a parent myself, I would be confident if my child were cleared post-incident using the ImPACT system that he could safely return to the game." •
John Leighty is a freelance writer.
Computer testing to establish a baseline of a healthy student athlete's normal problem-solving abilities, verbal and visual memory and reaction times for certain functions can help determine later whether a concussion has occurred on the playing field, said Christie, who helped initiate a screening program in central Texas.
Under the initiative, hundreds of local school athletes are required to take a 20-minute test called ImPACT — Immediate Post-Concussion and Cognitive Testing — a baseline computerized neurocognitive exam used to help protect players in 24 National Football League teams and other sports leagues, according to ImPACT Applications Inc., based in Pittsburgh (ImpactTest.com). The original software was launched in the early 1990s.
Christie said she became aware of ImPACT when Sports Training Physical Therapy clinic network in New Jersey offered online neurocognitive testing for $20. Maureen Wilhelm, PT, DPT, started the service to make it easier for concerned parents, coaches or health professionals to familiarize themselves with the test that incorporates a symptom scale to measure post-concussive severity ranging from zero (none) to six (severe) for about 20 symptoms, including headache, dizziness, fatigue, numbness and irritability.
"At the forefront of concussion management is the implementation of baseline and post-injury neurocognitive testing," Wilhelm said. "The test takes approximately 20 minutes and measures multiple aspects of cognitive functioning." These include:
• Attention span
• Working memory
• Sustained and selective attention time
• Response variability
• Nonverbal problem solving
• Reaction time
Christie said licensing ImPACT testing technology in a community can be cost-prohibitive, a barrier that can be overcome by forming partnerships with schools, athletic clubs or healthcare facilities. Several Texas PTS clinics administer group neurological testing of athletes at school computer labs with a portion of software costs paid by student athletic fees or private donations, she said.
Hospitals, schools and athletic organizations can purchase ImPACT on a yearly subscription basis with packages that include technical support and software updates, a company spokesman said. These range from $350 annually for 75 baseline and 10 post-injury exams to $750 for 500 baseline and 50 post-injury tests, and additional tests can be purchased as needed ($10 baseline; $20 post-injury).
A lot of athletes start playing sports at a very young age and recall "having their bell rung" by frequent hits to the head, so it is likely a large number of concussions go undiagnosed, Christie said. Educating parents about the need to monitor a young athlete's head injuries is a big part of sports therapy, she said.
Making brain tests mandatory
Sports concussion is a hot button topic that has resulted in wide support for the ImPACT program, especially in the wake of studies warning about dangers of a second-impact syndrome, said Jonathan Sams, PT, DPT, a certified orthopedic, sports and strength/conditioning specialist at a Texas PTS clinic in Belvedere, 15 minutes north of San Antonio.
"If a player returns too early from a concussion, usually within 14 days, another blow to the head — even a normal hit that's not very traumatic — can result in significant swelling of the brain," Sams said. "There have been sudden deaths due to this syndrome."
Second-impact syndrome is a rare but often fatal event that is preventable by removing concussed athletes from practice or play until they can be cleared by a health professional. The syndrome causes brain swelling and bleeding that can cause death or permanent disability and can show up weeks after a first concussion is diagnosed.
An analysis of sudden death in young athletes between 1980-2009 found 261 of 1,827 deaths of athletes age 21 or younger were caused by trauma-related injuries, usually involving the head and/or neck in 22 sports. The study was published in the July 1, 2011, issue of Pediatrics. The largest number of deaths during the 30-year period were in football (148), including 17 high school athletes who sustained concussions shortly before fatal head trauma, or second-impact syndrome.
Sams conducts ImPACT tests in a partnership with Bracken Christian School. "Bracken doesn't have the resources some of the larger schools have, such as athletic trainers or team doctors," Sams said. "We offered a sharing deal to purchase the baseline tests needed and split the costs."
Sams oversees the majority of some 250 initial baseline tests at the school's computer lab across the street from his clinic. "School officials made baseline neurocognitive testing mandatory for athletes as part of an annual physical exam," Sams said. "Students won't be cleared to compete in middle school or high school high-contact sports until they take the ImPACT test."'
For high school athletes, the baseline tests are given in the freshman year and repeated in the junior year because student brains are developing and changing, said Sams.
After his son suffered a concussion playing youth football, Gino Brunello, PT, CKTP, owner of Sims Physical Therapy Clinic in Santa Maria, Calif., also led an effort to bring ImPACT testing to local schools. The clinic's athletic trainers administer the baseline tests to about 2,500 athletes at four high schools and a junior college.
The tests are given to all football, basketball, soccer and wrestling athletes preseason at school computer labs using ImPACT software purchased by the regional Marian Medical Center, where neurology experts can interpret post-injury tests for concussions and provide specialty care and recovery management.
"If a head injury occurs, we retest the athlete within the first 48 hours and if the results deviate from baseline, we send them to a doctor with the exam results for a medical evaluation," Brunello said.
Smartphones allow sideline assessment
Short of being knocked unconscious, some brain trauma can be hard to detect in the heat of a game — a situation where a smartphone application comes in handy, Sams said. A parent or coach on the sidelines can use a free app developed by ImPACT to field a short list of questions that help determine whether a concussion has occurred.
"This action triggers the next step, deciding whether to seek immediate care for the player or wait and repeat the test within 42 to 72 hours," Sams said. "If scores deviate from the normal baseline, it raises a red flag that the individual needs a more definitive diagnosis and it is in their best interest to see a neuropsychologist or other medical doctor who handles concussions."
The tool, called ImCAT (ImPACT Concussion Awareness Tool), and available for both the iPhone and Android, is designed to be used immediately after a head injury. A GPS feature records where the incident took place, a camera feature photographs the injured player and documentation is emailed to healthcare providers. ImCAT also offers home symptom monitoring for post-injury follow-up and a five-step return-to-play tiered workout schedule.
Return to play process
Sams said if medical care is recommended by a follow-up ImPACT test, the athlete is told to avoid any activity for a few days. A clinic PT also may contact the school nurse and make recommendations regarding the demands of homework, classroom events and other activities. "It's vital to not tax a developing young brain after a concussion because it can delay the healing process," Sams said. "We would also coordinate care with the school's athletic training staff and coaching staff as needed."
The student should not resume normal activities until follow-up test results return to baseline levels, Sams said. Therapists and trainers do not interpret test results because deviations in scores must be evaluated carefully by a concussion specialist, usually an MD, DO or PhD.
Once medically cleared to play again, athletes treated for concussions don't go back onto the field immediately, Sams said. Instead, they progress from light to moderate exercises to test their physical tolerance and to make sure neurological symptoms are gone.
"We help oversee some post-concussion retraining and work with school coaches to make sure it is safe for a youngster to again compete," Sams said. "As a parent myself, I would be confident if my child were cleared post-incident using the ImPACT system that he could safely return to the game." •
John Leighty is a freelance writer.
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Monday January 23, 2012