Treatment of Acute Sports-Related Concussion

Navigating concussion - community rugby players' experiences of a concussion management initiative in New Zealand

OBJECTIVE

Concussion is a serious concern in sport, with the potential to cause short- and long-term health consequences. These concerns highlight the need for the translation of concussion management guidelines into use in real-world sports settings. This qualitative study explores community rugby players' concussion experiences as part of New Zealand Rugby's concussion management pathway.

METHODS

Semi-structured interviews were conducted with 36 rugby players (35 males and 1 female; 22 played at school and 14 at club-level; mean age 19.8 ± 4.8) Thematic analysis was utilized to analyze data.

RESULTS

Four themes were identified i) the symptom journey, ii) the role of a dedicated concussion management pathway in shaping players' experiences, iii) the influence of coaches and physiotherapists, and iv) rugby culture. Support received as part of the concussion management pathway, and from individuals who were part of players' concussion journey, deeply impacted their overall experience. However, players identified insufficient guidance while returning to school/work. At times, the sport's collective cultural values made it difficult for players to enact positive concussion management behavior.

CONCLUSION

The findings highlight the importance of a defined management pathway to support players' recovery. Addressing negative aspects of rugby's collectivist culture remains critical for optimal concussion management and recovery.

Management of concussion symptoms utilizing Mechanical Diagnosis and Therapy: a case series

OBJECTIVE

Concussions are a common condition in athletes leading to symptoms including headache, dizziness, and sometimes vestibular deficits. Concussion management typically involves rest and a gradual return to activity among other interventions. This case series includes three patients who were evaluated using Mechanical Diagnosis and Therapy (MDT) after sport-related injuries involving concussion-like symptoms. MDT is a system of evaluating patients using repeated movements and sustained positions to assess symptomatic and mechanical changes.

RESULTS

Patients in this case series demonstrated rapid reduction of symptoms using variations of repeated cervical movements and sustained positions, which enabled them to return to play with a lasting resolution of symptoms.

DISCUSSION/CONCLUSION

This highlights the importance of a classification system for the appropriate treatment of these cases who did not require management using concussion protocol, as they were classified as cervical derangement.

The Concussion, Exercise, and Brain Networks (ConExNet) study: a cohort study aimed at understanding the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion

BACKGROUND

Recent scientific evidence has challenged the traditional "rest-is-best" approach for concussion management. It is now thought that "exercise-is-medicine" for concussion, owing to dozens of studies which demonstrate that sub-maximal, graded aerobic exercise can reduce symptom burden and time to symptom resolution. However, the primary neuropathology of concussion is altered functional brain activity. To date, no studies have examined the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. In addition, although exercise is now more widely prescribed following concussion, its cardiopulmonary response is not yet well understood in this population. Our study has two main goals. The first is to understand whether there are exercise-induced resting state functional brain activity differences in children with concussion vs. healthy controls. The second is to profile the physiological response to exercise and understand whether it differs between groups.

METHODS

We will perform a single-center, controlled, prospective cohort study of pediatric concussion at a large, urban children's hospital and academic center. Children with sport-related concussion (aged 12-17 years) will be recruited within 4-weeks of injury by our clinical study team members. Key inclusion criteria include: medical clearance to exercise, no prior concussion or neurological history, and no implants that would preclude MRI. Age- and sex-matched healthy controls will be required to meet the same inclusion criteria and will be recruited through the community. The study will be performed over two visits separated by 24-48 h. Visit 1 involves exercise testing (following the current clinical standard for concussion) and breath-by-breath gas collection using a metabolic cart. Visit 2 involves two functional MRI (fMRI) scans interspersed by 10-minutes of treadmill walking at an intensity calibrated to Visit 1 findings. To address sub-objectives, all participants will be asked to self-report symptoms daily and wear a waist-worn tri-axial accelerometer for 28-days after Visit 2.

DISCUSSION

Our study will advance the growing exercise-concussion field by helping us understand whether exercise impacts outcomes beyond symptoms in pediatric concussion. We will also be able to profile the cardiopulmonary response to exercise, which may allow for further understanding (and eventual optimization) of exercise in concussion management.

TRIAL REGISTRATION

Not applicable.

Sleep/Wake Disorders After Sports Concussion: Risks, Revelations, and Interventions

SUMMARY

Sleep-wake disturbances (SWDs) are among the most prevalent, persistent, and often disregarded sequelae of traumatic brain injury. Identification and treatment of SWDs in patients with traumatic brain injury is important and can complement other efforts to promote maximum functional recovery. SWDs can accentuate other consequences of traumatic brain injury, negatively affect mood, exacerbate pain, heighten irritability, and diminish cognitive abilities and the potential for recovery. The risk for sports injuries increases when athletes are sleep deprived. Sleep deprivation increases risk-taking behaviors, predisposing to injuries. SWDs are an independent risk factor for prolonged recovery after sports-related concussion. SWDs following sports-related concussion have been shown to impede recovery, rehabilitation, and return to preinjury activities.

Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol

BACKGROUND

Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education.

OBJECTIVE

To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery.

METHODS

Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings.

RESULTS

Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol.

CONCLUSION

There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

Revised Dual Task Screen is a Valid Measure of Dual Task Performance: Developing a Motor and Cognitive Dual Task Measure with Healthy Female Athletes

Multitasking measures, such as dual task assessments, are particularly useful in detecting subtle deficits that can influence occupational performance after injuries, like sports-related concussion (SRC). In past work, our research team developed and revised a dual task assessment, the Dual Task Screen (DTS). Here, we evaluated nineteen healthy athletes using the revised DTS to address two specific research objectives. First, to replicate pilot study findings and demonstrate that the revised DTS is sensitive to dual task motor costs (i.e. poorer motor performance under dual task conditions, compared to single task conditions). Second, to evaluate if the revised DTS is sensitive to dual task cognitive costs (i.e. poorer cognitive performance under dual task conditions, compared to single task conditions). We confirmed that the revised DTS was sensitive to both dual task motor and cognitive costs; thus it is a valid measure of dual task performance. These positive findings support its prospective, future use by occupational therapists to evaluate multitasking performance after injuries, like SRC, or other injuries and illnesses that elicit deficits affecting optimal occupational performance.

Nutritional interventions to support acute mTBI recovery

When mild traumatic brain injury (mTBI) occurs following an impact on the head or body, the brain is disrupted leading to a series of metabolic events that may alter the brain's ability to function and repair itself. These changes may place increased nutritional demands on the body. Little is known on whether nutritional interventions are safe for patients to implement post mTBI and whether they may improve recovery outcomes. To address this knowledge gap, we conducted a systematic review to determine what nutritional interventions have been prescribed to humans diagnosed with mTBI during its acute period (<14 days) to support, facilitate, and result in measured recovery outcomes.

Methods

Databases CINAHL, PubMed, SPORTDiscus, Web of Science, and the Cochrane Library were searched from inception until January 6, 2021; 4,848 studies were identified. After removing duplicates and applying the inclusion and exclusion criteria, this systematic review included 11 full papers.

Results

Patients that consumed enough food to meet calorie and macronutrient (protein) needs specific to their injury severity and sex within 96 h post mTBI had a reduced length of stay in hospital. In addition, patients receiving nutrients and non-nutrient support within 24-96 h post mTBI had positive recovery outcomes. These interventions included omega-3 fatty acids (DHA and EPA), vitamin D, mineral magnesium oxide, amino acid derivative N-acetyl cysteine, hyperosmolar sodium lactate, and nootropic cerebrolysin demonstrated positive recovery outcomes, such as symptom resolution, improved cognitive function, and replenished nutrient deficiencies (vitamin D) for patients post mTBI.

Conclusion

Our findings suggest that nutrition plays a positive role during acute mTBI recovery. Following mTBI, patient needs are unique, and this review presents the potential for certain nutritional therapies to support the brain in recovery, specifically omega-3 fatty acids. However, due to the heterogenicity nature of the studies available at present, it is not possible to make definitive recommendations.

Systematic review registration

The systematic review conducted following the PRISMA guidelines protocol was registered (CRD42021226819), on Prospero.

Sports-Related Concussion Is a Personalized Issue—Evaluation of Medical Assessment and Subjective Feeling of the Athlete in a German Level 1 Trauma Center

Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes.

PHYSICAL EXERCISES IN RELIEVING THE CURRENT STATE OF DEPRESSION

ABSTRACT Introduction: Physical exercise has become a common method at home and abroad as a means of psychotherapy and mental health. Objective: Observing the current situation and characteristics of physical exercise and depressive disorders and examining the influence of physical exercise on depressive disorders in the human body. Methods: The article compares and analyzes the relationship between human physical exercise and the level of depression and body self-esteem from the perspective of psychology. Results: The incidence of depression is higher. There are significant differences in the attitude towards physical exercise and the degree of depression in the three types of subjects in the study. Physical exercise is conducive to the relief of depression. Conclusion: Physical exercise is one of the effective ways to improve the depressive state of the human body. The effect of an exercise has no relation with the specific exercise method selected. Level of evidence II; Therapeutic studies - investigation of treatment results.

Concussion in the Athletic Training Room: a Team Physician Narrative

PURPOSE OF THE REVIEW

Concussion evaluation and management has changed significantly. Understanding proper recognition, evaluation, and management allows for improved provision of care to patients. This paper will approach this topic from a sideline to training room management versus the traditional clinic evaluation RECENT FINDINGS: Research is continuing to refine and examine tools to assist in proper concussion evaluation. Concussion recovery protocols are becoming more conservative as patients are taking longer to recover than previously thought. Treatment of concussion is becoming more sophisticated and patient involved. Concussion research has increased dramatically over the last 30 years changing our approach to diagnosis and treatment. The area of concussion will continue to evolve as research continues to look at effective tools and markers for diagnosis and effective treatment protocols become substantiated through research.

A Role for the Amygdala in Impairments of Affective Behaviors Following Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) results in chronic affective disorders such as depression, anxiety, and fear that persist up to years following injury and significantly impair the quality of life for patients. Although a great deal of research has contributed to defining symptoms of mild TBI, there are no adequate drug therapies for brain-injured individuals. Preclinical studies have modeled these deficits in affective behaviors post-injury to understand the underlying mechanisms with a view to developing appropriate treatment strategies. These studies have also unveiled sex differences that contribute to the varying phenotypes associated with each behavior. Although clinical and preclinical studies have viewed these behavioral deficits as separate entities with unique neurobiological mechanisms, mechanistic similarities suggest that a novel approach is needed to advance research on drug therapy. This review will discuss the circuitry involved in the expression of deficits in affective behaviors following mild TBI in humans and animals and provide evidence that the manifestation of impairment in these behaviors stems from an amygdala-dependent emotional processing deficit. It will highlight mechanistic similarities between these different types of affective behaviors that can potentially advance mild TBI drug therapy by investigating treatments for the deficits in affective behaviors as one entity, requiring the same treatment.

Combined Optokinetic Treatment and Vestibular Rehabilitation to Reduce Visually Induced Dizziness in a Professional Ice Hockey Player After Concussion: A Clinical Case

Background: The appropriate detection and therapy of concussion symptoms are of great importance to avoid long-term impairment and absence from pre-concussive activities, such as sport, school or work. Post-traumatic headache and dizziness are known as risk factors of persistent symptoms after a concussion. Dizziness has even been classified as a predictor for symptom persistence. One type of dizziness, which has never been considered is visually induced dizziness (VID) often develops as a consequence of vestibular impairment. This manuscript presents the clinical case of a 25-year-old male, professional ice hockey player, whereby a therapeutic approach to VID after concussion is demonstrated.

Case: A detailed interdisciplinary clinical and laboratory-assisted neurological, neurovestibular and ocular-motor examination was performed 20 days post-concussion, which indicated VID symptoms. Thus, the player qualified for a 5-day combined vestibular, balance and optokinetic therapy, which aimed to reduce the player's increased sensitivity to visual information. Each treatment day consisted of two sessions: vestibular/ocular-motor training and exposure to optokinetic stimuli combined with postural control exercises. The optokinetic stimulus was delivered in the form of a rotating disk. VID symptoms were recorded daily via posturography and a visual analog scale prior to the optokinetic sessions. The player improved over the course of each treatment day and was able to return to ice hockey 15 days after the final treatment session. Three months later the player reported no symptoms in the follow up questionnaire.

Conclusion: The combination of vestibular, balance and optokinetic therapy led to remission of VID symptoms in a professional ice hockey player after multiple concussions, within a short time frame after his last concussion. Thus, this case study highlights the significant benefit of treating post-concussive VID symptoms utilizing a multi-modal approach.