Reviewing the David Backes injury, diagnosing a concussion

WHAT IS 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: http://www.impacttest.com/about/)
• 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. 

CONCUSSION MANAGEMENT AND RECOVERY

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.

THE BACKES 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. 

On-ice evaluation and management of head and neck injuries

In last night's final regular season game for the Vancouver Canucks, a scary incident occurred towards the end of the second period. While going to retrieve the puck in the defensive zone, Daniel Sedin skated towards the end boards and took a hit from behind from Calgary Flames forward Paul Byron, going head-first into the glass.

Sedin lay still on the ice for several minutes before the Canucks physician and medical staff were able to complete the thorough neurological protocol. Sedin was taken to Vancouver General Hospital in stable condition on a stretcher and underwent further evaluation. Byron was assessed a five-minute major for boarding and a game misconduct.

The video below recaps the whole situation, including Sedin being stretchered off the ice:

The good news is that Sedin was released from the hospital later that night. He acquired a CT scan and is apparently injury free. He recaps the situation here on Canucks clean-out day:

Following a head or neck injury like Sedin's last night, there is strict protocol medical staff must follow.  I'll try to detail that as much as possible.

Head and neck injuries are usually the result of either direct (hit to the head) or indirect contact (hit causing the head/neck to be injured, a la Sedin). Head and neck injuries are the most serious in all of sports, as consequences of neurological injuries have a potentially high incidence of morbidity and mortality. Studies have estimated that 70% of traumatic deaths and 20% of permanent disability in sports-related injuries are due to head and neck injuries (Van Camp et al, Mueller et al.).

Head and neck injuries require immediate assessment and action. The initial assessment of an injury is important, but challenging for physicians. If an injury is fatal, it causes immediate neurological consequences that are easy to identify (ex: Professor Sid Watkins account of Aryton Senna's death from the documentary Senna). The most challenging aspect of assessing a neurological injury is identifying athletes with a 'mild' injury without immediate symptoms. Often, it takes concussion symptoms up to 24 hours to manifest. When initially assessing the injury, the mechanism and amount of force are considered in the diagnosis.

There are five steps to managing a head or neck injury that occurs during play. Physicians will always err on the side of caution. They are:

1. Preparation for any neurological injury (assembling paramedics, equipment, worst-case scenarios)
2. Suspicion and recognition (no official diagnosis made, based on observation and patient reporting)
3. Stabilization and safety (depending on severity, could mean securing the body on a stretcher or just moving to a better location off-ice in a safe manner).
4. Immediate treatment and possible secondary treatment (CPR if necessary, etc.)
5. Evaluation for return to play (long-term...players suffering a possible concussion should NOT return to play the same day)

A physician will start with a basic safety evaluation which includes the ABC (Airway, Breathing and Circulation) evaluation. If the athlete doesn't have the normal ABC's (not breathing, no pulse) CPR should be initiated immediately (this is what happened with Peverley a few months ago).

Additionally, if there is any suspicion of a head or neck injury, the athlete should immediately be assessed for level of consciousness. The most extensively used tool that provides a prognostic indicator for recovery is the Glascow Coma Scale:

A score of >11 is associated with a good prognosis for recovery, while <7 is quite serious with a less favorable prognosis. These 'scales' are debated among the neurological community, however. Is there such a thing as 'mild' head injury if it has lifelong effects?

After checking the ABCs, if an athlete is conscious and alert, the physician will caution them to remain still; they will also ask them what is wrong and if they feel any pain. If an athlete has any head, neck, or back pain, they should not be moved until the spine is stabilized. The player's helmet and padding should not be removed; removal can cause unwanted motion or worsening of the fracture which could result in permanent nerve damage/paralysis. Players should not be moved until trained paramedics are able to assist. If players are in the prone position, proper log rolling technique is used to move them into a supine position for better assessment.

A hard cervical collar and a spine board should always be used to prevent further injury until a cervical injury can definitely be excluded. As seen in the image below from last night, Sedin is completely immobilized. He is strapped securely to the spine board, is wearing a neck brace (after having his helmet carefully removed by a trainer), and his head is strapped down.

Unlike in Sedin's situation, if a cervical spine injury is excluded but there is still fear of a head injury, the player can be slowly assisted to a sitting position which could help decrease intracranial pressure. If the athlete is stable while sitting, they can be assisted to help stand and then escorted to the locker room for further evaluation. During this time, the physician should conduct a complete neurological exam and evaluation. If a head injury is suspected, the player should not return. If the athlete is in unstable condition or is at risk for a deterioration in condition, they should be transported to the hospital.


Sources:

Mueller FO, Cantu RC. Catastrophic injuries and fatalities in high school and college sports, fall
1982 – spring 1988. Med Sci Sports Exerc 1990;22(6):737 – 41.

G. Ghiselli et al. / Clin Sports Med 22 (2003) 445–465.

Van Camp SP, Bloor CM, Mueller FO, et al. Nontraumatic sports death in high school and
college athletes. Med Sci Sports Exerc 1995;27(5):641 – 7.

Collection of posts at Sports Injury Alert

Lately I've been writing a few short-form articles for Sports Injury Alert's NHL Division when I have the spare time. They don't go as in-depth as some of my posts on my personal site as I aim for a quick analysis of an injury. You can find them here: