51
|
Returning Adolescents to Driving after Sports-Related Concussions: What Influences Physician Decision-Making. J Pediatr 2018; 194:177-181. [PMID: 29198541 DOI: 10.1016/j.jpeds.2017.10.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/07/2017] [Accepted: 10/12/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine which data collected on an initial patient clinic visit for a sports-related concussion (SRC) might influence physicians to clear an adolescent to return to drive (RTD) after injury. STUDY DESIGN Retrospective cohort study of 189 adolescents with a SRC referred to a hospital-based concussion clinic between June 1, 2015, and May 31, 2016. Subjects were ≥16 years with a valid driver's license (median age = 16, IQR [16, 17]). Concussion evaluations included Post-Concussion Symptom Scale, modified Balance Error Scoring System, and postinjury computerized neurocognitive testing (CNT). Clearance for RTD was the main outcome. Statistical comparisons were conducted with Mann-Whitney U and χ2 tests and logistic regression. RESULTS In multivariable analysis, odds of being fully cleared to drive were 5.9-fold greater among patients who were administered CNT. Stated symptoms of "headache" and "sensitivity to light" were statistically significantly associated with RTD clearance. For a subset of 113 individuals undergoing CNT, each additional 10-millisecond decrease in simple reaction time was associated with 9% greater odds of being cleared to drive. Each additional 10-millisecond decrease in choice reaction time was associated with 4% greater odds of being cleared to drive. CONCLUSIONS CNT and associated reaction time measures may facilitate a physician's objective decision-making. Making a RTD determination for adolescents recovering from an SRC should be a core component of a physician's assessment.
Collapse
|
52
|
Lal A, Kolakowsky-Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. Am J Sports Med 2018; 46:743-752. [PMID: 28570092 DOI: 10.1177/0363546517706137] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data evaluating the role of exercise in patients with a concussion are contradictory. Studies have reported improvement in the Post-Concussion Symptom Scale (PCSS) score, whereas others showed no effect on the PCSS score. PURPOSE To conduct a systematic review and meta-analysis on the role of physical exercise on different outcomes in patients with a concussion. STUDY DESIGN Systematic review and meta-analysis. METHODS A search of 5 databases from the earliest available date to September 30, 2016, and a hand search of a few articles were performed. Trial registries were reviewed, and authors of multiple studies were contacted to find additional published or unpublished studies. Randomized controlled trials (RCTs), cohort studies, and before and after (pre-post) studies evaluating the effect of physical exercise, compared with control, in patients with a concussion or mild traumatic brain injury were included. RESULTS The search generated 1096 studies. Of these, 14 studies (5 RCTs, 1 propensity score matching study, 3 cohort studies, and 5 before and after studies) met our inclusion criteria. Exercise significantly decreased the PCSS score (mean difference, -13.06; 95% CI, -16.57 to -9.55; P < .00001; I2 = 44%), percentage of patients with symptoms of a concussion (risk ratio, 0.74; 95% CI, 0.63 to 0.86; P = .0001; I2 = 0%), and days off work (17.7 days vs 32.2 days, respectively; P < .05) compared with control. Exercise improved the reaction time (standard mean difference, -0.43; 95% CI, -0.80 to -0.06; P = .02) component of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) score without affecting the Balance Error Scoring System (BESS) score and neuropsychological parameters. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) scores were moderate for the PCSS, symptoms, ImPACT, BESS, and neuropsychological tests. CONCLUSION Physical exercise appears to improve the PCSS score and symptoms in patients with a concussion. A high-quality RCT evaluating different intensities of exercise at different time points, for different durations after a concussion, for different races/ethnicities, and for sex needs to be conducted to evaluate a clear effect of exercise in patients with a concussion.
Collapse
Affiliation(s)
- Avtar Lal
- Brain Trauma Foundation, Campbell, California, USA
| | | | - Jamshid Ghajar
- Brain Trauma Foundation, Campbell, California, USA.,Stanford Concussion and Brain Performance Center, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | | |
Collapse
|
53
|
Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial. J Head Trauma Rehabil 2018; 32:79-89. [PMID: 27120294 DOI: 10.1097/htr.0000000000000238] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents. SETTING Outpatient research setting. PARTICIPANTS Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms. DESIGN Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program. MAIN MEASURES The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described. RESULTS Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P = .044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean [SD] times per week = 4.42 [1.95] vs 5.85 [1.37], P < .0001) over the duration of the study. CONCLUSION Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit.
Collapse
|
54
|
Abstract
PURPOSE OF REVIEW This article summarizes the impact and complications of mild traumatic brain injury and concussion in children and outlines the recent evidence for its assessment and early management. Useful evidence-based management strategies are provided for children who have a typical recovery following concussion as well as for those who have persistent postconcussion syndrome. Cases are used to demonstrate the commonly encountered pathologies of headache, cognitive issues, and mood disturbances following injury. RECENT FINDINGS A clinical risk score using risk factors for poor recovery (eg, female sex, adolescence, previous migraine, and a high degree of acute symptoms) can be used to help the clinician plan follow-up in the community. Prolonged periods of physical and cognitive rest should be avoided. Multidisciplinary treatment plans are often required in the management of persistent postconcussion syndrome. SUMMARY A paucity of research exists for the treatment of postconcussion syndrome. Current treatments target individual symptoms.
Collapse
|
55
|
Zafonte RD, Shih SL, Iaccarino MA, Tan CO. Neurologic benefits of sports and exercise. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:463-471. [PMID: 30482373 DOI: 10.1016/b978-0-444-63954-7.00042-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Traumatic brain injury (TBI) is associated with several pathophysiologic changes, including: neurostructural alterations; molecular changes with shifts in circulating neurotrophins; impaired neural metabolism; changes in cerebrovascular autoregulation, vasoreactivity, and neurovascular coupling; and alterations in functional brain connectivity. In animal models of TBI, aerobic exercise reduces neuronal injury, promotes neuronal survival, and enhances the production of neuroprotective trophic factors. However, the timing of exercise initiation is an important consideration as early exercise in the acute postinjury period may impede recovery mechanisms, although evidence for this in humans is lacking. Though human clinical studies are limited, aerobic exercise post-TBI engages cerebrovascular mechanisms and may impart neurophysiologic benefits to mitigate post-TBI pathophysiologic changes. Additionally, subsymptom threshold exercise in humans has been demonstrated to be safe, feasible, and effective in decreasing symptom burden in individuals with mild TBI, and to counteract the detrimental effects of prolonged inactivity, subsequent physical deconditioning, and its negative emotional sequelae. This chapter will explore the potential role of aerobic exercise in neurorecovery after TBI.
Collapse
Affiliation(s)
- Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.
| | - Shirley L Shih
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Can Ozan Tan
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| |
Collapse
|
56
|
Paquin H, Taylor A, Meehan WP. Office-based concussion evaluation, diagnosis, and management: pediatric. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:107-117. [PMID: 30482337 DOI: 10.1016/b978-0-444-63954-7.00011-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More children and adolescents are participating in competitive sports than ever before, causing an overall increase in sport-related injuries. Concussion is a common injury in the pediatric population and its prevalence has increased with increased visibility and awareness. This chapter will discuss the clinical presentation, evaluation, and management of concussions sustained by pediatric athletes, while addressing the distinctive factors that pertain to this population. Management of concussion should be tailored to patients' symptoms and should focus on an early and gradual return to both cognitive and noncontact low-risk physical activity. A multidisciplinary approach is often helpful in addressing more specific symptoms, which fall into the somatic, cognitive, vestibular, emotional, and sleep domains. A prolonged recovery is defined by symptoms lasting more than 4 weeks. Individualized return-to-play decisions should focus on the safety of the young athlete.
Collapse
Affiliation(s)
- Hugo Paquin
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montreal, QC, Canada.
| | - Alex Taylor
- Division of Neurology and Psychiatry, Boston Children's Hospital, Boston, MA, United States
| | - William P Meehan
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States
| |
Collapse
|
57
|
Howell DR, Brilliant A, Berkstresser B, Wang F, Fraser J, Meehan WP. The Association between Dual-Task Gait after Concussion and Prolonged Symptom Duration. J Neurotrauma 2017; 34:3288-3294. [DOI: 10.1089/neu.2017.5191] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David R. Howell
- Sports Medicine Center, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
| | - Anna Brilliant
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
| | | | - Francis Wang
- Harvard University Health Service, Cambridge, Massachusetts
| | - Joana Fraser
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
| | - William P. Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
- Departments of Pediatrics and Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
58
|
Albalawi T, Hamner JW, Lapointe M, Meehan WP, Tan CO. The Relationship between Cerebral Vasoreactivity and Post-Concussive Symptom Severity. J Neurotrauma 2017; 34:2700-2705. [DOI: 10.1089/neu.2017.5060] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tamadher Albalawi
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Jason W. Hamner
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Matthew Lapointe
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - William P. Meehan
- The Micheli Center for Sports Injury Prevention, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics and Orthopedics, Harvard Medical School, Boston, Massachusetts
| | - Can Ozan Tan
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
59
|
Abstract
Concussion has been recognized as a clinical entity for more than 1000 years. Throughout the 20th century it was studied extensively in boxers, but it did not pique the interest of the general population because it is the accepted goal of the boxer to inflict such an injury on their opponent. In 2002, however, the possibility that repetitive concussions could result in chronic brain damage and a progressive neurologic disorder was raised by a postmortem evaluation of a retired player in the most popular sports institution in the United States, the National Football League. Since that time concussion has been a frequent topic of conversation in homes, schools, and on television and has become a major focus of sports programs in communities and schools at all levels. Now all 50 states, the District of Columbia, and the National Collegiate Athletic Association have enacted laws and rules to protect the athlete.
Collapse
Affiliation(s)
- William J Mullally
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, Mass.
| |
Collapse
|
60
|
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.
Collapse
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.
| |
Collapse
|
61
|
Davis GA, Anderson V, Babl FE, Gioia GA, Giza CC, Meehan W, Moser RS, Purcell L, Schatz P, Schneider KJ, Takagi M, Yeates KO, Zemek R. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017; 51:949-957. [PMID: 28455361 DOI: 10.1136/bjsports-2016-097415] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 11/03/2022]
Abstract
AIM To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp). DESIGN Systematic review. DATA SOURCES MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC. RESULTS A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5-12 years. SUMMARY/CONCLUSIONS This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2016:CRD42016039184.
Collapse
Affiliation(s)
- Gavin A Davis
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Vicki Anderson
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Franz E Babl
- Murdoch Childrens Research Institute, Melbourne, Australia
| | | | | | - William Meehan
- Micheli Center for Sports Injury Prevention, Massachusetts, USA
| | | | - Laura Purcell
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, Canada
| | - Michael Takagi
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Research Institute & Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| |
Collapse
|
62
|
Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann-Demont N, Iverson GL, Hayden A, Makdissi M. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017; 51:930-934. [PMID: 28341726 DOI: 10.1136/bjsports-2016-097475] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 12/19/2022]
Abstract
AIM OR OBJECTIVE The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC). DESIGN Systematic review. DATA SOURCES MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded. RESULTS Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care. SUMMARY/CONCLUSIONS A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2016:CRD42016039570.
Collapse
Affiliation(s)
| | - John J Leddy
- Department of Orthopaedics, SUNY Buffalo, Buffalo, New York, USA
| | - Kevin M Guskiewicz
- Sports Medicine Research laboratory, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tad Seifert
- Norton Healthcare, Louisville, Kentucky, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Noah D Silverberg
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nina Feddermann-Demont
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Schulthess Clinic, Zurich, Switzerland
| | - Grant L Iverson
- Physical Medicine and Rehabilitation, Harvard Medical School; and Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts, USA
| | - Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Michael Makdissi
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia.,Olympic Park Sports Medicine Centre, Melbourne, Australia
| |
Collapse
|
63
|
Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scand J Med Sci Sports 2017; 27:2009-2018. [PMID: 28211600 DOI: 10.1111/sms.12827] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 12/30/2022]
Abstract
The purpose of this study was to (a) assess the feasibility of recruitment/retention of participants, protocol/resource management, and participant safety, and (b) estimate the size of the effect between the experimental and control groups. This was a feasibility study conducted as a prospective pilot double-blind randomized clinical trial. Subjects aged 10-23 years old with acute concussion and dizziness were enrolled from sports medicine centers. Forty-one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post-concussion. Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions. Subjects in the control received prescriptive sham to minimally progressive interventions. The two primary outcomes were medical clearance for return-to-play and symptomatic recovery. The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26. The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control. According to Cox proportional hazards regression for time to medical release for return-to-play, the experimental group demonstrated a hazard ratio of 2.91 (95% CI: 1.01, 8.43) compared to the control. For time-to-symptomatic recovery, those in the experimental group demonstrated a hazard ratio of 1.99 (95% CI: 0.95, 4.15) compared to the control. The results indicate that it is feasible and safe to complete this type of intervention study. The results provide strong support for the allocation of resources to conduct well-powered randomized clinical trials of this intervention.
Collapse
Affiliation(s)
- J C Reneker
- Department of Physical Therapy, School of Health Related Professions, University of Mississippi Medical Center, Jackson, MS, USA
| | - A Hassen
- Walsh University, North Canton, OH, USA
| | | | - M C Moughiman
- Louis Stokes Cleveland Veterans Administration Medical Center, Akron, OH, USA
| | | | - J Moughiman
- Louis Stokes Cleveland Veterans Administration Medical Center, Akron, OH, USA
| |
Collapse
|
64
|
Klein TA, Graves JM. A Comparison of Psychiatric and Nonpsychiatric Nurse Practitioner Knowledge and Management Recommendations Regarding Adolescent Mild Traumatic Brain Injury. J Am Psychiatr Nurses Assoc 2017; 23:37-49. [PMID: 27601433 DOI: 10.1177/1078390316668992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nurse practitioners (NPs) are statutorily authorized to provide assessment and cognitive recommendations for concussion in most states. Their scope of practice includes assessment and management of concussion sequalae including anxiety, insomnia, and depression, as well as return to school and activity guidance. OBJECTIVES Analysis of symptom-based diagnosis of mild traumatic brain injury (TBI) in adolescents, including return to school and school workload recommendations comparing psychiatric and nonpsychiatric NPs. DESIGN Cross-sectional Web-based survey with embedded videos using standardized actors and scripts randomized for patient sex and sport. A total of 4,849 NPs licensed in Oregon or Washington were invited by e-mail to view and respond to this study, with a response rate of 23%. RESULTS Psychiatric mental health nurse practitioners (PMHNPs) were 44% less likely than family NPs to report using standardized concussion tools. 17% had completed continuing education on mild TBI compared to 54.5% of family NPs. Seven PMHNPs provided additional feedback related to discomfort in completing the survey due to lack of comfort or experience. Return to school recommendations and reduced workload advice did not significantly differ by NP type. CONCLUSION PMHNPs may support individualized assessment through concussion evaluation, use of standardized tools, and differential consideration of TBI for mental health symptoms. More research is required related to the role and contribution of cognitive rest to full recovery.
Collapse
Affiliation(s)
- Tracy A Klein
- 1 Tracy A. Klein, PhD, FNP, ARNP, FAANP, FRE, FAAN, Washington State University Vancouver, Vancouver, WA, USA
| | - Janessa M Graves
- 2 Janessa M. Graves, PhD, MPH, Washington State University Spokane, Spokane, WA, USA
| |
Collapse
|
65
|
Abstract
A concussion is a relatively common sports-related injury that affects athletes of all ages. Although orthopaedic surgeons are not expected to replace sports medicine physicians and neurologists with regard to the management of concussions, orthopaedic surgeons, particularly those who are fellowship-trained in sports medicine, must have a current knowledge base of what a concussion is, how a concussion is diagnosed, and how a concussion should be managed. Orthopaedic surgeons should understand the pathophysiology, assessment, and management of concussion so that they have a basic comprehension of this injury, which is at the forefront of the academic literature and North American media. This understanding will prepare orthopaedic surgeons to work in concert with and assist sports medicine physicians, athletic trainers, and physical therapists in providing comprehensive care for athletes with a concussion.
Collapse
|
66
|
Pfaller AY, Nelson LD, Apps JN, Walter KD, McCrea MA. Frequency and Outcomes of a Symptom-Free Waiting Period After Sport-Related Concussion. Am J Sports Med 2016; 44:2941-2946. [PMID: 27371548 PMCID: PMC6589833 DOI: 10.1177/0363546516651821] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines and practices for the management of sport-related concussion (SRC) have evolved swiftly over the past 2 decades. Despite common recommendations for a symptom-free waiting period (SFWP) before returning to sport, past reports have suggested poor utilization rates for this intervention. PURPOSE To obtain current estimates of the utilization and characterization of SFWPs with high school and collegiate athletes. STUDY DESIGN Descriptive epidemiology study. METHODS Data were extracted from a larger prospective study that followed athletes with SRC across 13 institutions in southeastern Wisconsin from 2012 to 2014. Participants included 143 contact and collision sport athletes who were followed serially through their recoveries after SRCs. RESULTS In the current study sample, 99.3% of athletes used an SFWP. The mean self-reported symptom duration was 6.35 days (median, 5 days), with 72.7% reporting symptom recovery within 1 week of injury, 93.7% within 2 weeks, and 99.3% within 30 days. Rate of same-season repeat concussion was low (3.8%) and was similar to or lower than the overall rate of concussion (4.3%). Five same-season repeat concussions occurred at a range of 8 to 42 days after initial injuries. CONCLUSION In comparison with prior published data collected from 1999 to 2004, utilization and duration of SFWPs were higher in the current study samples (99.3% vs 60.3% of athletes reported an SFWP; mean duration, 6.1 vs 3.2 days), and athletes were withheld from sports for more days than previously reported (12.3 vs 7.4 days). Rate of same-season repeat concussion was equivalent to that of prior published data. The findings support improved adherence to clinical management guidelines through increased utilization of SFWPs after SRC.
Collapse
Affiliation(s)
- Adam Y. Pfaller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA., Address correspondence to Adam Y. Pfaller, BS, Department of Neurosurgery, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226 ()
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer N. Apps
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kevin D. Walter
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatric and Adolescent Sports Medicine, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|