Concussion Management

Sports Medicine is a certified Complete Concussion Management clinic providing the most current concussion treatment and rehabilitation techniques for athletes. We provide direct access to our clinical team within 24 - 48 hours of a possible concussion.

Most concussions resolve with the right care, education and with a managed Return to Play Program. Our Certified Complete Concussion Management professionals provide evidence-based, research-driven concussion assessment and treatment, which includes education, vestibular rehabilitation, manual therapy, vision and balance assessment, as well as academic accommodation recommendations. Athletes should complete a baseline test prior to a concussion to make return to play decisions with a higher level of efficiency, precision and safety. Concussions require immediate care. A supervised 10 step Return to Learn and Return to Play process is implemented to ensure athletes are progressed and monitored step by step toward a safe and full recovery prior to returning to their sport.

Working with a physician, our therapist provides education, treatment and coordinates 360 degree communication with the parent, coach and physician ensuring everyone knows the next steps in the process.

Concussion management at Sports Medicine is covered by most extended health care benefit insurance plans and is provided by our Certified CCM Sport Physiotherapist. To book a concussion assessment, or to learn more about concussion management please contact Denyse Beaumont, Registered Physiotherapist and SPC at 705-734-3340, extension 213.

What Sports Medicine can do for you

  1. Direct access to our clinical team within 24 - 48 hours of a possible concussion
  2. Supervised 10 step Return to Learn and Play process to ensure athletes are progressed and monitored step by step toward a safe and full recovery prior to returning to game play.
  3. Work with a physician to provide education, treatment and coordinate 360-degree communication with the parent, player, coach and teacher.
  4. Access to our in-house team of Sport Medicine Physicians.
  5. Rapid access to a Physician Specialty network when required - visual, neuro, etc.

Post-injury assessment and injury management

(a) Treatment/management:

  • Comprehensive concussion & neurological assessment
  • Return-to-learn and return-to-work programs
  • Co-management through stepwise return-to-sport stages according to best practices and worldwide consensus statements, including multistage physical exertion testing
  • Neurocognitive, vestibular, balance and visual assessments & therapy

(b) Concussion rehabilitation for chronic symptoms (Post-Concussion Syndrome)

  • Including manual therapy, nutrition and dietary counselling, vestibular rehabilitation, exercise rehabilitation

(c) Coach & Trainer education and certification programs, as well as education seminars for players and parents

What is a concussion?

A concussion can be simply defined as a disruption in neurological functioning following a significant impact to the head or elsewhere on the body. This causes a biochemical imbalance within brain cells as well as decreased blood flow and temporary energy deficits within the brain.

Following a suspected concussion, a player should be immediately removed from play, assessed and placed on complete rest in order to recover from the energy deficit. Studies have shown that any activity, both mental and physical, in the immediate days following concussion can delay the process of recovery and should be avoided until the athlete is completely symptom free.

Concussions are an injury to the brain that, if not dealt with appropriately, may cause long-lasting damage. They are a serious issue and require immediate care and attention. The biggest concern surrounding concussions comes from the energy deficit that occurs in the brain following injury. When the brain is in this low energy state, it has been well established that the brain is extremely vulnerable to additional trauma, where even smaller impacts can lead to another concussion; and these second concussions can cause severe brain injuries with potentially permanent or fatal outcomes.

With respect to Baseline Testing, research indicates that NCT or ImPact style Baseline Testing of youth athletes (under 18 years of age) using any tool or combination of tools is not required to provide post-injury care of those who sustain a suspected or diagnosed concussion. NCT or ImPact style Baseline testing is not recommended in youth athletes regardless of the sport or level of play. The problem is that symptoms (meaning how someone feels) do not coincide with brain recovery. The only way to know when the brain has fully recovered and is out of this “vulnerable period” is to compare current brain function to when the individual was healthy; we provide this using a multimodal preseason test.

There are forty four scientific studies that utilize and support multimodal testing, both for confirmation of diagnosis as well as indication of recovery. Research shows that having a multimodal test prior to a concussion helps clinicians make Return to Play decisions with a higher level of efficiency, precision and safety. Holland- Bloorview Kids Rehabilitation Hospital endorses and offers this type of testing. The NCAA Sports Medicine Handbook considers multi-modal pre-season testing to be best-practice for all athletes involved in high-risk sports and the Centres for Disease Control and Prevention also suggests that these tests be repeated annually to establish a valid comparison.

Sports Medicine, through Complete Concussion Management (CCMI), offers comprehensive, preseason multimodal testing for at risk athletes, as well as return-to-play management, multistage physical exertion tests, and re-testing of injured individuals. All of this information can be provided to the overseeing physician in a detailed report; providing additional insight to make your clearance decision.

All patient data is stored on a secure electronic medical record system that connects all CCMI clinic locations worldwide. This allows patients and athletes to access their baseline results and concussion specific medical records at any location.

The CCMI test protocol consists of the following test areas:

  • Concussion history, medical history, learning disabilities, psychiatric history
  • Symptom score
  • Orientation
  • Auditory Memory
  • Concentration
  • Visual tracking and processing speed
  • Balance (sideline measure)
  • Balance (using force-plates to measure postural sway)
  • Reaction Time
  • Strength
  • Delayed Recall
  • ImPACT neurocognitive testing
    • Visual word & shape memory
    • Go/No-go tests
    • Reaction Time (with cognitive processing component)
    • Effort tests

**Note: Re-testing prior to return to play also involves physical exertion testing immediately prior to conducting the multimodal re-assessment. This method (testing in a physically exerted state) has been shown to be a more sensitive way of testing, revealing up to 28% more neurocognitive impairment than neurocognitive testing at rest (11,12).

Symptom Score

The Post-Concussion Symptom Score (PCSS) is the most widely used concussion symptom inventory worldwide. Adapted by the Concussion In Sport Group as part of the Sideline Concussion Assessment Tool (SCAT), the PCSS is a 22-item measure with each symptom scored on a 7-point likert scale (13). A study by McCrea et al., found that the PCSS demonstrated the most sensitive and specific measure for concussion at the time of injury (when compared to balance and a neurocognitive examination); however, fewer than 5% of athletes reported higher symptom scores than baseline at 7 days post injury(14, 5). This indicates that the symptom score, while potentially the most useful parameter for making the initial diagnosis of concussion, does not coincide with the recovery of the brain following concussion (22 to 30 days in previous metabolic studies). Therefore, more objective testing parameters are required to inform safer return-to-play decision-making.

Standard Assessment of Concussion (SAC)

Also a component of the SCAT, the SAC is a verbal/auditory neurocognitive test, which consists of Orientation, Immediate Memory, Concentration, and Delayed Memory Recall Tests. The SAC has been validated in several studies for use in the assessment of sport-related concussion(15-17). Because the SAC does not yet have established normative data, this test must be administered at baseline to establish individualized scores(18). Barr & McCrea found that immediate SAC scores decrease in concussion patients by an average of 4 points from baseline. Using multiple regression, the authors found that a 1-point decrease from baseline SAC carried a 94% sensitivity and 76% specificity for the diagnosis of concussion (19). Marindes et al., found that the SAC alone was only able to accurately diagnose concussion 52% of the time, however adding in balance assessments and the King-Devick test improved the diagnostic accuracy to 100% (20). This demonstrates that the strength of concussion assessment rests in having numerous testing parameters versus relying on one single test. This test has also been found to demonstrate objective impairment in individuals reporting a complete resolution of symptoms (14).

King-Devick Test

Originally developed for the assessment of dyslexia, the King-Devick (K-D) test has emerged as one of the most popular and useful sideline concussion tests. The K-D test is an easily administered and scored test for visual tracking and processing speed. Dhawan et al., found that following a concussion, there is an average drop from baseline score by 7.3 seconds. These deficits can also remain for some time beyond the symptomatic period (30 to 40 days post-injury), which makes the K-D test not only a good immediate sideline test, but also a good return-to-play assessment measure (21). Marindes et al., found that the K-D test alone was able to pick up 79% of concussion injuries and when combined with balance and SAC testing, 100% of concussions were accurately diagnosed(20). In healthy individuals, scores tend to improve over time due to a known learning effect; however with

concussion, scores significantly worsen making this a good test for distinguishing healthy vs. concussed individuals (22-24).

Balance Assessment

CCMI performs a two-part balance assessment, which consists of the Balance Error Scoring system from the SCAT as well as a more objective measure of postural sway utilizing force-plate technology.

The BESS test has been studied extensively in the concussed population(16,25,26). Research in this area has found that the range of baseline scores in healthy individuals is quite wide and age dependent, making the utilization of normative data virtually useless as a comparison(27,28). This test has been shown to be most useful for acute concussion as scores have been found to normalize within 3 days from injury(26,29). As such, the Complete Concussion Management program utilizes a secondary balance assessment examining centre of pressure measurements from force-plate technology that has been found to show deficits beyond resolution of symptoms, SAC scores, BESS, and computerized neurocognitive test scores(30). Other studies have demonstrated more sophisticated measures of balance utilizing force-plate technology can show impairments for up to 30-days following injury(31).

Clinical Reaction Time

This test was developed and validated by Dr. James Eckner and Dr. Jeff Kutcher, of the University of Michigan. Dr. Jeff Kutcher is a neurologist at Michigan and the head concussion physician for the NHLPA. This test is easily administered in a seated position using the athlete’s non-dominant hand to grasp a dropped measuring stick with a standardized weight and spacer. This test has been found to show immediate deficits following concussion (32) and has been validated against both computerized neurocognitive measures (33,34) as well as a ‘functional head protective response’ (the ability for an athlete to react to and protect themselves from incoming objects aimed at their head) (35), making this a useful test when determining the safety of an athlete to return to play. This test has also been found to have moderate test-retest reliability over 1 to 2 seasons in NCAA athletes (36).

Motor Strength

Tests of motor strength are currently being studied at Holland-Bloorview kids rehabilitation hospital with preliminary findings demonstrating that non-dominant hand grip strength shows concussion deficits beyond symptomatic recovery in children between the ages of 5 and 18.

CCMI Baseline and Concussion Management Summary

CCMI was developed from the necessity to provide high-risk athletes with evidence-based concussion management strategies. The baseline testing protocol outlined above was developed through years of research to establish the most comprehensive testing battery to assess both acute injuries and the readiness to return to high-risk sporting activities. The period of brain vulnerability prior to full recovery from concussion injuries has been shown to result in long lasting and potentially permanent or fatal outcomes should an individual suffer another concussion during this time. It has been well established through the literature that symptoms alone do not reflect true recovery of the brain, making it imperative that objective measures be incorporated into the decision making process. In addition, healthcare practitioners often face pressure from athletes and/or their parents to provide clearance because the symptoms have dissipated. Having rigorous objective testing parameters can relieve this pressure and provide the clinician with the needed evidence to hold an athlete back from an early return to competition.

As was demonstrated above, no single concussion test is adequate to be used in isolation for either diagnosis or return-to-play decision-making. CCMI utilizes a multi-modal baseline test from the most current research to improve accuracy and reliability. Clearance of any athlete is not granted until there is a complete return to baseline of ALL pre-season measures following the passing of all step-wise return-to-learn and return-to-play stages including a 2-step process of physical exertion testing.

**references cited in the text above are available upon request**

Complete Concussion Management™

Complete Concussion Management™ is a concussion research company that educates healthcare practitioners on cutting-edge concussion therapies and management strategies based on the most current medical research so that they may provide the highest quality of concussion treatment and follow-up outside of professional sports. Certified Complete Concussion Management™ practitioners are continuously updated on current research and treatments in order to manage these injuries properly and safely to ensure adequate recovery, thereby limiting the risk of further injury and long-term brain damage.

For help managing your concussion, please contact our Huronia Rd. clinic (705.734.3340).

Proudly building concussion management strategies with these local organizations: