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Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Phys Med Rehabil Clin N Am 2018; 27:437-54. [PMID: 27154855 DOI: 10.1016/j.pmr.2015.12.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Concussion is a physiological brain injury with physical, cognitive, and emotional sequelae. The macrophysiological insult to the brain affects the autonomic nervous system and its control of cerebral blood flow. Most patients recover within 2 weeks, but some do not. Persistence of symptoms beyond the generally accepted time frame for recovery is called post-concussion syndrome (PCS). PCS is not a single entity; it is a group of disorders that requires specific forms of therapy. Rest has been the mainstay of the treatment for concussion and PCS. This article discusses the rationale for the active treatment of concussion and PCS.
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Affiliation(s)
- John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, SUNY Buffalo, 160 Farber Hall, Buffalo, NY 14214, USA.
| | - John G Baker
- UBMD Department of Orthopaedics and Sports Medicine and Nuclear Medicine, Jacobs School of Medicine and Biomedical Sciences, School of Social Work, University at Buffalo, Buffalo, NY, USA
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Abstract
Objective: To develop a tool for assessing intentions to continue or change activities for recovery following mild traumatic brain injury (mTBI) and determine if they are dependent on injury context or activity type. Method: Adult volunteers with no (or no recent) history of mTBI were randomly allocated to one of two vignette conditions, each with a different injury context. The vignette described an mTBI due to a motor vehicle accident (MVA, n = 76) or sport (SPORT, n = 89). Volunteers reported their rest or activity plans for 39 behaviours comprising three behaviour types (cognitive, physical, and restful). Results: Compared to a cut-score representing no change, on average there was a significant (p <= .001) planned decrease in physical and cognitive behaviours (MVAphysicalt(53) = 7.373; SPORTphysicalt(41) = 9.281; MVAcognitivet(41) = 9.367; SPORTcognitivet(51) = −3.521) and a significant planned increase in restful behaviours, such as sleep (MVArestfult(72) = 10.006; SPORTrestfult(86) = 9.566). An overall within-group effect for behaviour-type was not identified and there was no effect of condition (MVA vs. SPORT). Conclusion: The acute rest and activity plans for a simulated mTBI are behaviour specific and not dependent on context. An expectation for blanket-rest was not was observed but rest was planned for specific behaviours. This tool could be used to guide discussions with mTBI patients about their recovery so that their plans align with advice, and it could aid further research into the relation between intended and actual rest and activity and the effect on eventual outcomes.
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53
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Quatman-Yates C, Bailes A, Constand S, Sroka MC, Nissen K, Kurowski B, Hugentobler J. Exertional Tolerance Assessments After Mild Traumatic Brain Injury: A Systematic Review. Arch Phys Med Rehabil 2018; 99:994-1010. [PMID: 29277373 PMCID: PMC5924441 DOI: 10.1016/j.apmr.2017.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/09/2017] [Accepted: 11/25/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To review the literature to identify and summarize strategies for evaluating responses to physical exertion after mild traumatic brain injury (mTBI) for clinical and research purposes. DATA SOURCES PubMed and EBSCOhost through December 31, 2016. STUDY SELECTION Two independent reviewers selected studies based on the following criteria: (1) inclusion of participants with mTBI/concussion, (2) use of a measurement of physiological or psychosomatic response to exertion, (3) a repeatable description of the exertion protocol was provided, (4) a sample of at least 10 participants with a mean age between 8 and 65 years, and (5) the article was in English. The search process yielded 2685 articles, of which 14 studies met the eligibility requirements. DATA EXTRACTION A quality assessment using a checklist was conducted for each study by 2 independent study team members and verified by a third team member. Data were extracted by one team member and verified by a second team member. DATA SYNTHESIS A qualitative synthesis of the studies revealed that most protocols used a treadmill or cycle ergometer as the exercise modality. Protocol methods varied across studies including differences in initial intensity determination, progression parameters, and exertion duration. Common outcome measures were self-reported symptoms, heart rate, and blood pressure. CONCLUSIONS The strongest evidence indicates that exertional assessments can provide important insight about mTBI recovery and should be administered using symptoms as a guide. Additional studies are needed to verify optimal modes and protocols for post-mTBI exertional assessments.
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Affiliation(s)
- Catherine Quatman-Yates
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH.
| | - Anna Bailes
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Sara Constand
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Mary Claire Sroka
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Katharine Nissen
- Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Brad Kurowski
- Physical Medicine and Rehabilitation, Cincinnati Children's Hospital, Cincinnati, OH
| | - Jason Hugentobler
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH
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54
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Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One 2018; 13:e0196062. [PMID: 29668716 PMCID: PMC5905975 DOI: 10.1371/journal.pone.0196062] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
Abstract
Objective To determine whether earlier time to initiation of aerobic exercise following acute concussion is associated with time to full return to (1) sport and (2) school or work. Methods A retrospective stratified propensity score survival analysis of acute (≤14 days) concussion was used to determine whether time (days) to initiation of aerobic exercise post-concussion was associated with, both, time (days) to full return to (1) sport and (2) school or work. Results A total of 253 acute concussions [median (IQR) age, 17.0 (15.0–20.0) years; 148 (58.5%) males] were included in this study. Multivariate Cox regression models identified that earlier time to aerobic exercise was associated with faster return to sport and school/work adjusting for other covariates, including quintile propensity strata. For each successive day in delay to initiation of aerobic exercise, individuals had a less favourable recovery trajectory. Initiating aerobic exercise at 3 and 7 days following injury was associated with a respective 36.5% (HR, 0.63; 95% CI, 0.53–0.76) and 73.2% (HR, 0.27; 95% CI, 0.16–0.45) reduced probability of faster full return to sport compared to within 1 day; and a respective 45.9% (HR, 0.54; 95% CI, 0.44–0.66) and 83.1% (HR, 0.17; 95% CI, 0.10–0.30) reduced probability of faster full return to school/work. Additionally, concussion history, symptom severity, LOC deleteriously influenced concussion recovery. Conclusion Earlier initiation of aerobic exercise was associated with faster full return to sport and school or work. This study provides greater insight into the benefits and safety of aerobic exercise within the first week of the injury.
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55
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Wallace J, Covassin T, Lafevor M. Use of the stepwise progression return-to-play protocol following concussion among practicing athletic trainers. JOURNAL OF SPORT AND HEALTH SCIENCE 2018; 7:204-209. [PMID: 30356457 PMCID: PMC6180544 DOI: 10.1016/j.jshs.2016.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/04/2016] [Accepted: 08/23/2016] [Indexed: 06/08/2023]
Abstract
PURPOSE The purpose of this study was to determine whether practicing athletic trainers (ATs) were using the stepwise progression to make return-to-play (RTP) decisions after concussion and to determine what factors influenced their decision to use the stepwise progression. METHODS A total of 166 ATs (response rate = 16.6%) completed a 21-item questionnaire that evaluated participant demographics, methods of concussion management, and RTP decision-making using the stepwise progression. Descriptive statistics and a logistic regression were completed to analyze data. RESULTS Factors such as education level (p = 0.05) and number of concussions treated (p = 0.05) predicted use of the stepwise progression, whereas sex (p = 0.17), employment setting (p = 0.17), state law (p = 0.86), and years practicing (p = 0.17) did not predict whether ATs were following the stepwise progression. CONCLUSION The majority of the ATs from this study are employing the stepwise progression to safely return athletes to play after sustaining a concussion. This demonstrates that ATs are providing a standard of care for concussed athletes across various athletic training settings; however, having a graduate degree and treating more concussions per year are predictors of whether an AT follows all steps of the stepwise progression.
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Affiliation(s)
- Jessica Wallace
- Department of Kinesiology, Michigan State University, East Lansing, MI 48824, USA
- Human Performance & Exercise Science Department, Youngstown State University, Youngstown, OH 44555, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, MI 48824, USA
| | - Meghan Lafevor
- Department of Kinesiology, Michigan State University, East Lansing, MI 48824, USA
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56
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57
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Affiliation(s)
- Davin K Quinn
- From the Department of Psychiatry and Behavioral Sciences, the MIND Research Network, and the Department of Psychology, University of New Mexico, Albuquerque; the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and the Division of Orthopedics and Sports Medicine, Children's Hospital of Philadelphia, Philadelphia; and the Departments of Psychiatry and Behavioral Sciences and of Physical Medicine and Rehabilitation, University of Washington, Seattle
| | - Andrew R Mayer
- From the Department of Psychiatry and Behavioral Sciences, the MIND Research Network, and the Department of Psychology, University of New Mexico, Albuquerque; the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and the Division of Orthopedics and Sports Medicine, Children's Hospital of Philadelphia, Philadelphia; and the Departments of Psychiatry and Behavioral Sciences and of Physical Medicine and Rehabilitation, University of Washington, Seattle
| | - Christina L Master
- From the Department of Psychiatry and Behavioral Sciences, the MIND Research Network, and the Department of Psychology, University of New Mexico, Albuquerque; the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and the Division of Orthopedics and Sports Medicine, Children's Hospital of Philadelphia, Philadelphia; and the Departments of Psychiatry and Behavioral Sciences and of Physical Medicine and Rehabilitation, University of Washington, Seattle
| | - Jesse R Fann
- From the Department of Psychiatry and Behavioral Sciences, the MIND Research Network, and the Department of Psychology, University of New Mexico, Albuquerque; the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and the Division of Orthopedics and Sports Medicine, Children's Hospital of Philadelphia, Philadelphia; and the Departments of Psychiatry and Behavioral Sciences and of Physical Medicine and Rehabilitation, University of Washington, Seattle
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58
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Abstract
PURPOSE OF REVIEW The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations. RECENT FINDINGS Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.
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Affiliation(s)
- David A Brent
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Room 311 Bellefield Towers, Pittsburgh, PA, 15213, USA. .,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jeffrey Max
- Department of Psychiatry, University of California, San Diego, CA, USA.,Rady Children's Hospital, San Diego, CA, USA
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59
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Irvine A, Babul S, Goldman RD. Return to learn after concussion in children. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:859-862. [PMID: 29138156 PMCID: PMC5685447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Question Despite recent interest in the pathophysiology and management of concussion in children, as well as the ongoing concern about return to activity, advice regarding the type and length of cognitive rest has been inconsistent. What should I recommend to the children and adolescents in my clinic regarding cognitive rest following mild concussion? Answer Strict cognitive rest is not needed in those with mild concussion. Evidence suggests a decrease in usual activity to a level that allows children to remain asymptomatic, followed by a gradual return to learning, is appropriate. It is clear that either too little or too much activity is disadvantageous to recovery and can worsen outcomes.
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60
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Abstract
Pediatric mild traumatic brain injuries, most of which are concussions, are an increasingly common reason for presentation to emergency departments. The diagnosis of concussion has increased dramatically over the past decade, necessitating the acute care provider to have up-to-date knowledge of the definition, pathophysiology, signs and symptoms, physical examination findings, and acute management of pediatric concussion. This article also addresses populations most vulnerable to prolonged recovery from pediatric concussion and referral recommendations.
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Affiliation(s)
- Daniel J Corwin
- *Attending Physician (Corwin, Joffe), Division of Emergency Medicine, †Associate Fellow (Corwin), Center for Injury Research and Prevention, ‡Attending Physician (Grady), Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Philadelphia, PA; §Assistant Professor of Clinical Pediatrics (Grady), Associate Professor of Pediatrics (Joffe), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and ∥Attending Physician and Associate Professor (Zonfrillo), Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
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61
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Dachtyl SA, Morales P. A Collaborative Model for Return to Academics After Concussion: Athletic Training and Speech-Language Pathology. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2017; 26:716-728. [PMID: 28793153 DOI: 10.1044/2017_ajslp-16-0138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 03/17/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE In this article, we describe an academic concussion management protocol designed for grades Pre-K to 12, called Cognitive Return to Exertion (CoRTEx). Collaboration between the speech-language pathologist (SLP) and athletic trainer (AT) is highlighted. METHOD A description of CoRTEx is provided, and the need for collaboration is emphasized. A case study illustrates an example of how CoRTEx can be implemented at the individual student level. RESULTS A total of 165 students went through CoRTEx from the pilot in April 2014 through December 2016. Referrals to CoRTEx were highest for football, blows to the head, and soccer. Anecdotal evidence suggests that CoRTEx provided necessary support for students and their families, although research is needed to provide objective data. CONCLUSIONS CoRTEx and other similar protocols can be used as models for SLPs to create their own academic concussion management protocols. For cases in which the injured student is an athlete, the SLP-AT collaboration is critical to carefully coordinate return to academics and return to play so that students are successful in school, as well as ready to safely return to sport. Suggestions are made for designing research studies that can provide empirical evidence for the efficacy of such academic concussion management protocols.
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Affiliation(s)
- Sarah A Dachtyl
- Sahuarita Unified School District, Arizona
- Northern Arizona University, Flagstaff
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62
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Turner S, Langdon J, Shaver G, Graham V, Naugle K, Buckley T. Comparison of Psychological Response between Concussion and Musculoskeletal Injury in Collegiate Athletes. ACTA ACUST UNITED AC 2017; 6:277-288. [PMID: 29250458 DOI: 10.1037/spy0000099] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The psychological response to musculoskeletal injuries has been well documented, however, research on the psychological response to concussion is limited. The Profile of Mood States (POMS) and the State-Trait Anxiety Inventory (STAI) have recently been used to assess the psychological recovery of concussions. Although some studies indicate that psychological response is different for musculoskeletal injuries and concussion, there is currently not enough information to indicate this difference occurs at specific clinical milestones. The purpose of this study was to compare the psychological responses of student-athletes who have been diagnosed with a concussion to those of athletes diagnosed with musculoskeletal injuries with similar recovery duration. Fifteen collegiate athletes who sustained a musculoskeletal injury were recruited and matched with 15 previously collected concussion participants. The main outcome measures were the scores of POMS constructs: tension-anxiety, anger-hostility, fatigue-inertia, depression-dejection, vigor-activity, confusion-bewilderment, and total mood disturbance and STAI (state anxiety only). Two-way MANOVAs was run to determine the effects of group and time on POMS and STAI constructs. There were no significant interactions identified, but follow-up ANOVAs identified a main effect for time for most POMS subscales, with POMS scores improving over time in both groups. Analyses also revealed that tension-anxiety, vigor-activity and the STAI were not affected by time or group. The findings of this study, that both groups' psychological response to injury improves over time and at similar clinical milestones suggests reduction in sports and team related activities may play a substantial role in the psychological response to either concussion or musculoskeletal injury.
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Affiliation(s)
| | | | | | | | - Kelly Naugle
- Indiana University Purdue University-Indianapolis
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63
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Sufrinko AM, Kontos AP, Apps JN, McCrea M, Hickey RW, Collins MW, Thomas DG. The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion. J Pediatr 2017; 185:167-172. [PMID: 28365025 DOI: 10.1016/j.jpeds.2017.02.072] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/18/2017] [Accepted: 02/27/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?<?.05) for the symptoms group. Rest was beneficial for patients in the signs group on verbal memory performance (t?=??2.28, P?=?.029), but not for the symptoms group. CONCLUSION Compared with patients with signs of injury, patients with predominantly symptoms were more likely to remain symptomatic after injury if prescribed rest, whereas patients with signs of injury benefited from rest after a concussion. Individualized treatment planning after concussion should start in the emergency department. TRIAL REGISTRATION ClinicalTrials.gov: NCT01101724.
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Affiliation(s)
- Alicia M Sufrinko
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Anthony P Kontos
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer N Apps
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert W Hickey
- Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
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64
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Leddy J, Baker JG, Haider MN, Hinds A, Willer B. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train 2017; 52:299-308. [PMID: 28387557 DOI: 10.4085/1062-6050-51.11.08] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.
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Affiliation(s)
- John Leddy
- UBMD Department of Orthopaedics and Sports Medicine
| | - John G Baker
- UBMD Department of Orthopaedics and Sports Medicine.,Department of Nuclear Medicine, and
| | - Mohammad Nadir Haider
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo
| | - Andrea Hinds
- UBMD Department of Orthopaedics and Sports Medicine
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65
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McLeod TCV, Lewis JH, Whelihan K, Bacon CEW. Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature. J Athl Train 2017; 52:262-287. [PMID: 28387547 DOI: 10.4085/1052-6050-51.6.06] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To systematically review the literature regarding rest and return to activity after sport-related concussion. DATA SOURCES The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity. STUDY SELECTION Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression. DATA EXTRACTION The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article. DATA SYNTHESIS Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables. CONCLUSIONS Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.
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Affiliation(s)
- Tamara C Valovich McLeod
- Athletic Training Programs and.,School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa
| | - Joy H Lewis
- School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa
| | - Kate Whelihan
- School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa
| | - Cailee E Welch Bacon
- Athletic Training Programs and.,School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa
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66
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Buckley TA, Baugh CM, Meehan WP, DiFabio MS. Concussion Management Plan Compliance: A Study of NCAA Power 5 Conference Schools. Orthop J Sports Med 2017; 5:2325967117702606. [PMID: 28473995 PMCID: PMC5407527 DOI: 10.1177/2325967117702606] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: In response to concerns over concussions and repeated head impacts that occur during sports, the National Collegiate Athletic Association (NCAA) mandated that all member institutions enact a concussion management plan (CMP). Although institutional and health care provider self-reports have been investigated, compliance with NCAA protocol recommendations has not been examined. Purpose: To examine the CMPs from the 65 institutions within the NCAA Power 5 conferences for compliance with the NCAA 2015 concussion guidelines. Study Design: Descriptive epidemiology study. Methods: Each institution’s publicly available CMP was obtained in 2015, reviewed, and coded for compliance with each of the required 47 components. Overall compliance rate, item-level, category-level, and institution-level compliance was assessed. Independent predictors of compliance, including each institution’s athletic training staff size, academic performance, and athletic performance, were examined with quasi-binomial regression. Results: CMPs varied substantially in length and level of detail. The overall compliance rate for all components across all institutions was 94.3% (2880/3055). Twelve components achieved 100% (65/65) compliance, and the lowest levels of compliance were clustered in “return to learn.” There were 22 institutions that achieved a 100% compliance rate; the lowest institutional compliance was 59.6%. There were no significant associations between the independent predictors and institutional compliance. Conclusion: Overall compliance with NCAA concussion management requirements was high, but there remains room for improvement. The lowest level of compliance was clustered in the return-to-learn section. There were limited details provided in the reducing head trauma component. Items with lower compliance (reducing head trauma, return to learn) tended to be outside the core competencies of the medical staff, indicating an area for improvement. Encouragingly, many institutions and specific components demonstrated full compliance.
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Affiliation(s)
- Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, Delaware, USA
- Thomas A. Buckley, EdD, Department of Kinesiology and Applied Physiology, University of Delaware, 541 South College Avenue, 150 Human Performance Lab, Newark, DE 19716, USA ()
| | - Christine M. Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
- Micheli Center for Sport Injury Prevention, Division of Sports Medicine, Boston Children's Hospital, Waltham, Massachusetts, USA
| | - William P. Meehan
- Micheli Center for Sport Injury Prevention, Division of Sports Medicine, Boston Children's Hospital, Waltham, Massachusetts, USA
| | - Melissa S. DiFabio
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, Delaware, USA
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67
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Radhakrishnan R, Garakani A, Gross LS, Goin MK, Pine J, Slaby AE, Sumner CR, Baron DA. Neuropsychiatric aspects of concussion. Lancet Psychiatry 2016; 3:1166-1175. [PMID: 27889010 DOI: 10.1016/s2215-0366(16)30266-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/13/2016] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
Abstract
Over the past decade, concussion has become the most widely discussed injury in contact sports. However, concussions also occur in several other settings, such as non-contact sports, elderly individuals, young children, military personnel, and victims of domestic violence. Concussion is frequently undiagnosed as a cause of psychiatric morbidity, especially when the patient has no history of loss of consciousness or direct head trauma. Almost all of the extant literature focuses on traumatic brain injury and assumes that concussion is merely a mild form of traumatic brain injury, which has resulted in a lack of understanding about what concussion is, and how to diagnose, monitor, and treat its varied neuropsychiatric symptoms. In this Review, we address key issues so that the psychiatric clinician can better understand and treat patients with a clinical phenotype that might be the direct result of, or be exacerbated by, concussion. Future research needs to focus on prospective clinical trials in all affected patient populations (ie, those affected by concussion and those affected by various degrees of traumatic brain injury), the identification of reliable biomarkers that can be used to assist with diagnosis and treatment response, and the development of effective treatment interventions. Clearly differentiating concussion from traumatic brain injury is essential to achieve reliable and clinically relevant outcomes.
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Affiliation(s)
- Rajiv Radhakrishnan
- Yale University School of Medicine, New Haven, CT, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Amir Garakani
- Yale University School of Medicine, New Haven, CT, USA; Silver Hill Hospital, New Canaan, CT, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Lawrence S Gross
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Marcia K Goin
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Janet Pine
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Andrew E Slaby
- New York University, New York, NY, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Calvin R Sumner
- Pearson North America, Boston, MA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - David A Baron
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA.
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Collins MW, Kontos AP, Okonkwo DO, Almquist J, Bailes J, Barisa M, Bazarian J, Bloom OJ, Brody D, Cantu R, Cardenas J, Clugston J, Cohen R, Echemendia R, Elbin R, Ellenbogen R, Fonseca J, Gioia G, Guskiewicz K, Heyer R, Hotz G, Iverson GL, Jordan B, Manley G, Maroon J, McAllister T, McCrea M, Mucha A, Pieroth E, Podell K, Pombo M, Shetty T, Sills A, Solomon G, Thomas DG, Valovich McLeod TC, Yates T, Zafonte R. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery 2016; 79:912-929. [PMID: 27741219 PMCID: PMC5119544 DOI: 10.1227/neu.0000000000001447] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.
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Affiliation(s)
- Michael W. Collins
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jon Almquist
- Fairfax Family Practice Comprehensive Concussion Center, Fairfax, Virginia
| | - Julian Bailes
- Department of Neurosurgery, NorthShore University Health System, Chicago, Illinois
| | - Mark Barisa
- Baylor Institute for Rehabilitation, Frisco, Texas
| | - Jeffrey Bazarian
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - O. Josh Bloom
- Carolina Sports Concussion Clinic, Cary, North Carolina
| | - David Brody
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Robert Cantu
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Boston University, Concord, Massachusetts
| | - Javier Cardenas
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Jay Clugston
- Community Health and Family Medicine, University of Florida, Gainesville, Florida
| | - Randall Cohen
- Athletics Department, University of Arizona, Tucson, Arizona
| | - Ruben Echemendia
- Psychological and Neurobehavioral Associates, State College, Pennsylvania
| | - R.J. Elbin
- Office for Sports Concussion Research, University of Arkansas, Fayetteville, Arkansas
| | - Richard Ellenbogen
- Department of Neurological Surgery University of Washington, Seattle, Washington
| | - Janna Fonseca
- Carolina Sports Concussion Clinic, Cary, North Carolina
| | - Gerard Gioia
- Division of Neuropsychology, Children’s National Health System, Washington, District of Columbia
| | - Kevin Guskiewicz
- College of Arts and Sciences, University of North Carolina, Chapel Hill, North Carolina
| | - Robert Heyer
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gillian Hotz
- Neuroscience Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Grant L. Iverson
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry Jordan
- Neurorehabilitation, Burke Rehabilitation & Research, White Plains, New York
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Joseph Maroon
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Michael McCrea
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne Mucha
- University of Pittsburgh Medical Center Centers for Rehabilitation Services, Pittsburgh, Pennsylvania
| | - Elizabeth Pieroth
- Neurological Institute, NorthShore University Health System, Chicago, Illinois
| | - Kenneth Podell
- Houston Methodist Concussion Center, Houston Methodist Hospital, Houston, Texas
| | - Matthew Pombo
- Department of Orthpoedics, Emory University Healthcare, Atlanta, Georgia
| | - Teena Shetty
- Department of Neurology, Hospital for Special Surgery, Weill Cornell Medical College, New York City, New York
| | - Allen Sills
- Department of Neurosurgery, Vanderbilt University, Vanderbilt Sports Concussion Center, Nashville, Tennessee
| | - Gary Solomon
- Department of Neurosurgery, Vanderbilt University, Vanderbilt Sports Concussion Center, Nashville, Tennessee
| | - Danny G. Thomas
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Pediatric Emergency Medicine, Children’s Hospital of Wisconsin, Wauwatosa, Wisconsin
| | | | - Tony Yates
- Pittsburgh Steelers, Pittsburgh, Pennsylvania
| | - Ross Zafonte
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Neuropsychological Assessment Following Concussion: an Evidence‐Based Review of the Role of Neuropsychological Assessment Pre- and Post-Concussion. Curr Pain Headache Rep 2016; 20:38. [DOI: 10.1007/s11916-016-0571-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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