Saturday, April 19, 2014

Reviewing the David Backes injury, diagnosing a concussion


Also known as a mild traumatic brain injury, the concussion is the most common type of traumatic brain injury. At the 4th International Conference on Concussion in Sport (Zurich, November 2012), a panel discussion took place to obtain a consensus-based definition of a concussion. The Concussion in Sport Group (CISG) defined a concussion as follows:
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:
In essence, a concussion is a head injury with a temporary loss of brain function that may result in a variety of physical, cognitive, and emotional symptoms.

Right now, a concussion is a clinical diagnosis based largely on the observed injury mechanism (point of contact, force on head area, etc.), signs, and symptoms. The first step towards a diagnosis of a concussion is actual recognition of the injury.

The hallmark signs of acute sports concussion include:
  • Loss of consciousness (LOC)
  • Problems with attentional mechanisms
    • Manifested as (but not limited to): slowness to answer questions and follow directions, easily distracted, poor concentration, vacant stare/glassy eyed. 
  • Memory disturbance
  • Balance disturbance
Over the course of the first 24 hours following a concussion injury, other signs and symptoms may manifest. However, it's important to note that there is a large range of these symptoms and they often vary, not all of these symptoms are seen in every case of sports concussion. The most common symptoms reported in concussion literature include:
  • Somatic symptoms such as headache
  • Cognitive symptoms such as feeling like in a fog
  • Emotional symptoms such as lability
  • Physical symptoms such as LOC and amnesia
  • Behavior changes such as irritability
  • Cognitive impairment
  • Sleep disturbance (insomnia)
  • Dizziness and balance problems
  • Blurred vision
  • Fatigue
If any one or more of these symptoms is recognized, a concussion should be suspected and a management plan should be implemented.

Since concussions are often hard to recognize and to diagnose, the Zurich Consensus on Concussion in Sport proposed diagnostic criteria for sideline evaluation. An athlete shows any of the following, they need to be removed from play and assessed.
  • Initial obvious physical signs consistent with concussion (LOC, balance problems)
  • Teammates, trainers, coaches observe cognitive or behavior changes in functioning consistent with concussion symptoms reported
  • Any concussion symptoms reported by the athlete injured
  • Abnormal neurocognitive or balance examination
Following a removal from play:
  • Physician evaluated the player using standard emergency management principles, most notably to exclude  severe head trauma or cervical spine injury
  • Once first aid issues are addressed, assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools (NHL uses ImPACT concussion testing, read here:
  • The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury
  • A player with diagnosed concussion should not be allowed to return to play on the same day. 
    • It has been unanimously agreed that an athlete should not return to play on the same day of the injury. Studies have shown that athletes allowed back into play following a concussion may demonstrate neuropsychological deficits post injury. 

The graduated return to play protocol following a concussion is a stepwise process and is outline below: 

In this stepwise progression, an athlete only proceeds to the next level if they are asymptomatic at the current level. Each step should take at least 24 hours, making the minimum amount of time to proceed through the full rehabilitation protocol one full week. Athletes should never return to play on the same day as an injury.


St. Louis Blues captain David Backes left Game 2 today with 4:51 to play after a brutal check to the head by Chicago Blackhawks defenseman Brent Seabrook. Backes was behind the Blackhawks' net and overskated the puck, as he attempted to curl back towards the puck, Seabrook approached from the circles and leveled Backes with a check to the head.

Credit to @myregularface

The principal point of contact is Backes' head. Not only does Seabrook's shoulder hit Backes' head directly, but the back of his head hits the boards immediately after. Backes laid motionless on the ice following the hit, although he didn't lose consciousness, this isn't a good sign. When he tried to get up, Backes had balance issues and clearly looked dazed. As the Blues' athletic trainer held him back, Backes struggled to stay on his skates and needed help getting to the locker room. 

As bolded above, Backes clearly exhibits signs of a concussion with balance issues, a vacant stare and the inability to follow the athletic trainer's directions of staying out of the scrum following the hit. Backes left the game and didn't return for overtime which is the right move. Following a hit to the head, especially this severe, the player should never return to play the same day.

Backes will need a lot of rest. The Blues doctors will make a detailed management plan after an assessment today and tomorrow morning. Backes will want to play Monday night undoubtedly, but it probably isn't the best move following a hit like this. Concussions require a minimum of 6 days of recovery as detailed above, but this isn't often followed. Backes shouldn't be rushed back, especially considering the Blues are up 2-0 in the series.