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Tucker R, Cross M, Stokes K, Starling L, Hyman R, Kemp S, West S, Raftery M, Falvey E, Brown J. Symptom presentation and evolution in the first 48 hours after injury are associated with return to play after concussion in elite Rugby Union. JOURNAL OF SPORT AND HEALTH SCIENCE 2024; 13:387-397. [PMID: 38232900 PMCID: PMC11117005 DOI: 10.1016/j.jshs.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 10/17/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Return to play (RTP) in elite rugby is managed using a 6-stage graduated RTP protocol, which can result in clearance to play within 1 week of injury. We aimed to explore how symptom, cognitive, and balance presentation and evolution during concussion screens 2 h (head injury assessment (HIA) 2) and 48 h (HIA3) after injury were associated with time to RTP) to identify whether a more conservative graduated RTP may be appropriate. METHODS A retrospective cohort study was conducted in 380 concussed rugby players from elite men's rugby over 3 consecutive seasons. Players were classified as shorter or longer returns, depending on whether RTP occurred within 7 days (allowing them to be considered to play the match 1 week after injury) or longer than 8 days, respectively. Symptom, cognitive, and balance performance during screens was assessed relative to baseline (normal or abnormal) and to the preceding screen (improving or worsening). Associations between sub-test abnormalities and RTP time were explored using odds ratios (OR, longer vs. shorter). Median day absence was compared between players with abnormal or worsening results and those whose results were normal or improving. RESULTS Abnormal symptom results during screens 2 h and 48 h after concussion were associated with longer return time (HIA2: OR = 2.21, 95% confidence interval (95%CI): 1.39-3.50; HIA3: OR = 3.30, 95%CI: 1.89-5.75). Worsening symptom number or severity from the time of injury to 2 h and 48 h post-injury was associated with longer return (HIA2: OR = 2.49, 95%CI: 1.36-4.58; HIA3: OR = 3.34, 95%CI: 1.10-10.15. Median days absence was greater in players with abnormal symptom results at both HIA2 and HIA3. Cognitive and balance performance were not associated with longer return and did not affect median days absence. CONCLUSION Symptom presentation and evolution within 48 h of concussion were associated with longer RTP times. This may guide a more conservative approach to RTP, while still adhering to individualized concussion management principles.
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Affiliation(s)
- Ross Tucker
- Institute of Sport and Exercise Medicine (ISEM), Department of Exercise, University of Stellenbosch, Tygerberg 7505, South Africa; World Rugby Ltd., Dublin D02 AE93, Ireland.
| | | | - Keith Stokes
- Centre for Health, and Injury and Illness Prevention in Sport, University of Bath, Claverton Down BA2 7AY, UK; UK Collaborating Centre on Injury and Illness Prevention in Sport (UKCCIIS), University of Bath, Claverton Down BA2 7AY, UK; Rugby Football Union, London TW2 7BA, UK
| | - Lindsay Starling
- World Rugby Ltd., Dublin D02 AE93, Ireland; Centre for Health, and Injury and Illness Prevention in Sport, University of Bath, Claverton Down BA2 7AY, UK
| | - Rosy Hyman
- London School of Tropical Medicine, London WC1E 7HT, UK
| | - Simon Kemp
- Rugby Football Union, London TW2 7BA, UK; London School of Tropical Medicine, London WC1E 7HT, UK
| | - Stephen West
- Centre for Health, and Injury and Illness Prevention in Sport, University of Bath, Claverton Down BA2 7AY, UK; UK Collaborating Centre on Injury and Illness Prevention in Sport (UKCCIIS), University of Bath, Claverton Down BA2 7AY, UK; Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary T2N 1N4, Canada
| | | | - Eanna Falvey
- World Rugby Ltd., Dublin D02 AE93, Ireland; Department of Medicine, School of Medicine and Health, University College Cork, Cork T12 EC8P, Ireland
| | - James Brown
- Institute of Sport and Exercise Medicine (ISEM), Department of Exercise, University of Stellenbosch, Tygerberg 7505, South Africa; Carnegie Applied Rugby Research (CARR) centre, Carnegie School of Sport, Leeds Beckett University, Leeds LS6 3QS, UK
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Annalisa G, Davide B, Marco A. Sport and migraine—a dynamic relationship. Neurol Sci 2022; 43:5749-5751. [DOI: 10.1007/s10072-022-06273-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/08/2022] [Indexed: 10/17/2022]
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La Fountaine MF, Hohn AN, Leahy CL, Weir JP, Testa AJ. Observations from a prospective small cohort study suggest that CGRP genes contribute to acute posttraumatic headache burden after concussion. Front Neurol 2022; 13:947524. [PMID: 35989941 PMCID: PMC9389220 DOI: 10.3389/fneur.2022.947524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionPost-traumatic headache (PTH) is commonly reported after concussion. Calcitonin gene-related peptide (CGRP) is implicated in the pathogenesis of migraine. We explored how single nucleotide polymorphisms (SNPs) from CGRP-alpha (CALCA) and the receptor activity modifying protein-1 (RAMP1) related to headache burden during the first week after concussion.MethodsA prospective study was performed in 34 collegiate athletes who sustained a concussion. Participants completed the symptom evaluation checklist from the SCAT3 within 48 h of injury (V1), and again 4 (V2) and 7 (V3) days after injury. For each visit, the self-reported score (0–6) for headache, pressure in head, blurred vision, and sensitivity to light/noise were reported and summed to calculate the headache burden. A saliva sample was obtained and genotyped for CALCA (rs3781719) and RAMP1 (rs10185142). RAMP1 (TT, TC, CC) and CALCA (AA, AG, GG) were dichotomized (A+, A- and T+, T-, respectively), and concatenated (T+A+, T+A-, T-A+, T-A-) for analyses.ResultsHeadache Burden at Visit 1 was greatest in T+A+ compared to T-A+, and trended toward a significant difference with T+A-. Repeated-measures ANOVA revealed the presence of significant visit main effects (p < 0.001, η2 = 0.404), but the group (p = 0.055) and interaction effects only trended (p = 0.094). Pearson's χ2-tests revealed that 88% of those with return-to play (RTP) exclusions ≥15 days had PTH with multi-sensory symptoms (PTH+SENS) as compared to 35% in those with RTP < 14 day.ConclusionKnowledge of RAMP1 and CALCA genotypes appear to improve an understanding the presenting features and magnitude of headache burden after concussion injury.
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Affiliation(s)
- Michael F. La Fountaine
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, NJ, United States
- *Correspondence: Michael F. La Fountaine
| | - Asante N. Hohn
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
| | - Caroline L. Leahy
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
| | - Joseph P. Weir
- Department of Health, Sport and Exercise Sciences, University of Kansas, Lawrence, KS, United States
- Osness Human Performance Laboratories, University of Kansas, Lawrence, KS, United States
| | - Anthony J. Testa
- Center for Sports Medicine, Seton Hall University, South Orange, NJ, United States
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Watanabe TK. Recovery After Sports Concussions: Focus on Psychological Factors. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Langer LK, Bayley MT, Lawrence DW, Comper P, Kam A, Tam A, Saverino C, Wiseman-Hakes C, Ruttan L, Chandra T, Foster E, Gladstone J. Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion. Cephalalgia 2022; 42:1172-1183. [PMID: 35546269 PMCID: PMC9536000 DOI: 10.1177/03331024221099216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury. METHODS Adults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI). RESULTS A total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness. CONCLUSIONS This study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.
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Affiliation(s)
- Laura Kathleen Langer
- KITE Research Institute at Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Mark Theodore Bayley
- KITE Research Institute at Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - David Wyndham Lawrence
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, Mt Sinai Hospital, Toronto, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.,Rehabilitation Sciences Institute and Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Alice Kam
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Alan Tam
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Cristina Saverino
- Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Catherine Wiseman-Hakes
- KITE Research Institute at Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Lesley Ruttan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Jonathan Gladstone
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Pediatrics (Division of Neurology), Hospital for Sick Children, Toronto, Canada.,Gladstone Headache Clinic, Toronto, Canada
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Leddy JJ, Haider MN, Noble JM, Rieger B, Flanagan S, McPherson JI, Shubin-Stein K, Saleem GT, Corsaro L, Willer B. Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists. Curr Neurol Neurosci Rep 2021; 21:72. [PMID: 34817719 DOI: 10.1007/s11910-021-01160-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS). RECENT FINDINGS Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.
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Affiliation(s)
- John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
| | - Mohammad Nadir Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,Department of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - James M Noble
- Department of Neurology, Taub Institute for Research On Alzheimer's Disease and the Aging Brain, and G.H. Sergievsky Center, Columbia University, New York, NY, USA
| | - Brian Rieger
- Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Steven Flanagan
- Department of Rehabilitation Medicine, Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | | | - Ghazala T Saleem
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Louis Corsaro
- Northern Westchester and Southern Putnam County School Districts, New York, NY, USA
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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Chowdhary K, Enam N. Post-traumatic Headaches After Traumatic Brain Injury: Current Clinical Approaches. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00314-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Wilber CG, Leddy JJ, Bezherano I, Bromley L, Edwards AE, Willer BS, Haider MN. Rehabilitation of Concussion and Persistent Postconcussive Symptoms. Semin Neurol 2021; 41:124-131. [PMID: 33663005 DOI: 10.1055/s-0041-1725134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies.
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Affiliation(s)
- Charles G Wilber
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
| | - John J Leddy
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
| | - Itai Bezherano
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
| | - Lacey Bromley
- Department of Physical Therapy, School of Health Professions, D'Youville College, Buffalo, New York.,Bennett Rehabilitation Institute, Buffalo, New York
| | - Amanda E Edwards
- UB Counseling Services, Department of Athletics, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Mohammad N Haider
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York.,PhD Program in Biomedical Science, Program of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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Headache- and Dizziness-Specific Health-Related Quality-of-Life Impairments Persist for 1 in 4 Amateur Athletes Who Are Cleared to Return to Sporting Activity Following Sport-Related Concussion: A Prospective Matched-Cohort Study. J Orthop Sports Phys Ther 2020; 50:692-701. [PMID: 33256513 DOI: 10.2519/jospt.2020.9485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To prospectively investigate the recovery of athlete-reported symptoms and the condition-specific health-related quality of life (HRQoL) following sport-related concussion. DESIGN Prospective matched-cohort study. METHODS We recruited amateur athletes who were diagnosed with sport-related concussion by emergency department physicians. Study participants were assessed at 3 time points following sport-related concussion. At each assessment, participants completed 5 condition-specific HRQoL patient-reported outcome measures to evaluate participants' perceptions of the effects of specific concussion-related symptoms on their HRQoL. We performed log-linear analyses to assess the proportion of concussed participants with clinically impaired condition-specific HRQoL compared with the proportion of participants in the control group with clinically impaired condition-specific HRQoL. RESULTS Fifty participants with sport-related concussion and 50 control participants matched by sex, age, and activity completed the study. Upon return to sporting activity, there was a significantly greater proportion of participants in the concussion group who perceived that headache, neck pain, and dizziness had an adverse effect on their HRQoL compared with the control group. Two weeks after return to sporting activity, there was still a significantly greater proportion of participants in the concussion group who perceived that headache (χ21 = 9.0; odds ratio [OR] = 4.4; 95% confidence interval [CI]: 1.5, 15.2; P = .003) and dizziness (χ21 = 9.5; OR = 13.5; 95% CI: 1.8, 604.9; P = .006) had an adverse effect on their HRQoL compared with the proportion of clinically impaired participants in the control group. CONCLUSION Of concussed participants, 1 in 4 perceived that headache and dizziness had adverse effects on their HRQoL after returning to sporting activity following sport-related concussion compared with nonconcussed, control participants. J Orthop Sports Phys Ther 2020;50(12):692-701. doi:10.2519/jospt.2020.9485.
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