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This chapter is a review and analysis of quantitative EEG (qEEG) for the evaluation of the locations and extent of injury to the brain following rapid acceleration/deceleration trauma, especially in mild traumatic brain injury (TBI). The earliest use of qEEG was by Hans Berger in 1932 and since this time over 1,600 peer reviewed journal articles have been published in which qEEG was used to evaluate traumatic brain injury. Quantitative EEG is a direct measure of the electrical energies of the brain and network dynamics which are disturbed following a traumatic brain injury. The most consistent findings are: 1- reduced power in the higher frequency bands (8 to 40 Hz) which is linearly related to the magnitude of injury to cortical gray matter, 2- increased slow waves in the delta frequency band (1 to 4 Hz) in the more severe cases of TBI which is linearly related to the magnitude of cerebral white matter injury and, 3- changes in EEG coherence and EEG phase delays which are linearly related to the magnitude of injury to both the gray matter and the white matter, especially in frontal and temporal lobes. A review of qEEG reliability and clinical validation studies showed high predictive and content validity as determined by correlations between qEEG and clinical measures such as neuropsychological test performance, Glasgow Coma Scores, length of coma and MRI biophysical measures. Inexpensive and high speed qEEG NeuroImaging methods were also discussed in which the locations of maximal deviations from normal in 3-dimensions were revealed. Evaluation of the sensitivity and specificity of qEEG with a reduced number of EEG channels offers the feasibility of real-time monitoring of the EEG using Blue Tooth technology inside of a football helmet so that immediate evaluation of the severity and extent of brain injury in athletes can be accomplished. Finally, qEEG biofeedback treatment for the amelioration of complaints and symptoms following TBI is discussed.

The ideal neuroimaging study for the patient with concussion depends primarily on what one is seeking and what types of studies are available to satisfy that need. There is a variety of tests that can be ordered, therefore it is usually the time since the injury and the patient’s symptoms that dictate what one should be concerned about, and which test is most useful. Accordingly, this chapter is partially addressing this issue and may help medical practitioner to further appreciate possible brain structural changes and functional abnormalities as result of concussion.

With the rapid development of neuroimaging and neuroscience in the past several years, the body of research and clinical knowledge about concussion processes in adults continues to rapidly increase. Nevertheless, many questions involving the functioning of a human brain post-head injury and its recover remain unanswered. There is even less known about neurodynamics of concussive processes and recovery in children, whose young brain remains in a state of constant developmental change. There is enormous amount of variations, which are introduced in to the picture of pediatric concussion, that have to do with the child’s brain developmental phase at the time of the injury, its capacity for plasticity and adaptation to TBI, and other factors. This chapter attempts to provide an overview of research and clinical data relevant to the complex interplay of a child’s developing brain and the effects of a mild head injury. There is a growing body of research suggesting that even mild head injuries produce significant neurocognitive and neurobehavioral deficits in children and adolescents. As elucidated below, there is some uncertainty and controversy in regards to the definition, sequelae of, and recovery from pediatric concussions. The review of literature supports the idea that concussive processes produce a unique profile of neurocognitive and neurobehavioral deficits that is different for each child, given his developmental phase at the onset of injury and pre- and post-injury characteristics. The role of a comprehensive neuropsychological examination in detection of these deficits is substantial, as it delineates child’s unique profile of strengths and weaknesses that are essential for effective treatment planning and adequate academic placement.

The purpose of this study was to provide an initial examination of the effects of aerobic fitness and concussion history on concussion risk, symptoms and neurocognitive impairment, and recovery in high school football players. Participants ( N =158) completed estimated VO2 max and baseline neurocognitive tests (i.e., ImPACT). Concussed athletes completed ImPACT 24–72 hours post-injury, and again every 48–72 hours until they were asymptomatic or returned to baseline levels. Twenty-three players incurred concussions. The concussion incidence rate was 2.63/1000 exposures. Initial on-field assessments of post-traumatic amnesia (PTA) corresponded to post-concussion symptoms and neurocognitive declines on ImPACT. Previously concussed athletes were 3.71 times more likely to be concussed than those with no concussion history. A trend indicated that athletes low in aerobic fitness might be at greater risk ( OR = 1.80) for concussion than those high in aerobic fitness. Aerobic fitness and history of concussion were not related to concussion symptoms and neurocognitive impairment. Athletes with no history of concussion and those initially evaluated with PTA recovered faster than those with a history of concussion and those initially evaluated without PTA. A trend suggested that high aerobic fitness might be related to faster recovery times.

This chapter explores the contribution that electroencephalographic (EEG) recordings and balance testing can make in the areas of concussion assessment and return to play decisions. Current literature in these areas and empirical research that combines these assessment tools is reviewed. Research findings support the view that it is not symptom resolution, rather resolution of the concussion pathology that should determine whether an athlete is ready to return to competition. The current gold standard measures used for evaluation of both concussion severity and return to play rely heavily on measures of loss of consciousness and post-traumatic amnesia. The limitations of these current standards are discussed and a proposal is made concerning how concussion assessment might be improved through the addition of functional motor tests and objective EEG measures that reflect cortical functioning. The combination of electroencephalographic recordings and motor testing allows practitioners to assess two crucial elements of athletic functioning. First, basic physical capabilities of an athlete are assessed via balance testing. Second, neuronal functioning of the cortex is assessed in both resting and task conditions to determine whether the athlete has returned to pre-injury levels of cortical functioning. New research in the field is revealing that by challenging concussed people to perform postural tasks while simultaneous electroencephalographic recordings are taken, insights into long lasting cognitive functional deficits can be revealed. Research applied to frequency analysis, event-related potentials, movement related cortical potentials and injury source localization associated with the electroencephalograph recordings will be presented and commented on, The goal of this chapter is to provide the reader with an overview of the current state of research in concussion assessment and diagnosis and to lead the reader through the groundbreaking work being performed using functional testing paradigms during electroencephalographic recordings. The reader will be left with an understanding of why the combination of motor and cerebral testing is essential in performing a sensitive and reliable measure of concussion severity and return to play readiness.

In sports such as football, wrestling, and ice hockey, a minor “ding” or mild concussion is often an expected right of passage, or at least an expected injury. Being “in a fog” after a tackle, or a minor headache after a collision, is often considered “no big deal” to most athletes. Master comments that in boxing “being knocked-out is not considered dangerous but just part of the sport”, in fact few coaches are aware that this change in mental status is actually a sign of brain injury. (McCrory, 2004) These neurological injuries both in isolation and in series must be taken seriously if we are to protect the athlete. Numerous physicians and clinical researchers have dedicated their lives work to a systematic approach to the early detection and management of concussions. Although it has taken a few well publicized cases of significant injury and death to bring this issue to the forefront of sports medicine, our basic understanding of concussion management needs to continue to advance. By educating the medical community on the hazards associated with MTBI, it has also made both athletes and coaches aware that further medical assessment and evaluations should not be put off when an athlete is exhibiting post concussive signs and symptoms. At the most basic level, athletes are being protected from further brain injury by not being allowed to return to play until they are asymptomatic. Ultimately our role is to protect the athlete from further harm.

The major focus of this chapter is two-fold: 1) to deliver a clear message that athletic injuries, including traumatic brain injury, are not simply accidents, but instead, they have definite patterns and distinct non-random and more or less predictable characteristics; and 2) to elaborate on current understanding of head protection by means of a scientific database approach to the mechanics of helmetry. It is the responsibility of athletes’ health care providers and sport clinicians to continually make adjustments to rules and protective devices in order to reach an optimal level of safe participation without changing the integrity of the game. These steps may ensure that protective devices are indeed performing as expected and not causing harm to athletes and to other participants.

Injury is one of the unfortunate risks that collegiate athletes are faced with today. Even worse, is the possibility that some athletes experience re-injury or multiples injuries during their athletic careers. Athletes who experience multiple injuries are often labeled as injury prone and are treated numerous times for their physical injuries, but are never examined or treated for possible neural, behavioral or psychological deficits. For standard orthopedic injuries, it is assumed that the athlete is healthy once motor performance has reached pre-injury levels. For athletes that suffer concussions, it is assumed that the athlete is healthy once they are asymptomatic. Recent research has begun to target these misconceptions by providing data which suggest that neural symptoms, behavioral and psychological factors may exist as a by product of injury. Additionally, if injured athletes harbor any of these deficits during return to play, they may become more susceptible to re-injury. This paper attempts to attack the issue of re-injury by specifically addressing the psychological issues of fear related to re-injury of all sorts as well as neural substrates and behavioral deficits existing in concussed athletes. Using neural (EEG) basis of behavioral data (Balance), and psychological data (Tampa Scale of Kinesiophobia) we will ultimately be able to identify athletes at risk for re-injury. The results presented differences in athletes related to fear levels and gender, severity of injury and number of injuries experienced. EEG data was consistent in its findings in that concussed subjects showed an increase in the frequency bands of delta and theta, and a decrease in alpha compared to non-concussed subjects. Differences were also found in Balance levels in which concussed subjects showed high levels of instability particularly during eyes closed conditions in comparison to non-concussed subjects. Specific data analysis gives rise to psychological interventions that may help to identify athletes at risk for re-injury. With this identification athletes may seek the training needed to address neural, behavioral and psychological deficits.

The concussion in athletics is the most puzzling neurological and functional abnormality facing sport medicine today. Neuropsychology has focused on the assessment and management of Mild Traumatic Brain Injury (MTBI) for many years but only recently have neuropsychological measures and techniques been used with sports-related concussion. The nature of the pathology underlying MTBI makes it difficult to visualize the injury using modern neuroimaging techniques. In contrast, functional techniques like those used in neuropsychological assessment provide sensitive, validated and cost-effective approaches to assessing sports concussions. A rich literature has now developed that demonstrates the effectiveness of both traditional and computerized neuropsychological batteries. Data have revealed that these techniques can reliably distinguish between athletes with concussion and those without concussion within 2 hours of injury. These studies have also shown that recovery following concussion is dynamic with neurocognitive symptom patterns changing over time. Children appear to be more vulnerable to concussion than adults and have more protracted symptoms than adults. Although very useful, neuropsychological techniques provide only one component in the complex interplay of variables that comprise the return to play decision. Much attention has been paid to the diagnosis of sports-related concussion but little has been paid to the rehabilitation of these injuries. Although the vast majority of players with concussions achieve symptom resolution and neurocognitive baseline status within 7–10 days of injury, some do not. Rehabilitation efforts are discussed. It was noted that those approaches aimed at education and amelioration of the psychological factors associated with concussion have proven to be the most useful.

The purpose of this chapter is twofold (1) to provide some general information on the psychology of injury, specifically emphasizing the issue of fear of injury in athletes; and (2) to explore the collegiate coaches’ perspective regarding the causes and consequences of sport-related injuries including traumatic brain injuries. Several predisposing factors for development of fear of injury were identified, including gender, classification of injury in terms of its severity, and the number of previous injuries. These findings were shared with several collegiate coaches via personal interviews. Coaches’ perspective and views on injury are described including the discussions of various notions regarding the causes and consequences of injury, including traumatic brain injuries in collegiate athletics. Clearly, as evidenced by coaches’ responses, more education and knowledge about the causes, symptoms and long-term disabilities as a result of traumatic brain injury are needed to identify athletes at risk and to prevent brain injury in athletics.