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BULLETIN

ISSUE 6 l DECEMBER 2013

www.spnz.org.nz

SPNZ EXECUTIVE COMMITTEE

President Dr Angela Cadogan

Secretary Michael Borich

Treasurer Michael Borich

Website & IT Hamish Ashton

Committee Dr Tony Schneiders

Bharat Sukha

Dr David Rice

Chelsea Lane

Kara Thomas

EDUCATION SUB-COMMITTEE

Chair: Chelsea Lane

Dr Grant Mawston Dr David Rice

BULLETIN EDITOR

Aveny Moore

SPECIAL PROJECTS

Alex Ashton Monique Baigent

Karen Carmichael Deborah Nelson

Kate Polson Amanda O’Reilly

Charlotte Raynor Pip Sail

Louise Turner

LINKS

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List of Open Access Journals

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Asics Education Fund information

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CONTACT US

Michael Borich (Secretary)

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FEATURE TOPIC: Concussion

Welcome to the December 2013 Edition

In this Edition:

EDITORIAL:

It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss

About? By Dr Tony Schneiders 2

SPNZ SYMPOSIUM 2014

SPNZ Symposium Rotorua 15-16 March 2014 “Sport and Exercise Across the

Lifespan” 5

MEMBERS ’ BENEFITS

IT Benefits 6

CLINICAL SECTION

Article Review: Day of Injury Assessment of Sport-related Concussion 7

RESEARCH SECTION

SPNZ Research Reviews: Sports Concussion - Assessment and Prevention 9

RESEARCH PUBLICATIONS

JOSPT: December 2013 15

ASICS

Cricket Shoes: From the Ground Up, No Shortcuts 16

CONTINUING EDUCATION

SPNZ Symposium 18

Continuing Education Calendar 19

APA CPD Event Finder 19

Page 2

EDITORIAL

Concussion has been around since the beginning of

civilisation but it has recently come to the forefront of

societal debate via the media for all the right, and may-

be the wrong, reasons. While as a health-conscious

society we see participation in activity and exercise as

synonymous with health and well-being, it must be ac-

cepted that sport and recreational pursuits also expose

participants to significant risks, with one of them being

the possibility of head injury, particularly in contact and

collision sports.

Sport-related concussion is a transient functional injury

to the brain and considered a sub-category of mild trau-

matic brain injury (mTBI)1. Concussion is considered to

be among the more difficult injuries in sports medicine

to diagnose and manage, with a myriad of mechanisms,

presentations, manifestations, and resolutions which

are most often individualized to the specific athlete.

There is no doubt that the science behind concussion

assessment continues to evolve and that management

principles should be based on sound clinical judgement

underpinned by an evidence based approach.2 There is

currently no single “gold standard” for diagnosing con-

cussion3 and multiple assessment domains are utilised

by health professionals in order to make a diagnosis

which is fundamentally clinical in nature.

While the majority of sports concussions resolve within

7-10 days, symptoms can become chronic in some

people especially those with anxiety or other mental

health comorbidities, and repeated concussions are

also now considered to put the athlete at risk of long

term consequences.

One recently identified medical condition considered to

be associated with repeated exposure to concussion is

IT ’ S JUST A HEAD KNOCK AND PART OF THE GAME.

CONCUSSION: WHAT ’ S ALL THE FUSS ABOUT?

By Dr Tony Schneiders

CONTINUED ON NEXT PAGE.

Chronic Traumatic Encephalopathy (CTE), formerly

known as athletica pugilistica (punch-drunk syndrome).

This condition has been in the media ever since former

Chicago Bears NFL player Dave Duerson tragically

committed suicide in 2011 and donated his brain to

Boston University who confirmed CTE on autopsy. The

Sports Legacy Institute at Boston University accepts

donations of brain tissue from deceased sporting and

military personal and cites that the brain tissue of 18 of

19 deceased former NFL players have tested positive

for CTE. Since this revelation, there has been a proces-

sion of ex-football stars lining up to report to their attor-

neys a long list of neurological mediated signs and

symptoms that include forgetfulness, short temper, apa-

thy and depression which has resulted in multiple class-

action lawsuits being filed against the NFL. The cynics

amongst you, especially those that have been married

to men in their 5th decade, might suggest a likely cause

for these symptoms as being the medical condition an-

dropause, colloquially known as Irritable Male Syn-

drome (IMS) or grumpy man syndrome. This alternate

view may also hold some credence given last year’s

tragic suicide by ex-San Diego Charger Junior Seau

(also a claimant in the NFL law suit) who apparently

had no reported medical history of sustaining a concus-

sion during his entire football career.

Additionally, at this point in time we must consider the

best evidence available to determine whether CTE ac-

tually occurs as a result of repeated concussions in

sport. It was recently agreed by the Concussion in

Sport Group in the latest Consensus Statement on

Concussion in Sport4 that CTE was not related to con-

cussions alone, or simple exposure to “contact sports”,

Page 3

and that due to the limited published research “the

speculation that repeated concussion or sub-

concussive impacts causes CTE remains unproven”.4

However, this has not stopped the NFL recently pro-

posing to settle out of court with former players to the

tune of 765 million dollars.

Closer to home we have had a number of high profile

head injuries from our national game, rugby. Most will

remember Steve Devine’s public battle with repeated

concussions that eventually ended his career, Darryl

Sabin’s ill-informed decision to return to rugby which

lead to his permanent disability, and earlier this year

the tragic death of Takapuna Rugby Club player Willie

Halaifonua. It must be remembered that acute traumat-

ic brain injury (TBI) is a continuum with concussion at

one end and severe TBI, that occurred in the latter two

examples, at the other. In fact it seems that some peo-

ple appear to be more susceptible to catastrophic head

injury in the form of subdural haematomas than others.

Why is this the case? Well, one area worth investigat-

ing from my perspective might be the presence of a

congenital arachnoid cyst in these players. The inci-

dence of this developmental anomaly is around 1-2% in

the normal population and the condition is up to 4 times

higher in males than females. These usually benign

cysts torsion the bridging veins in the brain making

them more likely to rupture in the event of a head

knock. A question here that we may need to consider is

should we be screening for these anomalies using MRI

in young males taking up collision sports?

This also begs the question, are we doing enough to

prevent concussions and other related head injuries in

sport? America now has the Lystedt law, the first law

ever to cover a medical condition, and one which has

been invoked by nearly all the states across the USA.

This legislation requires athletes, coaching and training

It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss About? cont’d …..

EDITORIAL

CONTINUED FROM PREVIOUS PAGE.

CONTINUED ON NEXT PAGE.

staff to be appropriately educated on concussion in or-

der to manage high school athletes in at-risk sporting

codes. As it currently stands, education and law chang-

es have been the most successful intervention strate-

gies to date. Closer to home the ACC RugbySmart pro-

gramme has led to a reduction in reported concussions

since its inception so perhaps the message is getting

through to match officials and coaches that a head inju-

ry can have serious consequences. However at the top

level of the game poor examples of concussion assess-

ment and management are still being displayed. We all

saw the Australian loose forward George Smith’s sick-

ening head clash with the British Lions hooker earlier

this year when he fell to the ground unconscious. He

was clearly concussed but put back on the field 5

minutes later. What signal does this send to young

players? In the NRL, teams are also getting around the

concussion regulations by not having players assessed

by the doctor. As concussion is a medical diagnosis, if

the doctor doesn’t attend the injury, then they can’t di-

agnose a concussion and the player returns to the field

of play. Obviously we still have some way to go in the

education of our sports teams and administrators re-

garding the assessment and management of concus-

sion.

Given the current discussion and debate around head

injury in sport this issue of the SPNZ Bulletin therefore

focuses on the most recent and up to date information

available from the consensus statement on concussion

in sport following the meeting in Zurich late last year. If

you work with sports teams or individuals at risk of

head injury the summaries presented in this newsletter

are a must read. I am sure you will find them informa-

tive and I thank the special projects team who took the

time to summarise the best information available at pre-

sent on this topic.

Page 4

Finally, on behalf of the SPNZ executive, I would like to wish you all

a very happy Christmas and a profitable and (head) injury free

New Year.

I look forward to further discussing concussion with you at the SPNZ

Symposium in March. See you there.

Ka kite ano

Dr Tony Schneiders

References:

McCrory, P., Meeuwisse, W. H., Echemendia, R. J., Iverson, G. L., Dvořák, J., & Kutcher, J. S. (2013). What is

the lowest threshold to make a diagnosis of concussion?. British Journal of Sports Medicine, 47(5), 268-271.

Schneiders, A.G. (2013). A heads-up on what's new in sports-related concussion assessment and management.

Physical Therapy in Sport; 14 (2), Pages 75-76.

Guskiewicz, K. M., Register-Mihalik, J., McCrory, P., McCrea, M., Johnston, K., Makdissi, M., & Meeuwisse, W.

(2013). Evidence-based approach to revising the SCAT2: introducing the SCAT3. British Journal of Sports

Medicine,47(5), 289-293.

McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, R. C., Dvorák, J., Echemendia, R. J., ... & Turner, M. (2013).

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zur-

ich, November 2012. Journal of athletic training, 48(4), 554-575.

EDITORIAL

CONTINUED FROM PREVIOUS PAGE.

Dr Tony Schneiders is currently senior lecturer at the University of Otago and has been actively researching concussion in sport for the last 10 years. His work on the sideline assessment of

sports concussion appears in the last two versions of the Sports Concussion Assessment Tool

(SCAT).

Tony is on the executive of the International Federation of Sports Physical Therapy and the Associate Editor for Australasia of the journal Physical Therapy in Sport. Early next year he will be

taking up the role of Discipline Leader Physiotherapy and Professor at the University of

Central Queensland.

It’s Just a Head Knock and Part of the Game. Concussion: What’s All the Fuss About? cont’d …..

Page 5

Confirmed Key Note Speakers:

Professor Craig Purdam - Head of Physiotherapy Australian Institute of Sport

Mary Magarey - Specialist APA Sports & Musculoskeletal Physiotherapist

Dr Ben Speedy - Exercise and the older person

Dr Nic Gill - All Blacks Trainer

Dr Erica Hinckson - Exercise in children

Mr Andy Stokes - Shoulder surgery through

the ages

Dr Tony Schneiders - Concussion

Dr Lynley Anderson - Sports ethics

Early Bird Registration Open Fri 29 Nov 6pm - Jan 20th

See the symposium website for registration details : www.spnz.org.nz/symposium

Free Workshops: Craig Purdam – Hamstring Injuries Sat 9-11

Mary Magarey – Shoulder Injuries Sun 1.30-3.30

Limited to 30 each workshop SPNZ Members Only

ONLY A FEW SPACES STILL AVAILABLE!!!

One workshop each only – Register and pay early or you will miss out!!!!

Early Bird Registrations are now open

SPNZ SYMPOSIUM 2014

Other Great Speakers Include:

SPNZ Symposium Rotorua

15-16 March 2014

SPORT AND EXERCISE ACROSS THE LIFESPAN

Page 6

IT BENEFITS

MEMBERS ’ BENEFITS

Facebook - facebook.com/SportsPhysiotherapyNZ

Sports Physiotherapy New Zealand has a Facebook page to help keep

our members up to date with the latest news and articles out there on

the web.

“Like us” and receive regular news and information.

Twitter - twitter.com @SportsPhysioNZ

We have recently added a Twitter account to our list of ways of keeping

contacted with the world.

Follow us and join in the conversations.

Follow links through to interesting articles and hear titbits from

conferences as they happen.

Podcasts - SPNZ Members Section

In the Members Resources Section of the website there are links to

some free podcasts.

These are a great way to listen to world renowned experts from your

home in your own time and credit some CPD at the same time.

There are many benefits to be obtained from being an SPNZ member.

For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/

Starting now, in each Bulletin we will be highlighting individual member benefits

in order to help members best utilise all benefits available.

Page 7

ARTICLE REVIEW

Day of Injury Assessment of Sport-related Concussion

McCrea M, Iverson G, Echemendia R, Makdissi M, Raftery M (2013), Day of injury assessment of sport-related con-

cussion. British Journal of Sports Medicine 47:272-284. doi 10.1136/bjsport-2013-092145.

Clinicians consider that concussion is among the most complex injuries in sports medicine to diagnose, assess and

manage. It is a clinical diagnosis based largely on the observed injury mechanism, signs and symptoms. Sports-

related concussion is not necessarily synonymous with loss of consciousness or frank neurological signs. Mild con-

cussion may induce slight confusion without clearly identifiable retrograde or post-traumatic amnesia. It also cannot

be diagnosed by neuroimaging (CT or MRI).

A standardisation movement of identifying concussion will ensure that athletes and clinicians (to name a few) are

able to recognise the signs and symptoms that indicate possible concussion. Performance-based assessment

measures may be superior to an athlete’s reporting of symptoms which might be unreliable due to the athletes’ ten-

dency to under-report or fail to recognise their symptoms. Standardised tests have been devised to provide a more

objective performance based method of measuring post injury recovery and determining an athlete’s fitness to return

to play.

The aim of the article was to review whether the existing tests and measures currently used are sensitive enough

and reliable enough on the day of injury to assist clinicians in accurately evaluating sports-related concussion. The

authors conducted a thorough search of the literature of the main databases for relevant sub-headings relevant to

sports-related concussion. Articles looking at the assessment or diagnosis data collected within 24 hours of the injury

were analysed.

Of the original 577 articles a total of 41 qualified for the review.

Symptom Rating Scale

Most common and consistently reported acute symptoms across the studies are headaches, dizziness and some

form of mental state disturbance such as mental clouding, confusion or a slowing down feeling. Other acute symp-

toms include visual problems, fatigue and nausea. Some observational signs included a dazed facial expression and

unsteady gait.

Post Concussion Scale; 0.88-0.94 internal consistency in college students and 0.92-0.93 in concussed ath-

letes.

SCAT2; includes symptom ratings, balance testing and cognitive screening. Normative values available, but

data not available on large samples of concussed athletes.

Concussion Symptom Inventory (CSI); 12 item scale that was developed using samples from 16,000 non-

injured athletes and 600 concussed athletes.

Neurocognitive Tests

Most studies used brief cognitive screening tests intended for rapid assessment, side-line or rink side. Few studies

used conventional paper and pen neuropsychological testing within 24 hours of injury.

Neuropsychological tests can detect changes across multiple domains of cognitive function that are susceptible to

the acute effects of concussion such as cognitive processing speed, working memory, attention and concentration,

new learning and memory and executive functioning. A high percentage of symptomatic athletes exhibited a signifi-

cant decline in both computerised and conventional neuropsychological testing on the day of injury. The studies illus-

trated significant decline in cognitive functioning compared with an athlete’s individual pre-injury baseline perfor-

mance, relative to the performance of non-injured control athletes.

CLINICAL SECTION

CONTINUED ON NEXT PAGE.

Page 8

ARTICLE REVIEW CONTINUED...

Postural stability/balance tests

Numerous studies illustrate that balance is typically affected in concussed athletes in the early post-injury stage. The

majority of studies examine group data in concussed athletes compared with their own baseline and/or compared

with uninjured controls. Most, but not all, concussed athletes had significant balance deficits following injury. Balance

is an important component of the sideline assessment.

Electrophysiological Tests

These are used to examine athletes and non-athletes following concussion; only recently have these been used dur-

ing the acute phase of injury. Studies have reported significant differences using qEEG between mild-moderate con-

cussion and control groups.

CLINICAL SECTION

CONCLUSION

This review illustrates that concussion produces an excess of self-reported symptoms and impairments in cognitive

functioning, balance and other functional capacities during the acute (24 hour) initial phase. These tests do not diag-

nose if concussion has occurred, they provide data on the physiological, psychological and behavioural changes as-

sociated with the injury. These aid the clinician in the overall diagnosis, injury severity, assessing clinical recovery

and determining return to play. The literature highlights the use of symptoms scales combined with functional tests.

The concussed athlete can display a complex set of symptoms and therefore a multidimensional approach that inte-

grates assessment of self-reported symptoms and other functional domains (cognitive function and balance) is rec-

ommended to maximise the sensitivity of clinical evaluation on the day of injury.

Reviewed by Charlotte Raynor MPhty, BSc(Hons), NZRP, MNZSP

CONTINUED FROM PREVIOUS PAGE.

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Page 9

www.sportsphysiotherapy.org.nz/resources

Sports Concussion - Assessment and Prevention

Article Summary

This article is systematic review investigating onfield concussion assessment and management. A search was con-

ducted in the PubMed, MEDLINE, Psych Info and Cochrane Library databases using a variety of associated key-

words. Inclusion/exclusion criteria were then applied to get the final number of articles. These articles were then re-

viewed by the authors with the objective of reviewing the evidence for what is ‘best practice’ for evaluating the adult

athlete on the sports field. Additionally they also looked at whether an athlete with concussion should return to play

on the same day, what to do for situations in the community when no doctor is available, and the benefits of remote

notification of potential concussive events on the playing field. Prior consensus statements and sideline assessment

tools were also reviewed.

This article suggests that the onfield assessment of an athlete is geared towards excluding cervical spine injury and

serious brain injury, while evaluating the general disposition of the athlete. If signs and symptoms of concussion are

noted the athlete should be removed from play and evaluated on the sideline. The sideline concussion test should

include a symptom checklist, balance assessment, and cognitive assessment such as the SCAT3 or another stand-

ardised sideline assessment tool. But clinical suspicion should overrule a negative SCAT3 or other sideline assess-

ment. The research indicated a ‘no return to play in the same game or same day’. This was due to the fact that

symptoms may be delayed and not be present at initial assessment. In the event that no doctor is present at a sport-

ing event when a possibility of a concussion exists, the player should be removed from the field. The player should

be observed by a responsible adult, and transported to medical care by ambulance if there is concern. Medical eval-

uation is recommended prior to return to practice or play. The benefits of remote notification of potential concussive

events appears unclear.

Clinical Applications

This article was very clinically relevant and provided quite clear guidelines for the assessment and management of

concussion. It highlighted the need for the use of a standardised assessment such as the SCAT3. So it is important

to be familiar with such tools and be comfortable using them. But it also noted that clinical suspicion overruled a

‘negative’ SCAT3. This was really important and emphasised the need to back our own clinical assessment and if

concussion was still suspected then the athlete should not return to the field of play. The guidelines for ‘return to play’

and ‘if no Doctor is present’ are also quite useful and should aid the decision making process in this event.

Reviewed by Greg Usherwood MPhty, BPhEd

Onfield assessment of concussion in the adult athlete

Putukian M, Raftery M, Guskiewicz K et al (2013). Onfield assessment of concussion in the adult athlete. British

Journal of Sports Medicine 47:285-288.

RESEARCH SECTION

For more information about SCAT3 click here

Page 10

www.sportsphysiotherapy.org.nz/resources

Sports Concussion - Assessment and Prevention continued……..

What are the most effective risk-reduction strategies in sport concussion?

Benson BW, McIntosh AS, Maddocks D et.al. (2013). British Journal of Sports Medicine 47:321-326.

Article Summary

This was a review paper, looking at the effectiveness of protective equipment (head gear and mouth guards), rule

changes (in ice hockey), neck strength and legislation in reducing the risk of concussion. They looked at a variety of

studies covering rugby, American and Australian football, and ice hockey.

“Concussion may be caused either by a direct blow to the head or an indirect blow elsewhere to the body that cre-

ates an ‘impulsive’ force that is transmitted to the head.” The best treatment for concussion appears to be preven-

tion, but what are the best ways to prevent it. This appears to be a little hard to answer, with most of the studies

looked at in this review showing little conclusive evidence in reducing the incidence of concussion.

Three studies looking at protective equipment were reviewed, two showed some minor reductions in concussion, one

for a customised mouthguard in American Football, and the other in standard head gear in amateur Australian Rugby

players, however both studies had limitations which called into question the validity of the results. The third study

looked at headgear in New Zealand Youth Rugby. This showed no difference between no headgear, standard thick-

ness and increased thickness. Again the study had limitations which needed to be considered along with the results.

Neck strength is another factor thought to have a role in concussion, but studies were of limited clinical value, as they

did not look at reduction of concussion on the field. So no meaningful, practical conclusions could be drawn in re-

gards to neck strength and reduction in concussion.

The last variable looked at was rule and legislation changes. It seemed that these things may have the most poten-

tial for concussion reduction; however there was a paucity of studies looking into this. The Rugby Smart programme

in New Zealand has shown a reduction in claims for concussion and brain injury since its introduction.

Clinical Applications

Clinically it seems all of the above measures may have some merit, and shouldn’t be “thrown out” because none of

them showed an increase in concussion rates and further studies of better quality may still show that they are effec-

tive. Mouthguards have also been shown in other studies to be of great benefit in reducing dental injuries. Pro-

grammes for coaches and referees have great potential but need to be run regularly so that as coaches move on

new coaches are kept up-to-date with best practice guidelines. The authors state that: ’’From a biomechanical per-

spective, the most effective method to prevent concussion is to minimise the likelihood and/or severity of a head im-

pact” however “sport-governing bodies need to carefully consider potential injury trade-offs associated with the im-

plementation of injury-prevention strategies.”

In conclusion it appears that more high-quality research is needed to determine which factors are most effective in

reducing the incidence of concussion.

Reviewed by Karen Carmichael BSc, BPhty, M(SportsPhysio)

RESEARCH SECTION

Page 11

www.sportsphysiotherapy.org.nz/resources

Sports Concussion - Assessment and Prevention continued……..

What is the lowest threshold to make a diagnosis of concussion?

McCrory, P., Meeuwisse, W. H., Echemendia, R. J., Iverson, G. L., Dvořák, J., & Kutcher J. S. (2013). What is the

lowest threshold to make a diagnosis of concussion? British Journal of Sports Medicine, 47, 268–271. doi:10.1136/

bjsports-2013-092247

Article Review

This systematic review looks at the evidence for diagnosing a sports-related concussion. The majority of concussions

occur without loss of consciousness or neurological signs and most cannot be diagnosed with neuroimaging.

There is no one reliable test or symptom that clinicians can use to diagnose concussion in the sporting environment.

Therapists can face significant pressures to make a rapid assessment of an athlete to return them to play.

Concussion results in a variety of somatic, cognitive and neurobehavioral symptoms that are typically the most se-

vere during the first 24–48 hours and lessen over several days to weeks. When obvious signs exist (i.e. loss of con-

sciousness or concussive convulsions) the diagnosis is relatively straightforward; however, there may be difficulty

when symptoms and/or cognitive disturbance are delayed or the signs are less clear.

Some of the characteristic signs of concussion include mental confusion, memory and balance disturbance. Over the

course of the first 24 hours, the most common symptoms include headache, nausea, dizziness and balance prob-

lems, visual disturbances, confusion, memory loss and fatigue.

The pathophysiology of sports concussion remains poorly understood. There appears to be a period of vulnerability

following concussion where brain metabolism and function are altered. During this time even a mild second concus-

sive episode may cause significant additional and/or dramatic brain damage. Athletes suspected of concussion

should be removed from play and evaluated thoroughly. Studies show cognitive impairments associated with the

time period of glucose metabolic dysfunction lasting about 7–10 days in adult rats.

The Concussion in Sport Group defines concussion as, ‘a complex pathophysiological process affecting the brain,

induced by traumatic biomechanical forces’ that ‘may be caused by a direct blow to the head, face, neck or else-

where in the body with an impulsive force transmitted to the head’. The mechanism of injury includes linear acceler-

ation or rotational shearing forces transmitted to the brain.

The terms mild traumatic brain injury (mTBI) and concussion are often used interchangeably. An mTBI however, is

part of a spectrum of injury severity that reflects a pathological injury, whereas a concussion is more transient.

An athlete who has any one or more of the following, needs to be removed from play with a suspected concussion

and then assessed in a thorough manner.

1. Initial obvious physical signs consistent with concussion (eg, loss of consciousness, convulsion or gait unsteadi-

ness).

2. Teammates, trainer or coaching staff observe cognitive or behavioural changes in functioning [eg, mental confu-

sion (often manifest as slowness to answer questions and follow directions, being easily distracted, has poor concen-

tration, vacant stare/glassy eyed or inappropriate playing behaviour) or emotional lability].

3. The athlete reports any concussive symptoms.

4. Abnormal neurocognitive and/or balance examination (eg amnesia, confusion or other neurological abnormalities).

Reviewed by Monique Baigent BHsc (Physiotherapy)

RESEARCH SECTION

Page 12

www.sportsphysiotherapy.org.nz/resources

Sports Concussion - Assessment and Prevention continued……..

Evidence-based approach to revising the SCAT 2: Introducing the SCAT 3.

Guskiewicz KM, Register-Mihalik J, Mc Crory P, et al Br J Sports Med 2013; 47: 289-293

Article Summary

This article reviews the Sport Concussion Assessment Tool 2 (SCAT2); outlining the shortcomings identified, when

trialled over a 4 year period. The purpose of the review is to identify the most sensitive and reliable assessment com-

ponents for concussion management for inclusion in a revised version-SCAT3. There is no single ‘gold’ standard for

assessing and diagnosing concussion. Concussion is still considered a functional injury, based on a combination of

symptoms, physical signs, and impairment in cognitive function which cannot be structurally identified on imaging.

In 2004 the Sport Concussion Assessment Tool (SCAT) was proposed by the Concussion in Sports Group (CISG) in

an attempt to standardise the assessment internationally. In 2008 this tool was modified by the CISG and the SCAT2

was introduced.

The purpose of this review was to search current evidence based literature to introduce a more sensitive and reliable

concussion assessment and present a revised version- the SCAT3.

Although to date, no studies have been conducted on the factors that may affect the SCAT2 as a whole, various

studies have addressed factors that may affect the components of the SCAT2. Specifically, base rates for many

symptoms are relatively high among healthy, non-concussed athletes. Factors such as gender,

dehydration and

oral contraceptive use in women may play a role in symptom reports. Mode of administration of the symptom check-

list also may be a factor. Concerning balance, the Balance Error Scoring System (BESS), it is suggested that training

fatigue, number of administrations,

ankle injury, sport played,

and testing environment,

can have significant effect on

the number of errors. Gender and order effects single leg stance and tandem gait tasks. Age and environmental fac-

tors may also complicate the concussion assessment and medical management.

Some sports have attempted to modify the SCAT2 for their specific needs, eg Bull Riding. Other authors have que-

ried specific aspects of scoring and/or the serial assessment template. The authors recommend the use of a modi-

fied tool for conducting serial assessments but conclude the need for validation.

Results published on baseline values in the original SCAT, highlight the need to consider post injury results in con-

text to an athlete’s own baseline.

Clinical Implications

Based on the available evidence and practical consideration, the SCAT2 is a useful and practical concussion assess-

ment tool. However, several modifications should be considered for refinement and inclusion in the SCAT3. There is

no evidence to support the use of a composite score, however, there is great evidence to support the use of several

components scored independently, in the SCAT3. Important clinical information can be ascertained through a multi-

modal assessment and diagnostic tool such as the SCAT3, when managing concussion.

Reviewed by Pip Sail

RESEARCH SECTION

For more information about SCAT3 click here

Page 13

What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assess-

ment of recovery?

Kutcher JS, McCroy P, Davis G, Ptito A, Meeuwisse WH, Broglio SP (2013). What Evidence Exists for new strate-

gies or technologies in the diagnosis of sports concussion and assessment of recovery?, British Journal of Sports

Medicine 47: 299-303.

Article Summary

At present there is an absence of objective tests that can confirm the presence of concussion or mild traumatic brain

injury (mTBI) and diagnosis and management relies largely on subjective clinical decision making processes. It has

hoped that newer diagnostic technologies will be of greater clinical use with regards to concussion diagnosis, as well

as guiding treatment and recovery.

This article reviewed the current literature regarding the newer diagnostic topics and/or technologies such as func-

tional neuroimaging, Quantitative EEG (qEEG), head impact sensors, telemedicine and mobile devices/applications.

Quantitative EEG

qEEG is a technique that involves the computer-aided analysis of electroenceohalographic data and in contrast to

standard EEG, qEEG allows for identification of subtle changes and patterns in source data.

Four studies were identified which showed the ability of the technology to document physiological dysfunction in the

setting of concussion and may act as a useful measure of tracking recovery if evaluated in future prospective studies.

At present there is no data which analyses the ability of qEEG to provide distinguishing features of concussion and

as the observed changes are non specific to the cause there is limited clinical utility of the technology.

Functional Neuroimaging

CT and standard MRI is of little clinical use in the diagnosis of sports related concussion, however, CT does have an

important role in screening for potential bleeding or identification of skull fracture. MRI may be of benefit in monitoring

of structural changes over time or evaluating concurrent pathology that complicate concussion.

Functional neuroimaging refers to a subset of technologies that provide an estimating of function hence generating

interest in those investigating concussion.

Functional MRI (fMRI) is based on the relationship between blood flow and neuronal metabolism. It takes advantage

of the different magnetic states between oxygen rich and poor blood through the use of blood –oxygen-level-

dependent (BOLD) contrast technique. Advantages to using fMRI is that there is no contrast media or radiation ex-

posure and it can be used with other measures of brain pathology. Three studies found that there were differences

in the BOLD signal pattern between matched control groups and the symptomatic concussed group. There were no

differences between controls and asymptomatic concussion subject. One study (Talavage et al) of American college

football players found differences pre and post season in 11 subjects however only 4 had sustained a recognised

concussion.

Megnetoencephalography (MEG) is a brain mapping technique that records the magnetic fields produced by the

brains electrical activity. It has a higher degree of temporal resolution than fMRI and readings are less distorted by

the skull and scalp than EEG. There were no studies identified that used MEG in sports related concussion. It has

been shown to be sensitive to mTBI in those sustaining injuries from blast and nonblast causes.

Near-infrared spectroscopy (NIRS) detects changes in haemoglobin concentrations via measurement of the near-

infrared (800-2500mm) region of the electromagnetic spectrum. It is more portable than other functional neuroimag-

ing devices and can be used on moving subjects however it only detects changes in surface tissue and not deeper

brain structures. There have been no studies found using the NIRS in sports related concussion.

www.sportsphysiotherapy.org.nz/resources

Sports Concussion - Assessment and Prevention continued……..

RESEARCH SECTION

CONTINUED ON NEXT PAGE.

Page 14

Clinical Implications

At present may of the newer technologies have yet to prove to have clinical utility where they can provide distinguish-

ing features of a concussion and thus should be used with caution. Many of the technologies are expensive and im-

practical to administer in the general population.

The use of mobile applications for concussion may be of benefit for physiotherapists involved in sport as they have

instant access to education and measurement tools that can be employed easily and wherever it is needed.

Reviewed by Louise Turner B App Science (Physiotherapy), Masters of Health Practice (Musculoskeletal Physio-therapy)

Position emission tomography (PET) uses a biologically active molecule to introduce a positron emitting radionu-

clide. It has been used in military personnel with persistent concussion symptoms but there were no studies report-

ing its use in sports related concussion. It has been show to be sensitive to metabolic changes seen in the diagnosis

mild cognitive impairments therefore PET may be used a tool for demonstrating the metabolic changes in longer

term symptoms following concussion.

Single photon emission CT (SPECT) uses a radioactive tracer like PET but is significantly cheaper. There were no

identified studies using SPECT in sports related concussion.

Head Impact Sensors

Head impact sensors allow for the monitoring of impacts throughout an athletic even in the hope of providing a

threshold for injury but no threshold has been discovered. Although the onboard accelerometer may not be able to

accurately predict injury it may act as a screen device to alert sideline personnel that an impact has occurred.

Telemedicine

There is clear mismatch between the number of athletes who experience a sports-related concussion and the num-

ber of licensed health care providers who possess training in diagnosis and management of the injury. There have

been no studies using telemedicine in concussion. Telemedicine has been used successful in other neurological di-

agnoses such as stroke where a well studied, validated and reproducible measurement tool is used. However con-

sidering concussion symptoms are much more subtle establishing techniques for remote diagnosis and management

of concussion may be more difficult.

Mobile Devices

Mobile devices are uniquely placed to address gaps in concussion management and diagnosis. There is a need to

educate all participants in sports concussion care and mobile devices provide the opportunity to download educa-

tional materials quickly. It can also be used to organise information on injury demographics, symptom timing and

recovery milestones. Diagnostic screening tools such as the SCAT2 can be employed over any computing platform.

There have been no studies using mobile devices for sports concussion diagnosis or management however the

study found 17 applications created for sports concussion diagnosis, management or education.

RESEARCH SECTION

Sports Concussion - Assessment and Prevention continued……..

www.sportsphysiotherapy.org.nz/resources

Page 15

JOSPT

www.jospt.org

JOSPT ACCESS

All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT

website.

You will have needed to have followed the information within that email in order to create your own password.

If you did not follow this advice, have lost the email, have any further questions or require more information then

please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have.

If you have just forgotten your password then first please click on the “Forgotten your password” link found on the

JOSPT sign on page in order to either retrieve or reset your own password.

Only current financial SPNZ members will have JOSPT online access.

RESEARCH PUBLICATIONS

Current Issue December 2013

CASE REPORT

Varied Response to Mirror Gait Retraining of Gluteus Medius Control, Hip Kinematics, Pain, and Function in Two

Female Runners With Patellofemoral Pain

CLINICAL COMMENTARY

The Modified Sleeper Stretch and Modified Cross-body Stretch to Increase Shoulder Internal Rotation Range of Mo-

tion in the Overhead Throwing Athlete

MUSCULOSKELETAL IMAGING

Acute Exertional Rhabdomyolysis

Fracture of the Lateral Femoral Condyle

RESEARCH REPORT

Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound

Quadriceps and Hamstrings Morphology Is Related to Walking Mechanics and Knee Cartilage MRI Relaxation Times

in Young Adults RESEARCH REPORT

Arthritis Self-Efficacy Scale Scores in Knee Osteoarthritis: A Systematic Review and Meta-analysis Comparing Arthri-

tis Self-Management Education With or Without Exercise

Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the Ankle

The Effect of Burst-Duty-Cycle Parameters of Medium-Frequency Alternating Current on Maximum Electrically In-

duced Torque of the Quadriceps Femoris, Discomfort, and Tolerated Current Amplitude in Professional Soccer Play-

ers

Variability in Diaphragm Motion During Normal Breathing, Assessed With B-Mode Ultrasound

Page 16

ASICS REPORT

Page 17

flexibility and rearfoot cushioning. The main inspiration for

its design was the batsmen and fielders in the 20/20 circuit.

To achieved the desired flexibility and reduce weight whilst

still providing outstanding grip special inserts were used

with an integrated pin system, similar to that used in track

and field events but specifically positioned for the require-

ments of cricket. Additionally, these pins were bound by PU

strips to prevent them from being pulled out during play.

The underfoot feel of this shoe is amazing.

Subsequently, all the research and development being

done so successfully here at home has led other countries

like England and India to approach us for the supply of

their cricket shoes. As a matter of fact, while I sit here and

write this I am in India, on the final leg of my tour, showing

the range for the back half of 2014 to our distributors in

Bangalore, Mumbai and Delhi.

India is an amazing country that has both a passion for

cricket and a desire for access to better quality, higher per-

forming product. As a result our high end cricket shoes are

booming here. Simply put, they too have noticed that

ASICS built shoes that work better. According to one dis-

tributor; Indian consumers are like Australian consumers in

that they value quality product and don’t get sucked in too

much with gimmicks and hype.

We have been lucky enough in India to have many of the

national players wearing our shoes. Most of these players

have been recommended our shoes by others on the inter-

national circuit, predominantly health professionals. At

ASICS we are so grateful for the support and trust of the

medical fraternity here in Australia.

During my trips to India I have been lucky enough to have

met some of the most revered names in Indian cricket;

some current and some retired. These players have noth-

ing but praise and thanks for the ASICS shoes they had

worn during their careers or are currently wearing. That is

quite a buzz knowing that it all started here in Australia.

Now all we have to do is win the Ashes back and I will be a

happy man!

Participation in off road running events is increasing as

elite and recreational runners alike are taking a break from

the pavement and flocking to the mud, rock and dirt of a

good trail. The hard surfaces and repetitive stressors asso-

ciated with road running and the increased demand on the

bones and muscles are physiologically taxing. Trail running

on the other hand unloads the impact on the body which

acts to prevent injury while maintaining high mileage train-

ing for aerobic endurance. With this in mind the new ASICS

Fuji Sensor was created; a high performance trail shoe

built on a stable base with superior cushioning.

Regards,

Mark Doherty

GM Product

ASICS REPORT

CRICKET SHOES: FROM THE GROUND UP, NO SHORTCUTS cont...

The Cricket category has always been an excellent way for

ASICS to demonstrate its commitment not only to investing

in a diverse range of sports but also creating well thought

out, high quality products exclusively for the passions and

interests of the Australian/New Zealand population.

I’m sure I have previously mentioned that ASICS is a unique

company in that it allows us to design and develop shoes

here that are relevant specifically to the Australian and New

Zealand market. We are fortunate in this regard as some of

the sports we love dearly are quite small when you look at

them from a global perspective.

Because of the limited population in our region, south the

equator, it is common for footwear brands to take shoes

designed for use in the Northern Hemisphere, tweak them

slightly and then distribute them down here saying: “Here

you go sell this as a cricket shoe”. Instead, by allowing us to

build our own shoes, despite how expensive or time con-

suming they are to research and construct, they make our

shoes more technical and better suited to the sports they are

being marketed for. The ASICS Cricket range is a very good

example of the diligent attitude displayed by our parent com-

pany in Japan with respect to the sports we love.

Cricket shoes are highly specialized. They are not like run-

ning shoes, cross trainers or even netball shoes that can at

a push be worn for multiple sports. They have been purpose

built exclusively for one use: Cricket. Because the spread of

numbers sold is limited and production numbers are small

(from a global perspective) it means in some cases it can

literally take us years to recoup the money spent on midsole/

outsole tooling expenses.

Furthermore, cricket shoes are one of, if not, the most com-

plicated shoes to put together from a tooling perspective at

the factory level. They have internal spike plates, midsoles

that need to withstand an immense amount of stress, wear

and tear and uppers that need to do the same…Fast bow-

lers for example are tremendously hard on their shoes and

also require high levels of protection. This is why I take so

much pride in the fact that ASICS cricket shoes are not re-

hashed nor altered shoes but rather unique shoes designed

and built from the ground up for this sport in particular.

The humble cricket shoe has in fact evolved significantly

from the early cricket shoes that ASICS once sold. Original-

ly, they were constructed using golf plates which were quite

rigid and helped the wearer to get a firmer grip on the

ground when batting. Unfortunately they were not so crash

hot to walk around in. Funnily, the advances that we have

made in cricket shoe design are now influencing the golfing

industry as golfers now strive for the grip and flexibility

demonstrated by the flexible PU plate we embed into our

current cricket shoes.

Once we had researched and produced a few ranges it be-

came apparent to us that there was a need to provide differ-

ent shoes for different aspects of the game. The GEL Strike

Rate is an interesting development in that it was designed to

act just like a running shoe and provide incredible forefoot

SEPTEMBER 2013 FORERUNNER

Page 18

ACRS THE LIFESPAN

Key Note Speakers:

Professor Craig Purdam (Australia)

HEAD OF PHYSIOTHERAPY, AUSTRALIAN INSTITUTE OF SPORT

Craig Purdam is the Head of Physical Therapies at the Australian Institute of Sport. He has worked as a clinician

in elite sport for over 30 years and has been a physiotherapist at five Olympic Games (1984-2000) and a

longstanding physiotherapist to the Australian National Men’s Basketball team over that period. He has also had

other associations with the Australian national swimming, track and field and rowing teams. He was awarded the

Australian Sports medal in 2000 and in 2009 was appointed an adjunct Professor to the University of Canberra.

His undergraduate qualification was gained in 1975, a postgraduate diploma in Sports in 1992, a Masters in

Sports in 2000. He was awarded specialist status in Sports Physiotherapy through Fellowship of the Australian

College of Physiotherapists in 2009.

Mary Magarey (Australia)

SPECIALIST PHYSIOTHERAPIST

APA SPORTS AND MUSCULOSKELETAL PHYSIOTHERAPIST

Mary is a Fellow of the Australian College of Physiotherapists as a Specialist Musculoskeletal and Sports Physio-

therapist, the only Fellow in Australia in two areas of specialty. She also has a Doctorate (PhD) in Physiotherapy.

Her area of particular specialty is the shoulder but she is also passionate about injury prevention, particularly for

those athletes in throwing sports. Mary has over 20 years experience examining and managing complex shoulder

problems, in particular problems with shoulders of athletes who throw. She has been teaching physiotherapy at

the University of South Australia for over 30 years.

SPNZ Symposium Rotorua

15-16 March 2014

SPORT AND EXERCISE ACROSS THE LIFESPAN

For speakers’ profiles and provisional programme

check out the Symposium website.

SPNZ SYMPOSIUM 2014

Page 19

CONTINUING EDUCATION CALENDAR

Upcoming courses and conferences in New Zealand and overseas in 2013 & 2014.

For a full list of local courses visit the PNZ Events Calendar

LOCAL COURSES & CONFERENCES

When? What? Where?

2014

15-16 March 2014 3rd

SPNZ Symposium Rotorua

1 February 2014 University of Otago - Postgraduate Study - Introduction - Supporting Healthier Lifestyles

Nationwide

21-22 February 2014 Mulligan Concept - Update with Brian Mulligan Auckland

1-2 March 2014 Mulligan Concept Functional Treatment of the SIJ and Pubic Symphysis

Nelson

4 April 2014 Optimising 3D Biomechanics, The Pelvic and Lumbar Spine - Assess-ment & Treatment

Auckland

4 April 2014 Retraining Optimal Dynamic Function of the Hip Region Auckland

APA CPD EVENT FINDER

Course Town Dates

Sports Level 1 Silverwater, NSW 8-9 Feb 2014

Sports Level 1 Kent Town, SA 15-16 Feb 2014

Hamstring Assessment, Prevention and Rehabilitation St Leonards, NSW 16 Feb 2014

Sports Level 1 Silverwater, NSW 22-23 Feb 2014

Tendinopathy Update Bruce, ACT 24 Feb, 24 Mar 2014

Tendinopathy Pain, Pathology and Management Camberwell, VIC 5 Mar 2014

Sports Level 1 Warners Bay, NSW 8-9 Mar 2014

Sports Taping North Ryde, NSW 8 Mar 2014

The Sporting Elbow, Wrist and Hand Woodville South, SA 15 Mar 2014

Sports Level 2 Silverwater, NSW 28-30 Mar 2014

SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and

conferences at APA member rates. This includes all webinars and podcasts (no travel required!).

To see a full list visit the APA and SPA Events Calendar

For a list of international courses visit http://ifspt.org/education/conferences/