1
|
Pinto SM, Wright B, Annaswamy S, Nwana O, Nguyen M, Wilmoth K, Moralez G. Heart rate variability (HRV) after traumatic brain injury (TBI): a scoping review. Brain Inj 2024; 38:585-606. [PMID: 38590161 DOI: 10.1080/02699052.2024.2328310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/05/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Heart rate variability (HRV), defined as the variability between successive heart beats, is a noninvasive measure of autonomic nervous system (ANS) function, which may be altered following traumatic brain injury (TBI). This scoping review summarizes the existing literature regarding changes in HRV after TBI as well as the association between measures of HRV and outcomes following TBI. METHODS A literature search for articles assessing 'heart rate variability' and 'brain injury' or 'concussion' was completed. Articles were included if HRV was measured in human subjects with TBI or concussion. Review articles, protocol papers, and studies including non-traumatic injuries were excluded. RESULTS Sixty-three articles were included in this review. Varied methods were used to measure HRV in the different studies. Forty articles included information about differences in HRV measures after TBI and/or longitudinal changes after TBI. Fifteen studies assessed HRV and symptoms following TBI, and 15 studies assessed HRV and either functional or cognitive outcomes after TBI. CONCLUSIONS HRV has been studied in the context of mortality, clinical symptoms, and medical, functional, or cognitive outcomes following TBI. Methods used to measure HRV have varied amongst the different studies, which may impact findings, standardized protocols are needed for future research.
Collapse
Affiliation(s)
- Shanti M Pinto
- Department of Physical Medicine and Rehabilitation, O'Donnell Brain Institute Clinical Neuroscience Scholar, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Brittany Wright
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shreyas Annaswamy
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Ola Nwana
- Department of Neurology, Houston Methodist Neuroscience Center Team at Willowbrook, Houston, Texas, USA
| | - Michael Nguyen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Brain Injury and Stroke Medicine, TIRR Memorial Hermann, Houston, Texas, USA
| | - Kristin Wilmoth
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gilbert Moralez
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Ellingson CJ, Shafiq MA, Ellingson CA, Neary JP, Dehghani P, Singh J. Assessment of cardiovascular functioning following sport-related concussion: A physiological perspective. Auton Neurosci 2024; 252:103160. [PMID: 38428323 DOI: 10.1016/j.autneu.2024.103160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
There is still much uncertainty surrounding the approach to diagnosing and managing a sport-related concussion (SRC). Neurobiological recovery may extend beyond clinical recovery following SRC, highlighting the need for objective physiological parameters to guide diagnosis and management. With an increased understanding of the connection between the heart and the brain, the utility of assessing cardiovascular functioning following SRC has gained attention. As such, this review focuses on the assessment of cardiovascular parameters in the context of SRC. Although conflicting results have been reported, decreased heart rate variability, blood pressure variability, and systolic (ejection) time, in addition to increased spontaneous baroreflex sensitivity and magnitude of atrial contraction have been shown in acute SRC. We propose that these findings result from the neurometabolic cascade triggered by a concussion and represent alterations in myocardial calcium handling, autonomic dysfunction, and an exaggerated compensatory response that attempts to maintain homeostasis following a SRC. Assessment of the cardiovascular system has the potential to assist in diagnosing and managing SRC, contributing to a more comprehensive and multimodal assessment strategy.
Collapse
Affiliation(s)
- Chase J Ellingson
- College of Medicine, University of Saskatchewan Regina Campus, Regina, SK, Canada; Prairie Vascular Research Inc, Regina, SK, Canada
| | - M Abdullah Shafiq
- College of Medicine, University of Saskatchewan Regina Campus, Regina, SK, Canada; Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | - Cody A Ellingson
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | - J Patrick Neary
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | | | - Jyotpal Singh
- Prairie Vascular Research Inc, Regina, SK, Canada; Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada.
| |
Collapse
|
3
|
Cecchini AS, McCulloch K, Harrison C, Favorov O, Davila M, Zhang W, Prim J, Krok CDRM. Expanding capabilities to evaluate readiness for return to duty after mTBI: The CAMP study protocol. PLoS One 2024; 19:e0270076. [PMID: 38285693 PMCID: PMC10824418 DOI: 10.1371/journal.pone.0270076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 03/22/2023] [Indexed: 01/31/2024] Open
Abstract
Physical Therapists affiliated with Intrepid Spirit Centers evaluate and treat Active Duty Service Members (ADSM) who have duty-limiting post-concussion symptoms to improve the ability to perform challenging tasks associated with military service. The Complex Assessment of Military Performance (CAMP) is a test battery that more closely approximates the occupational demands of ADSM without specific adherence to a particular branch of service or military occupational specialty. Subtasks were developed with military collaborators to include high level skills that all service members must be able to perform such as reacting quickly, maintaining visual stability while moving and changing positions, and scanning for, noting, and/or remembering operationally relevant information under conditions of physical exertion. OBJECTIVE The purpose of this observational longitudinal study is to: 1- establish typical performance parameters for ADSM on the CAMP test battery 2- determine the element of the CAMP battery that demonstrate the greatest differences from standard performance and serve as predictors for successful return to duty and 3- develop clinician-facing feedback algorithms and displays and 4-develop materials for clinical dissemination. This ongoing multi-site study is currently funded through the CDMRP and has been approved by the Naval Medical Center Portsmouth IRB. METHODS ADSM undergoing post-concussion rehabilitation at the Intrepid Spirit Centers will be tested within one week of their initial Physical Therapy evaluation and after completing Physical Therapy. Control participants will include males, females, and ADSM from the Special Operations community. Participants will complete an intake form that includes questions about demographics, military service, deployment and concussion history, and profile and duty status. Other measures include those that explore concussion symptoms, sleep quality, post-traumatic stress, and perceptions of resilience. The CAMP includes three separate 10-15 minute tasks. Movement is recorded by wearable inertial sensors and heart rate variability is recorded with a POLAR10 monitor. The "Run-Roll" task requires rapid position changes, combat rolls and quick running forwards and backwards while carrying a simulated weapon. Visual stability before and after the task is also performed. The "Dual-Task Agility" task includes rapid running with and without a weighted vest and a working memory task. The "Patrol Exertion" task requires repeated stepping onto an exercise step while watching a virtual patrol video. Additional tasks include monitoring direction of travel, observing for signs of enemy presence, and reacting to multiple auditory signals embedded in the video. DISCUSSION Measures that evaluate relevant skills are vital to support safe return to duty for ADSM who may be exposed to imminent danger as part of training or mission demands. The CAMP is designed to be an ecologically valid and clinically feasible assessment that may be more sensitive to capturing subtle impairments that impact duty performance as test skills are integrated into dual and multi-tasks that reflect occupational demands. Assessment results may serve as a more robust indicator of readiness for full return to duty after concussion.
Collapse
Affiliation(s)
- Amy Seal Cecchini
- The Geneva Foundation, Womack Army Medical Center, Ft. Bragg, NC, United States of America
| | - Karen McCulloch
- Department of Human Movement Science, Division of Physical Therapy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Courtney Harrison
- Department of Human Movement Science, Division of Physical Therapy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Oleg Favorov
- Department of Biomedical Engineering, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Maria Davila
- Research Triangle Institue, Research Triangle Park, NC, United States of America
| | - Wanqing Zhang
- Department of Human Movement Science, Division of Physical Therapy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Julianna Prim
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - C. D. R. Michael Krok
- Womack Army Medical Center Intrepid Spirit Clinic, Ft. Bragg, NC, United States of America
| |
Collapse
|
4
|
Wesolowski E, Ahmed Z, Di Pietro V. History of concussion and lowered heart rate variability at rest beyond symptom recovery: a systematic review and meta-analysis. Front Neurol 2024; 14:1285937. [PMID: 38318235 PMCID: PMC10838961 DOI: 10.3389/fneur.2023.1285937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/26/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction Concussion is a growing concern in worldwide sporting culture. Heart rate variability (HRV) is closely tied with autonomic nervous system (ANS) deficits that arise from a concussion. The objective of this review was to determine if a history of concussion (HOC) can impact HRV values in the time-domain in individuals at rest. This review works to add to the literature surrounding HRV testing and if it can be used to check for brain vulnerabilities beyond the recovery of concussion symptoms. Materials and methods The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) method. A computer based systematic review scanned articles dating from 1996 to June 2023 through PubMed, Cochrane Library, Google Scholar, and EMBASE databases. A risk of bias assessment was conducted using the ROBINS-E tool. The average difference in time between heartbeats (MeanNN), the standard deviation of the differences (SDNN), and the root mean squared of the successive intervals (RMSSD) were measured. Results Six total studies were found that fit the inclusion criteria including a total of 242 participants (133 without HOC, 109 with HOC). The average age of the control group was 23.3 ± 8.2, while the average age of the history of TBI group was 25.4 ± 9.7, with no significant difference between the groups (p = 0.202). Four of the studies reported no significant difference in any of the three measures, while two of the studies reported significant difference for all three measures. The meta-analysis was conducted and found that MeanNN (p = 0.03) and RMSSD (p = 0.04) reached statistical significance, while SDNN did not (p = 0.11). Conclusion The results of this meta-analysis showed significant difference in two of the three HRV time-domain parameters evaluated. It demonstrates that there can be lowered HRV values that expand beyond the recovery of symptoms, reflecting an extensive period of ANS susceptibility after a concussion. This may be an important variable in determining an athlete's return to play (RTP). Lack of homogenous study populations and testing methods introduces potential for bias and confounding factors, such as gender or age. Future studies should focus on baseline tests to compare individuals to themselves rather than matched controls.
Collapse
Affiliation(s)
- Eric Wesolowski
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
| | - Valentina Di Pietro
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
5
|
Sinnott AM, Kochick VL, Eagle SR, Trbovich AM, Collins MW, Sparto PJ, Flanagan SD, Elbin RJ, Connaboy C, Kontos AP. Comparison of physiological outcomes after dynamic exertion between athletes at return to sport from concussion and controls: Preliminary findings. J Sci Med Sport 2023; 26:682-687. [PMID: 37793956 DOI: 10.1016/j.jsams.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/20/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Compare physiological (heart rate, heart rate variability, and blood pressure), performance (change-of-direction task completion time and errors), and clinical (symptoms and rating of perceived exertion) outcomes during dynamic exertion between athletes at return to sport after concussion to healthy athlete controls. DESIGN Case control. METHODS A sample of 23 (Female = 10; 43.5 %) athletes at medical clearance to play/activity from concussion (CONCUSS) and 23 sex-, age-, and sport-matched healthy athletes (CONTROLS) completed a 5-min seated rest before and after the dynamic exertion test. Independent sample t-tests were used to compare CONCUSS and CONTROLS for completion time, heart rate, and blood pressure; and Mann-Whitney U tests for symptoms, perceived exertion, and errors. A series of ANOVAs were conducted to compare heart rate variability between groups across pre- and post-exercise rest periods. RESULTS There were no differences in heart rate, blood pressure, symptoms, perceived exertion, and errors. CONCUSS were faster on Zig Zag (p = .048) and Pro Agility (p = .018) tasks, reported lower symptom severity (p = .019), and had lower post-EXiT HRV (p < .049) than CONTROLS. CONCLUSIONS Performance, symptoms, perceived exertion, and blood pressure outcomes from dynamic exertion were equivocal between athletes at medical clearance from concussion and healthy controls, which provide empirical support for dynamic exercise to inform medical clearance clinical decision making for sport-related concussion. However, differences in autonomic nervous system functioning indicate that additional research is needed to examine temporal changes in heart rate variability and other physiological outcomes following dynamic exertion.
Collapse
Affiliation(s)
- Aaron M Sinnott
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, United States of America; UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, United States of America; Matthew Gfeller Center, University of North Carolina at Chapel Hill, United States of America. https://twitter.com/AaronSinnottATC
| | - Victoria L Kochick
- Department of Physical Therapy, Slippery Rock University, United States of America; Centers for Rehabilitation Services-Department of Physical Therapy, University of Pittsburgh, United States of America
| | - Shawn R Eagle
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, United States of America; Department of Neurological Surgery, School of Medicine, University of Pittsburgh, United States of America
| | - Alicia M Trbovich
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, United States of America
| | - Michael W Collins
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, United States of America
| | - Patrick J Sparto
- Department of Physical Therapy University of Pittsburgh, United States of America
| | - Shawn D Flanagan
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, United States of America
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, United States of America
| | - Christopher Connaboy
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, United States of America; Center for Lower Extremity Ambulatory Research Team, Rosalind Franklin University, United States of America
| | - Anthony P Kontos
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, United States of America.
| |
Collapse
|
6
|
Lu HC, Gevirtz R, Yang CC, Hauson AO. Heart Rate Variability Biofeedback for Mild Traumatic Brain Injury: A Randomized-Controlled Study. Appl Psychophysiol Biofeedback 2023; 48:405-421. [PMID: 37335413 PMCID: PMC10582136 DOI: 10.1007/s10484-023-09592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 06/21/2023]
Abstract
To determine whether heart rate variability biofeedback (HRV-BF) training, compared to a psychoeducation control condition can strengthen the integration of the central and autonomic nervous systems as measured by neuropsychological measures in patients with mild traumatic brain injury (mTBI). Participants were recruited from two university hospitals in Taipei, Taiwan. A total of 49 participants with mTBI were recruited for this study. Forty-one participants completed the study, 21 in the psychoeducation group and 20 in the HRV-BF group. Randomized controlled study. The Taiwanese Frontal Assessment Battery, the Semantic Association of Verbal Fluency Test, the Taiwanese version of the Word Sequence Learning Test, the Paced Auditory Serial Addition Test-Revised, and the Trail Making Test were used as performance-based neuropsychological functioning measures. The Checklist of Post-concussion Symptoms, the Taiwanese version of the Dysexecutive Questionnaire, the Beck Anxiety Inventory, the Beck Depression Inventory, and the National Taiwan University Irritability Scale were used as self-report neuropsychological functioning measures. Furthermore, heart rate variability pre- vs. post-training was used to measure autonomic nervous system functioning. Executive, information processing, verbal memory, emotional neuropsychological functioning, and heart rate variability (HRV) were improved significantly in the HRV-BF group at the posttest whereas the psychoeducation group showed no change. HRV biofeedback is a feasible technique following mild TBI that can improve neuropsychological and autonomic nervous system functioning. HRV-BF may be clinically feasible for the rehabilitation of patients with mTBI.
Collapse
Affiliation(s)
- Hsueh Chen Lu
- California School of Professional Psychology at Alliant International University, Clinical Psychology PhD Program, San Diego, CA, USA
| | - Richard Gevirtz
- California School of Professional Psychology at Alliant International University, Clinical Psychology PhD Program, San Diego, CA, USA.
| | - Chi Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Alexander O Hauson
- California School of Professional Psychology at Alliant International University, Clinical Psychology PhD Program, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, USA
- Institute of Brain Research and Integrated Neuropsychological Services (iBRAINS.Org), San Diego, CA, USA
| |
Collapse
|
7
|
Flores G, Monteiro D, Silva F, Duarte-Mendes P. Heart rate variability behavior in athletes after a sports concussion: A systematic review. Scand J Med Sci Sports 2023; 33:1598-1606. [PMID: 37246359 DOI: 10.1111/sms.14409] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVE This systematic review aims to investigate the adaptations of the autonomic nervous system (ANS) after a concussion by measuring HRV in athletes over the age of 16 after injury. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Web of Science, Pubmed, SCOPUS, and Sport Discus were searched using predefined search terms to identify relevant original cross-sectional, longitudinal, and cohort epidemiological studies published before December 2021. RESULTS After screening 1737 potential articles, four studies met the inclusion criteria. Studies included participants with concussion (n = 63) and healthy control athletes (n = 140) who practised different sports. Two studies describe a decrease in HRV following a sports concussion, and one proposed that the resolution of symptoms does not necessarily reflect ANS recovery. Lastly, one study concluded that submaximal exercise induces alteration in ANS, not seen in rest after an injury. CONCLUSIONS In the frequency domain, a decrease in high frequency power and an increase of low frequency/high frequency ratio is expected, as the activity of the sympathetic nervous system increases, and the parasympathetic nervous system decreases after injury. In the frequency domain, heart rate variability (HRV) may help monitor the activity of ANS evaluating signals of somatic tissue distress and early identification of other types of musculoskeletal injuries. Further research should investigate the relationship between HRV and other musculoskeletal injuries.
Collapse
Affiliation(s)
| | - Diogo Monteiro
- ESECS-Polytechnic of Leiria, Leiria, Portugal
- Research Centre in Sport, Health and Human Development (CIDESD), Vila Real, Portugal
- Life Quality Research Center (CIEQV), Leiria, Portugal
| | - Fernanda Silva
- Research Unit for Sport and Physical Activity, University of Coimbra, Coimbra, Portugal
| | - Pedro Duarte-Mendes
- Department of Sports and Well-being, Polytechnic Institute of Castelo Branco, Castelo Branco, Portugal
- Sport, Health and Exercise Research Unit-SHERU, Polytechnic Institute of Castelo Branco, Castelo Branco, Portugal
| |
Collapse
|
8
|
Callahan CE, Stoner L, Zieff GH, Register-Mihalik JK. The Additive Benefits of Aerobic Exercise and Cognitive Training Postconcussion: Current Clinical Concepts. J Athl Train 2023; 58:602-610. [PMID: 35984726 PMCID: PMC10569252 DOI: 10.4085/1062-6050-0186.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Concussion induces the rapid onset of a short-lived neurophysiological disturbance that often results in autonomic nervous system dysfunction. This dysfunction affects both cardiovascular functioning and higher cognitive processing, inducing postconcussion clinical symptoms (somatic, cognitive, or emotional or a combination) and functional disturbances (impaired balance, cognition, and visual-vestibular performance). Current concussion rehabilitation paradigms using aerobic exercise may improve concussion symptoms. Additionally, cognitive training-focused rehabilitation interventions may enhance cognitive function postinjury. Though aerobic exercise and cognitive training-based concussion rehabilitation are successful independently, the multifaceted nature of concussion suggests the potential benefit of integrating both to improve concussion outcomes and clinician implementation. To support this clinical recommendation, we critiqued the existing research in which authors investigated aerobic exercise and cognitive training as postconcussion rehabilitation modalities, identified keys gaps in the literature, and proposed a practical clinical recommendation to integrate both modalities during concussion rehabilitation.
Collapse
Affiliation(s)
- Christine E. Callahan
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
- Human Movement Science Curriculum, The University of North Carolina at Chapel Hill
| | - Lee Stoner
- Cardiometabolic Laboratory, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
| | - Gabriel H. Zieff
- Human Movement Science Curriculum, The University of North Carolina at Chapel Hill
- Cardiometabolic Laboratory, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
| | - Johna K. Register-Mihalik
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill
- STAR Heel Performance Laboratory, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill
| |
Collapse
|
9
|
Ziadia H, Sassi I, Trudeau F, Fait P. Normative values of resting heart rate variability in young male contact sport athletes: Reference values for the assessment and treatment of concussion. Front Sports Act Living 2023; 4:730401. [PMID: 36699983 PMCID: PMC9869270 DOI: 10.3389/fspor.2022.730401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/07/2022] [Indexed: 01/12/2023] Open
Abstract
Objective The objective of this study was to identify the main determinants of heart rate variability (HRV) in male athletes aged 14 to 21 years who practice competitive contact sports and to integrate these determinants with the aim of defining normative values of short-term HRV in the time and frequency domains. Methods Participants (n = 369) were aged 14 to 21 years and included 221 football players and 148 ice hockey players. HRV was measured for 5 min at rest, and standard HRV parameters in the time and frequency domains were calculated. Heart rate (HR), age, body mass index (BMI), number of sports weekly practices (WSP) and concussion history (mTBI) were considered determinants potentially able to influence HRV. Results Multiple regression analysis revealed that HR was the primary determinant of standard HRV parameters. The models accounted for 13% to 55% of the total variance of HRV and the contribution of HR to this model was the strongest (β ranged from -0.34 to -0.75). HR was the only determinant that significantly contributes to all HRV parameters. To counteract this dependence, we calculated HRV corrected by the mean RR interval (RRm). Such corrections do not remove any physiological differences in HRV; they simply remove the mathematical bias. HRV parameters were therefore normalized, and their normative limits were developed relative to the mean heart rate. After correction, the correlation coefficients between HR and all corrected HRV parameters were not statistically significant and ranged from -0.001 to 0.045 (p > 0.40 for all). The automatically corrected HRV calculator, which recalculates standard HRV parameters and converts them into corrected parameters in addition to determining whether a given value is within normal limits, facilitates clinical interpretation. Conclusion This study provides for the first time corrected normative values of short-term and resting state HRV parameters in competitive contact sport athletes aged 14 to 21 years. These values were developed independently of the major determinants of HRV. The baseline values for HRV parameters given here could be used in clinical practice when assessing and monitoring cerebral concussions. They may assist in decision making for a safe return to play.
Collapse
Affiliation(s)
- Hatem Ziadia
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada,Exercise Physiology Laboratory, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada,Correspondence: Hatem Ziadia
| | - Idriss Sassi
- Exercise Physiology Laboratory, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada,Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - François Trudeau
- Exercise Physiology Laboratory, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada,Department of Human Kinetics, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Philippe Fait
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada,Research Group on Neuromusculoskeletal Conditions (GRAN), Trois-rivieres, QC, Canada,Centre for Research in Neuropsychology and Cognition (CERNEC), Montreal, QC, Canada,Cortex Concussion Clinic, Quebec City, QC, Canada
| |
Collapse
|
10
|
Huerta de la Cruz S, Santiago-Castañeda CL, Rodríguez-Palma EJ, Medina-Terol GJ, López-Preza FI, Rocha L, Sánchez-López A, Freeman K, Centurión D. Targeting hydrogen sulfide and nitric oxide to repair cardiovascular injury after trauma. Nitric Oxide 2022; 129:82-101. [PMID: 36280191 PMCID: PMC10644383 DOI: 10.1016/j.niox.2022.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
The systemic cardiovascular effects of major trauma, especially neurotrauma, contribute to death and permanent disability in trauma patients and treatments are needed to improve outcomes. In some trauma patients, dysfunction of the autonomic nervous system produces a state of adrenergic overstimulation, causing either a sustained elevation in catecholamines (sympathetic storm) or oscillating bursts of paroxysmal sympathetic hyperactivity. Trauma can also activate innate immune responses that release cytokines and damage-associated molecular patterns into the circulation. This combination of altered autonomic nervous system function and widespread systemic inflammation produces secondary cardiovascular injury, including hypertension, damage to cardiac tissue, vascular endothelial dysfunction, coagulopathy and multiorgan failure. The gasotransmitters nitric oxide (NO) and hydrogen sulfide (H2S) are small gaseous molecules with potent effects on vascular tone regulation. Exogenous NO (inhaled) has potential therapeutic benefit in cardio-cerebrovascular diseases, but limited data suggests potential efficacy in traumatic brain injury (TBI). H2S is a modulator of NO signaling and autonomic nervous system function that has also been used as a drug for cardio-cerebrovascular diseases. The inhaled gases NO and H2S are potential treatments to restore cardio-cerebrovascular function in the post-trauma period.
Collapse
Affiliation(s)
- Saúl Huerta de la Cruz
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico; Department of Pharmacology, University of Vermont, Burlington, VT, USA.
| | | | - Erick J Rodríguez-Palma
- Neurobiology of Pain Laboratory, Departamento de Farmacobiología, Cinvestav, Sede Sur, Mexico City, Mexico.
| | | | | | - Luisa Rocha
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico.
| | | | - Kalev Freeman
- Department of Emergency Medicine, University of Vermont, Burlington, VT, USA.
| | - David Centurión
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico.
| |
Collapse
|
11
|
Harrison A, Lane-Cordova A, La Fountaine MF, Moore RD. Concussion History and Heart Rate Variability During Bouts of Acute Stress. J Athl Train 2022; 57:741-747. [PMID: 36356617 PMCID: PMC9661928 DOI: 10.4085/1062-6050-0314.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT After a sport-related concussion, many athletes experience persisting neurophysiological alterations. These alterations may be absent at rest but emerge during moments of physiological stress. Unnoticed and untreated neurophysiological dysfunction may negatively affect long-term neurologic health in adolescent athletes, as they are at a critical point in development. OBJECTIVE To assess cardio-autonomic functioning in athletes with and those without a history of concussion by quantifying measures of heart rate variability (HRV) during times of physical and mental exertion. DESIGN Case-control study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty-four male Hockey Quebec Midget-AAA hockey players were separated into those with (n = 16; age = 16.06 ± 0.73 years, body mass index = 23.29 ± 1.79) and those without (n = 18; age = 15.98 ± 0.62 years, body mass index = 23.60 ± 2.49) a history of concussion. INTERVENTION(S) All athletes underwent a series of HRV recording sessions (1) at rest, (2) while completing a cognitive task at rest, and (3) while completing a cognitive task after a bout of submaximal aerobic exercise. MAIN OUTCOME MEASURE(S) Time-domain measures of HRV, including mean NN intervals, SD of NN intervals, and root mean square of successive NN interval differences, were quantified for each assessment. RESULTS No differences in characteristics were evident between groups. No between-groups differences in HRV at rest were observed. However, during the cognitive task at rest and after aerobic exercise, athletes with a history of concussion demonstrated a higher SD of NN intervals (78.1 ± 4.3 versus 63.2 ± 4.1 milliseconds and 71.2 ± 4.3 versus 65.2 ± 3.8 milliseconds, respectively; F1,31 = 4.31, P = .046) and root mean square of successive NN interval differences (75.8 ± 6.0 versus 59.0 ± 5.6 milliseconds and 74.0 ± 5.5 versus 59.0 ± 5.2 milliseconds, respectively; F1,31 = 4.88, P = .04) than athletes without a history of concussion. CONCLUSIONS Concussive injuries may result in long-term cardio-autonomic dysfunction. These deficits may not be present at rest but may be triggered by physiological stress.
Collapse
Affiliation(s)
- Adam Harrison
- Department of Exercise Science, University of South Carolina, Columbia
| | - Abbi Lane-Cordova
- Department of Exercise Science, University of South Carolina, Columbia
| | - Michael F. La Fountaine
- Department of Physical Therapy, The Institute for Advanced Study of Rehabilitation and Sports Science, Seton Hall University, Nutley, NJ
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Seton Hall University, Nutley, NJ
| | | |
Collapse
|
12
|
Worts PR, Mason JR, Burkhart SO, Sanchez-Gonzalez MA, Kim JS. The acute, systemic effects of aerobic exercise in recently concussed adolescent student-athletes: preliminary findings. Eur J Appl Physiol 2022; 122:1441-1457. [PMID: 35303160 DOI: 10.1007/s00421-022-04932-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/08/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Examine the acute effects (pre-, during, post-intervention) of two different intensities of aerobic exercise or rest on autonomic, oculomotor, and vestibular function and symptom burden in patients with a recent sport-related concussion (SRC) and compare their responses to sex-matched, age-stratified, non-concussed (HEALTHY) student-athletes. METHODS Student-athletes between the ages of 13 and 18 that presented to the sports medicine clinic within Day 3-7 post-SRC and from local schools were recruited for a randomized controlled trial (RCT). The participants were administered the Vestibular/Ocular Motor Screening (VOMS), King-Devick (K-D), and Post-Concussion Symptom Scale (PCSS) before and after the intervention. Heart rate variability (HRV) and mean arterial pressure (MAP) were collected before, during, and after the intervention. The intervention was either a single, 20-min session of treadmill walking at 40% (40HR) or 60% of age-predicted max heart rate (60HR), or seated, rest (NOEX). RESULTS 30 participants completed the intervention with the SRC group treated 4.5 ± 1.3 days post-injury. Pre-exercise HRV and MAP were significantly different (p's < 0.001) during treatment but returned to pre-exercise values within 5 min of recovery in both the SRC and HEALTHY groups. Both the SRC and HEALTHY groups exhibited similar reductions pre- to post-intervention for symptom severity and count (p's < 0.05), three VOMS items (p's < 0.05) but not K-D time. CONCLUSIONS To date, this is the first adolescent RCT to report the acute, systemic effects of aerobic exercise on recently concussed adolescent athletes. The interventions appeared safe in SRC participants, were well-tolerated, and provided brief therapeutic benefit. TRIAL REGISTRATION Clinicaltrials.gov Identifier NCT03575455.
Collapse
Affiliation(s)
- P R Worts
- Tallahassee Orthopedic Clinic, Tallahassee, FL, USA. .,Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, FL, USA. .,Institute of Sports Sciences and Medicine, Florida State University, Tallahassee, FL, USA.
| | - J R Mason
- Department of Occupational Therapy, University of Florida, Gainesville, FL, USA
| | - S O Burkhart
- Children's Health Andrews Institute, Plano, TX, USA.,Department of Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | | | - J-S Kim
- Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, FL, USA.,Institute of Sports Sciences and Medicine, Florida State University, Tallahassee, FL, USA
| |
Collapse
|
13
|
Mercier LJ, Batycky J, Campbell C, Schneider K, Smirl J, Debert CT. Autonomic dysfunction in adults following mild traumatic brain injury: A systematic review. NeuroRehabilitation 2022; 50:3-32. [PMID: 35068421 DOI: 10.3233/nre-210243] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Increasing evidence suggests autonomic nervous system (ANS) dysfunction may occur following mild traumatic brain injury (mTBI). Measures of heart rate, heart rate variability, blood pressure and baroreceptor sensitivity can be used to evaluate ANS dysfunction following mTBI. OBJECTIVE Summarize the evidence for ANS dysfunction in adults following mTBI. METHODS A search of Embase, MEDLINE, Cochrane Central Register, PsycINFO, CINAHL and SPORTDiscus databases was conducted. Search topics included: mTBI and ANS. Identified abstracts were independently reviewed by 2 reviewers followed by full text screening. Risk of bias was assessed using a modified SIGN checklist. A structured synthesis was performed. RESULTS Thirty-nine studies (combined 1,467 participants diagnosed with mTBI) evaluating ANS function were included. ANS function was evaluated under various conditions including: rest, during exertion, cold pressor test, Valsalva maneuver, using face cooling and eyeball pressure paradigms. Short-term or ultra-short-term recordings were most common. The majority of studies (28/39) were rated as "unacceptable" for quality of evidence. CONCLUSIONS Altered parameters of ANS function have been reported in multiple conditions following mTBI, both acutely and in the post-acute/chronic stages of recovery. However, due to methodological limitations, conclusions regarding the severity and timing of ANS dysfunction following mTBI cannot be drawn.
Collapse
Affiliation(s)
- Leah J Mercier
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Caglary, Calgary, AB, Canada
| | - Julia Batycky
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Caglary, Calgary, AB, Canada
| | - Christina Campbell
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Caglary, Calgary, AB, Canada
| | - Kathryn Schneider
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Jonathan Smirl
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, Univeristy of Calgary, Calgary, AB, Canada
| | - Chantel T Debert
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Caglary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
14
|
McDonald SJ, Sharkey JM, Sun M, Kaukas LM, Shultz SR, Turner RJ, Leonard AV, Brady RD, Corrigan F. Beyond the Brain: Peripheral Interactions after Traumatic Brain Injury. J Neurotrauma 2021; 37:770-781. [PMID: 32041478 DOI: 10.1089/neu.2019.6885] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability, and there are currently no pharmacological treatments known to improve patient outcomes. Unquestionably, contributing toward a lack of effective treatments is the highly complex and heterogenous nature of TBI. In this review, we highlight the recent surge of research that has demonstrated various central interactions with the periphery as a potential major contributor toward this heterogeneity and, in particular, the breadth of research from Australia. We describe the growing evidence of how extracranial factors, such as polytrauma and infection, can significantly alter TBI neuropathology. In addition, we highlight how dysregulation of the autonomic nervous system and the systemic inflammatory response induced by TBI can have profound pathophysiological effects on peripheral organs, such as the heart, lung, gastrointestinal tract, liver, kidney, spleen, and bone. Collectively, this review firmly establishes TBI as a systemic condition. Further, the central and peripheral interactions that can occur after TBI must be further explored and accounted for in the ongoing search for effective treatments.
Collapse
Affiliation(s)
- Stuart J McDonald
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia
| | - Jessica M Sharkey
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mujun Sun
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Lola M Kaukas
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sandy R Shultz
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Renee J Turner
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anna V Leonard
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rhys D Brady
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Frances Corrigan
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| |
Collapse
|
15
|
Charron J, Soto-Catalan C, Marcotte L'Heureux V, Comtois AS. Unclear outcomes of heart rate variability following a concussion: a systematic review. Brain Inj 2021; 35:987-1000. [PMID: 34255607 DOI: 10.1080/02699052.2021.1891459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE : To systematically regroup articles that were published since the latest systematic search, but with specific inclusion criteria to help comparison that will offer a focused presentation of methods and results. This will offer a full overview of HRV's behavior at rest and during exercise in adults post-concussion. METHODS : The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) method. A computer-based systematic search was conducted in December 2019 through the Pubmed, Scopus and SPORTDiscus databases. A manual search was performed through the reference list of all articles retained. The reliability of the systematic search was assured by having the article selection process entirely repeated by a second author. RESULTS : The systematic search yielded a total of 15 articles to be further analyzed. Results show impairment of HRV during exercise for individuals with concussion, heterogenous studies with lack of control over confounding factors and only less than half of the results showing a significant difference between individuals with concussion and controls. CONCLUSION : Further research should try standardizing HRV measurement protocols that control confounding factors to allow easier comparison between studies and allows the possibility for an eventual meta-analysis.
Collapse
Affiliation(s)
- J Charron
- Department of Exercise Science, University of Quebec in Montreal, Montreal, Canada
| | - C Soto-Catalan
- Department of Exercise Science, University of Quebec in Montreal, Montreal, Canada
| | - V Marcotte L'Heureux
- Department of Exercise Science, University of Quebec in Montreal, Montreal, Canada
| | - A S Comtois
- Department of Exercise Science, University of Quebec in Montreal, Montreal, Canada
| |
Collapse
|
16
|
Balestrini CS, Moir ME, Abbott KC, Klassen SA, Fischer LK, Fraser DD, Shoemaker JK. Autonomic Dysregulation in Adolescent Concussion Is Sex- and Posture-Dependent. Clin J Sport Med 2021; 31:257-265. [PMID: 30908327 PMCID: PMC8061339 DOI: 10.1097/jsm.0000000000000734] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/03/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study autonomic responses to postural changes in concussed adolescents. The influence of sex was also studied. DESIGN Longitudinal cohort observational study. PARTICIPANTS Concussed adolescents (CONC; n = 65; 26 male adolescents; age 15 ± 1 years, range = 12-18 years) and a control (CTRL) group of nonconcussed adolescents of similar age and sport (CTRL; n = 54; 29 male adolescents; age 14 ± 1 years, range = 12-18 years). INTERVENTIONS Concussed participants were monitored through 6 weekly visits throughout usual physician care. Control participants underwent 2 visits separated by at least 1 week to account for intrapersonal variation in testing measures. MAIN OUTCOME MEASURES Heart rate variability as the root mean square of successive differences in R-R intervals (RMSSD), heart rate (HR), and blood pressure [mean arterial pressure (MAP) and diastolic blood pressure (DBP)] were measured in supine, sitting, and standing postures. RESULTS A mixed analysis of variance revealed a group × sex × posture interaction (P = 0.04) where seated values of RMSSD were less in concussed female participants versus control female participants (42 ± 4 vs 61 ± 7 ms; P = 0.01; Mann-Whitney rank test). Compared with CTRL, CONC exhibited increased pretesting seated DBP (69 ± 1 vs 74 ± 1 mm Hg; P < 0.01), MAP (83 ± 1 vs 86 ± 1 mm Hg; P = 0.02), and baseline seated HR (72 ± 1 vs 77 ± 2 bpm; P = 0.03). Values of DBP (P = 0.03) and MAP (P < 0.01) improved at clinical discharge, whereas the RMSSD in female participants did not (P > 0.5). Data are mean ± SEM. CONCLUSIONS A modest reduction in female cardiac autonomic regulation was observed during seated postures. Alterations in seated concussed DBP and MAP, but not RMSSD, resolved at clinical discharge (median = 37 days). The results indicate that, in adolescents, concussion may impair cardiovagal function in a sex- and posture-dependent manner. The findings also suggest that BP metrics, but not RMSSD, are associated with clinical concussion recovery.
Collapse
Affiliation(s)
| | - Marcy Erin Moir
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
| | - Kolten C Abbott
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada ; and
| | - Stephen A Klassen
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
| | - Lisa K Fischer
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
| | - Douglas D Fraser
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada ; and
| | - Joel Kevin Shoemaker
- School of Kinesiology, Faculty of Health Sciences, London, ON, Canada
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| |
Collapse
|
17
|
Worley ML, O'Leary MC, Sackett JR, Schlader ZJ, Willer B, Leddy JJ, Johnson BD. Preliminary Evidence of Orthostatic Intolerance and Altered Cerebral Vascular Control Following Sport-Related Concussion. Front Neurol 2021; 12:620757. [PMID: 33897587 PMCID: PMC8062862 DOI: 10.3389/fneur.2021.620757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Concussions have been shown to result in autonomic dysfunction and altered cerebral vascular function. We tested the hypothesis that concussed athletes (CA) would have altered cerebral vascular function during acute decreases and increases in blood pressure compared to healthy controls (HC). Ten CA (age: 20 ± 2 y, 7 females) and 10 HC (age: 21 ± 2 y, 6 females) completed 5 min of lower body negative pressure (LBNP; −40 mmHg) and 5 min of lower body positive pressure (LBPP; 20 mmHg). Protocols were randomized and separated by 10 min. Mean arterial pressure (MAP) and middle cerebral artery blood velocity (MCAv) were continuously recorded. Cerebral vascular resistance (CVR) was calculated as MAP/MCAv. Values are reported as change from baseline to the last minute achieved (LBNP) or 5 min (LBPP). There were no differences in baseline values between groups. During LBNP, there were no differences in the change for MAP (CA: −23 ± 18 vs. HC: −21 ± 17 cm/s; P = 0.80) or MCAv (CA: −13 ± 8 vs. HC: −18 ± 9 cm/s; P = 0.19). The change in CVR was different between groups (CA: −0.08 ± 0.26 vs. HC: 0.18 ± 0.24 mmHg/cm/s; P = 0.04). Total LBNP time was lower for CA (204 ± 92 s) vs. HC (297 ± 64 s; P = 0.04). During LBPP, the change in MAP was not different between groups (CA: 13 ± 6 vs. HC: 10 ± 7 mmHg; P = 0.32). The change in MCAv (CA: 7 ± 6 vs. HC: −4 ± 13 cm/s; P = 0.04) and CVR (CA: −0.06 ± 0.27 vs. HC: 0.38 ± 0.41 mmHg/cm/s; P = 0.03) were different between groups. CA exhibited impaired tolerance to LBNP and had a different cerebral vascular response to LBPP compared to HC.
Collapse
Affiliation(s)
- Morgan L Worley
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Morgan C O'Leary
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - James R Sackett
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Zachary J Schlader
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States.,Human Integrative Physiology Laboratory, Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, NY, United States
| | - Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States.,Human Integrative Physiology Laboratory, Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, United States
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Haider MN, Bezherano I, Wertheimer A, Siddiqui AH, Horn EC, Willer BS, Leddy JJ. Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms. Sports Health 2021; 13:154-160. [PMID: 33147117 PMCID: PMC8167349 DOI: 10.1177/1941738120946015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
CONTEXT Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS. EVIDENCE ACQUISITION PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value. CONCLUSION Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes. STRENGTH OF RECOMMENDATION TAXONOMY 2.
Collapse
Affiliation(s)
- Mohammad Nadir Haider
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Itai Bezherano
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Alex Wertheimer
- Department of Emergency Medicine, State University of New York at Buffalo, Buffalo, New York
| | | | - Emily C Horn
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, New York
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| |
Collapse
|
20
|
Bonn MM, Harriss AB, Thompson JWG, Dickey JP. Performing more than 20 purposeful gameplay headers in a soccer season may alter autonomic function in female youth soccer players. Res Sports Med 2021; 29:440-448. [PMID: 33596738 DOI: 10.1080/15438627.2021.1888098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study evaluated the effects of cumulative purposeful soccer heading on autonomic nervous system function in 22 female youth soccer players (13.3 ± 0.9 years). A 10 minute electrocardiogram recording was collected at baseline and following the 20 game season (post-season) to calculate measures of heart rate variability (HRV), including standard deviation of the normal-normal intervals, total power, high frequency (HF), low frequency (LF), LF:HF, normalized HF and normalized LF. Participants were categorized into low- (<20 headers per season; n = 13) and high- (>20 headers per season; n = 9) exposure groups. Mann-Whitney U tests demonstrated no significant differences between groups for any HRV metric. However, the increased normalized LF power (low exposure 8.67 and high exposure -31.17, respectively; r = 0.35) and LF:HF power (-6.39 and 15.80, respectively; r = 0.35), between groups had moderate practical significance. Therefore, female youth players who perform more than 20 purposeful headers during a soccer season may exhibit altered autonomic function.
Collapse
Affiliation(s)
- Marquise M Bonn
- Health and Rehabilitation Sciences, Western University, London, Canada
| | | | | | | |
Collapse
|
21
|
Snyder A, Sheridan C, Tanner A, Bickart K, Sullan M, Craske M, Choe M, Babikian T, Giza C, Asarnow R. Cardiorespiratory Functioning in Youth with Persistent Post-Concussion Symptoms: A Pilot Study. J Clin Med 2021; 10:561. [PMID: 33546148 PMCID: PMC7913264 DOI: 10.3390/jcm10040561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/22/2021] [Accepted: 01/30/2021] [Indexed: 12/15/2022] Open
Abstract
Dysregulation of the autonomic nervous system (ANS) may play an important role in the development and maintenance of persistent post-concussive symptoms (PPCS). Post-injury breathing dysfunction, which is influenced by the ANS, has not been well-studied in youth. This study evaluated cardiorespiratory functioning at baseline in youth patients with PPCS and examined the relationship of cardiorespiratory variables with neurobehavioral outcomes. Participants were between the ages of 13-25 in two groups: (1) Patients with PPCS (concussion within the past 2-16 months; n = 13) and (2) non-injured controls (n = 12). Capnometry was used to obtain end-tidal CO2 (EtCO2), oxygen saturation (SaO2), respiration rate (RR), and pulse rate (PR) at seated rest. PPCS participants exhibited a reduced mean value of EtCO2 in exhaled breath (M = 36.3 mmHg, SD = 2.86 mmHg) and an altered inter-correlation between EtCO2 and RR compared to controls. Neurobehavioral outcomes including depression, severity of self-reported concussion symptoms, cognitive catastrophizing, and psychomotor processing speed were correlated with cardiorespiratory variables when the groups were combined. Overall, results from this study suggest that breathing dynamics may be altered in youth with PPCS and that cardiorespiratory outcomes could be related to a dimension of neurobehavioral outcomes associated with poorer recovery from concussion.
Collapse
Affiliation(s)
- Aliyah Snyder
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
| | - Christopher Sheridan
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Alexandra Tanner
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
| | - Kevin Bickart
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Departments of Neurology and Neuropsychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Molly Sullan
- Department of Psychiatry, Psychology Service, University of California, San Diego, CA 92093, USA;
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Michelle Craske
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
| | - Meeryo Choe
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- UCLA Mattel Children’s Hospital, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Talin Babikian
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
| | - Christopher Giza
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- UCLA Mattel Children’s Hospital, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Robert Asarnow
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
| |
Collapse
|
22
|
Coffman CA, Harrison AT, Kay JJM, Holloway JP, LaFountaine MF, Moore RD. The Influence of Family History of Neurodegenerative Disease on Adolescent Concussion Outcomes. J Clin Med 2021; 10:528. [PMID: 33540525 PMCID: PMC7867167 DOI: 10.3390/jcm10030528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/21/2021] [Accepted: 01/28/2021] [Indexed: 12/04/2022] Open
Abstract
Evidence suggests that factors associated with a family history of neurodegenerative disease (fhNDD) may influence outcomes following a concussion. However, the relevance of these findings in adolescent populations has not been fully explored. Therefore, the present study sought to evaluate the relationship between fhNDD and neurological outcomes following an adolescent concussion. Data from a local pediatric concussion clinic were used to compare adolescents with (n = 22) and without (n = 44) an fhNDD. Clinical symptom burden, emotional health, cardio-autonomic function, and cognitive performance were assessed at initial (~2 weeks) and follow-up (~5 weeks) post-injury evaluations. Cardio-autonomic function was assessed at rest and during isometric handgrip contraction (IHGC). Results indicated no significant group differences in emotional health or cognitive performance. Across evaluations, those with an fhNDD exhibited greater somatic symptom severity, alterations in HRV at rest, and early blunted cardio-autonomic reactivity during IHGC compared to those without an fhNDD. These findings suggest that positive fhNDD is negatively associated with clinical symptomology and cardio-autonomic functioning following an adolescent concussion. Further, these findings encourage clinicians to utilize a comprehensive neurological evaluation to monitor concussion recovery. Future studies should look into exploring the role of specific neurodegenerative processes and conditions on concussion outcomes in adolescents.
Collapse
Affiliation(s)
- Colt A. Coffman
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (A.T.H.); (J.J.M.K.)
| | - Adam T. Harrison
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (A.T.H.); (J.J.M.K.)
| | - Jacob J. M. Kay
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (A.T.H.); (J.J.M.K.)
| | - Jeffrey P. Holloway
- Department of Pediatrics—School of Medicine, University of South Carolina, Columbia, SC 29209, USA;
| | - Michael F. LaFountaine
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ 07110, USA;
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Robert Davis Moore
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (A.T.H.); (J.J.M.K.)
| |
Collapse
|
23
|
Memmini AK, Fountaine MFL, Broglio SP, Moore RD. Long-Term Influence of Concussion on Cardio-Autonomic Function in Adolescent Hockey Players. J Athl Train 2021; 56:141-147. [PMID: 33400783 DOI: 10.4085/1062-6050-0578.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Concussion may negatively influence cardiovascular function and the autonomic nervous system, defined by alteration in heart rate variability (HRV). Differences in HRV most commonly emerge during a physical challenge, such as the final steps of the return-to-sport progression. OBJECTIVE To assess the effect of concussion history on aspects of cardio-autonomic function during recovery from a bout of submaximal exercise in adolescent male hockey athletes. DESIGN Case-control study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty-three male athletes participating in Midget-AAA hockey were divided into those with (n = 15; age = 16 ± 1 years, height = 1.78 ± 0.06 m, mass = 73.9 ± 7.4 kg, 10.5 ± 1.6 years of sport experience, 25.2 ± 18.3 months since last injury) or without (n = 18; age = 16 ± 1 years, height = 1.78 ± 0.05 m, mass = 74.8 ± 7.6 kg, 10.6 ± 1.9 years of sport experience) a concussion history. Those with a concussion history were binned on total count: concussion) or 2 or more concussions. INTERVENTION(S) All athletes underwent 5 minutes of resting HRV assessment, followed by 20 minutes of aerobic exercise at 60% to 70% of their maximal target heart rate and a 9-minute, postexercise HRV assessment. MAIN OUTCOME MEASURE(S) Heart rate variability measures of mean NN interval, root mean square of successive differences, and standard deviation of NN interval (SDNN). RESULTS Group demographic characteristics were not different. When the control and concussed groups were compared, group and time main effects for heart rate recovery, root mean square of successive differences, and SDNN (P values < .01), and an interaction effect for SDNN (P < .05) were demonstrated. Recovery trends for each group indicated that a history of 2 or more concussions may negatively affect cardio-autonomic recovery postexercise. CONCLUSIONS Our findings suggest that those with more than 1 previous concussion may be associated with a greater risk for long-term dysautonomia. Future use of HRV may provide clinicians with objective guidelines for concussion-management and safe return-to-participation protocols.
Collapse
Affiliation(s)
| | - Michael F La Fountaine
- Department of Physical Therapy, School of Health and Medical Sciences; Institute for Advanced Study of Rehabilitation and Sports Science; Department of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Seton Hall University, Nutley, NJ
| | | | - Robert D Moore
- Arnold School of Public Health; Institute for Mind and Brain, University of South Carolina, Columbia
| |
Collapse
|
24
|
Coffman CA, Kay JJM, Saba KM, Harrison AT, Holloway JP, LaFountaine MF, Moore RD. Predictive Value of Subacute Heart Rate Variability for Determining Outcome Following Adolescent Concussion. J Clin Med 2021; 10:jcm10010161. [PMID: 33466532 PMCID: PMC7796512 DOI: 10.3390/jcm10010161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 01/28/2023] Open
Abstract
Objective assessments of concussion recovery are crucial for facilitating effective clinical management. However, predictive tools for determining adolescent concussion outcomes are currently limited. Research suggests that heart rate variability (HRV) represents an indirect and objective marker of central and peripheral nervous system integration. Therefore, it may effectively identify underlying deficits and reliably predict the symptomology following concussion. Thus, the present study sought to evaluate the relationship between HRV and adolescent concussion outcomes. Furthermore, we sought to examine its predictive value for assessing outcomes. Fifty-five concussed adolescents (12–17 years old) recruited from a local sports medicine clinic were assessed during the initial subacute evaluation (within 15 days postinjury) and instructed to follow up for a post-acute evaluation. Self-reported clinical and depressive symptoms, neurobehavioral function, and cognitive performance were collected at each timepoint. Short-term HRV metrics via photoplethysmography were obtained under resting conditions and physiological stress. Regression analyses demonstrated significant associations between HRV metrics, clinical symptoms, neurobehavioral function, and cognitive performance at the subacute evaluation. Importantly, the analyses illustrated that subacute HRV metrics significantly predicted diminished post-acute neurobehavioral function and cognitive performance. These findings indicate that subacute HRV metrics may serve as a viable predictive biomarker for identifying underlying neurological dysfunction following concussion and predict late cognitive outcomes.
Collapse
Affiliation(s)
- Colt A. Coffman
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (J.J.M.K.); (K.M.S.); (A.T.H.)
- Correspondence: (C.A.C.); (R.D.M.); Tel.: +1-(803)-777-3278 (C.A.C. & R.D.M.)
| | - Jacob J. M. Kay
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (J.J.M.K.); (K.M.S.); (A.T.H.)
| | - Kat M. Saba
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (J.J.M.K.); (K.M.S.); (A.T.H.)
| | - Adam T. Harrison
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (J.J.M.K.); (K.M.S.); (A.T.H.)
| | - Jeffrey P. Holloway
- Department of Pediatrics, School of Medicine, University of South Carolina, Columbia, SC 29209, USA;
| | - Michael F. LaFountaine
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ 07110, USA;
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Robert Davis Moore
- Concussion Health and Neuroscience Lab, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA; (J.J.M.K.); (K.M.S.); (A.T.H.)
- Correspondence: (C.A.C.); (R.D.M.); Tel.: +1-(803)-777-3278 (C.A.C. & R.D.M.)
| |
Collapse
|
25
|
Haider MN, Johnson BD, Horn EC, Leddy JJ, Wilber CG, Reed EL, O'Leary M, Bloomfield A, Decezaro LL, Willer BS. Blunted Cardiac Parasympathetic Activation in Student Athletes With a Remote History of Concussion: A Pilot Study. Front Neurol 2020; 11:547126. [PMID: 33101172 PMCID: PMC7554519 DOI: 10.3389/fneur.2020.547126] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/27/2020] [Indexed: 01/24/2023] Open
Abstract
Introduction: Blunted cardiac autonomic nervous system (ANS) responses, quantified using heart rate variability (HRV), have been reported after sport-related concussion (SRC). Research suggests this persists beyond clinical recovery. This study compared cardiac parasympathetic responses in student athletes with a remote history of SRC (> 1-year ago, Concussion History: CH) with those who reported no lifetime history of SRC (Concussion Naïve: CN). Design: Retrospective nested case-control. Setting: University laboratory. Patients or Other Participants: CH (n = 9, 18.3 ± 2 years, 44% male, median 2 years since injury) were student athletes with a remote history of concussion(s) from more than 1 year ago. CN (n = 21, 16.7 ± 3 years, 67% male) were student athletes with no lifetime history of concussion. Exclusion criteria included taking medications that could affect ANS function, history of concussion within the past year, persistent concussion symptoms, lifetime history of moderate to severe brain injury, and lifetime history of more than 3 concussions. Material and Methods: Participants performed the Face Cooling (FC) test for 3-min after 10-min of supine rest while wearing a 3-lead electrocardiogram in a controlled environment. Outcome Measures: Heart rate (HR), R-R interval (RRI), root mean square of the successive differences (RMSSD) of RRI, high frequency (HF) and low frequency to HF (LF:HF) ratios. Results: At baseline, CH had a lower resting HR than CN (62.3 ± 11 bpm vs. 72.9 ± 12, p = 0.034). CH had a different HR response to FC than CN (+8.9% change from baseline in CH vs. −7.5% in CN, p = 0.010). CH also had a smaller RMSSD increase to FC than CN (+31.8% change from baseline in CH vs. +121.8% in CN, p = 0.048). There were no significant group differences over time in RRI (p = 0.106), HF (p = 0.550) or LF:HF ratio (p = 0.053). Conclusion: Asymptomatic student athletes with a remote history of concussion had a blunted cardiac parasympathetic response to FC when compared with athletes with no lifetime history of concussion. These data suggest that an impaired autonomic response to a physiological stressor persists after clinical recovery from SRC for longer than previously reported.
Collapse
Affiliation(s)
- 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, United States.,Department of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States.,Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Blair D Johnson
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Emily C Horn
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| | - 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, United States
| | - Charles G Wilber
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| | - Emma L Reed
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Morgan O'Leary
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Adam Bloomfield
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Larissa L Decezaro
- Jundiaí Medical School, Faculdade de Medicina de Jundiaí (FMJ), Jundiai, Brazil
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| |
Collapse
|
26
|
McCabe JT, Tucker LB. Sex as a Biological Variable in Preclinical Modeling of Blast-Related Traumatic Brain Injury. Front Neurol 2020; 11:541050. [PMID: 33101170 PMCID: PMC7554632 DOI: 10.3389/fneur.2020.541050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022] Open
Abstract
Approaches to furthering our understanding of the bioeffects, behavioral changes, and treatment options following exposure to blast are a worldwide priority. Of particular need is a more concerted effort to employ animal models to determine possible sex differences, which have been reported in the clinical literature. In this review, clinical and preclinical reports concerning blast injury effects are summarized in relation to sex as a biological variable (SABV). The review outlines approaches that explore the pertinent role of sex chromosomes and gonadal steroids for delineating sex as a biological independent variable. Next, underlying biological factors that need exploration for blast effects in light of SABV are outlined, including pituitary, autonomic, vascular, and inflammation factors that all have evidence as having important SABV relevance. A major second consideration for the study of SABV and preclinical blast effects is the notable lack of consistent model design—a wide range of devices have been employed with questionable relevance to real-life scenarios—as well as poor standardization for reporting of blast parameters. Hence, the review also provides current views regarding optimal design of shock tubes for approaching the problem of primary blast effects and sex differences and outlines a plan for the regularization of reporting. Standardization and clear description of blast parameters will provide greater comparability across models, as well as unify consensus for important sex difference bioeffects.
Collapse
Affiliation(s)
- Joseph T McCabe
- Pre-clinical Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, IL, United States.,Department of Anatomy, Physiology & Genetics, F.E. Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Laura B Tucker
- Pre-clinical Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, IL, United States.,Department of Anatomy, Physiology & Genetics, F.E. Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| |
Collapse
|
27
|
Pyndiura KL, Di Battista AP, Hutchison MG. A history of concussion is associated with minimal perturbations to heart rate variability in athletes. Brain Inj 2020; 34:1416-1421. [DOI: 10.1080/02699052.2020.1802661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Kyla L. Pyndiura
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto ON, Canada
| | - Alex P. Di Battista
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto ON, Canada
| | - Michael G. Hutchison
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto ON, Canada
- Neuroscience Research Program, Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON, Canada
| |
Collapse
|
28
|
Neary JP, Dudé CM, Singh J, Len TK, Bhambhani YN. Pre-frontal Cortex Oxygenation Changes During Aerobic Exercise in Elite Athletes Experiencing Sport-Related Concussion. Front Hum Neurosci 2020; 14:35. [PMID: 32116614 PMCID: PMC7028689 DOI: 10.3389/fnhum.2020.00035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/23/2020] [Indexed: 12/28/2022] Open
Abstract
Aims: Recent research suggests that aerobic exercise can be performed safely within the first week following a concussion injury and that early initiation of exercise may speed recovery. To better understand the physiological changes during a concussion, we tested the hypothesis that mild-to-intense exercise testing can be performed within days immediately following injury, and can be used to discern differences between the concussed and normal healthy state. Thus, the purpose was to observe the cerebral hemodynamic responses to incremental exercise testing performed acutely post-concussion in high-performance athletes. Methods: This study was a within- and between-experimental design, with seven male university ice hockey teams participating. A subgroup of five players acted as control subjects (CON) and was tested at the same time as the 14 concussed (mTBI) players on Day 2, 4, and 7 post-concussion. A 5-min resting baseline and 5-min exercise bouts of mild (EX1), moderate (EX2), and high (EX3) intensity exercise were performed on a cycle ergometer. Near-infrared spectroscopy was used to monitor pre-frontal cortex oxy-haemoglobin (HbO2), deoxy-haemoglobin (HHb), and total blood volume (tHb) changes. Results: ANOVA compared differences between testing days and groups, and although large percentage changes in HbO2 (20-30%), HHb (30-40%), and tHb (30-40%) were recorded, no significant (p ≤ 0.05) differences in cerebral hemodynamics occurred between mTBI vs. CON during aerobic exercise testing on any day post-injury. Furthermore, there was a linear relationship between exercise intensity vs. cerebral hemodynamics during testing for each day (r 2 = 0.83-0.99). Conclusion: These results demonstrate two novel findings: (1) mild-to-intense aerobic exercise testing can be performed safely as early as Day 2 post-concussion injury in a controlled laboratory environment; and (2) evidence-based objective measures such as cerebral hemodynamics can easily be collected using near-infrared spectroscopy (NIRS) to monitor physiological changes during the first-week post-injury. This research has important implications for monitoring physiological recovery post-injury and establishing new rehabilitation guidelines.
Collapse
Affiliation(s)
- J. Patrick Neary
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | | | - Jyotpal Singh
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | - Trevor K. Len
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
| | - Yagesh N. Bhambhani
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
29
|
Johnson BD, Sackett JR, Schlader ZJ, Leddy JJ. Attenuated Cardiovascular Responses to the Cold Pressor Test in Concussed Collegiate Athletes. J Athl Train 2020; 55:124-131. [PMID: 31909640 DOI: 10.4085/1062-6050-573-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Cardiovascular responses to the cold pressor test (CPT) provide information regarding sympathetic function. OBJECTIVE To determine if recently concussed collegiate athletes had blunted cardiovascular responses during the CPT. DESIGN Cross-sectional study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 10 symptomatic concussed collegiate athletes (5 men, 5 women; age = 20 ± 2 years) who were within 7 days of diagnosis and 10 healthy control individuals (5 men, 5 women; age = 24 ± 4 years). INTERVENTION(S) The participants' right hands were submerged in agitated ice water for 120 seconds (CPT). MAIN OUTCOME MEASURE(S) Heart rate and blood pressure were continuously measured and averaged at baseline and every 30 seconds during the CPT. RESULTS Baseline heart rate and mean arterial pressure were not different between groups. Heart rate increased throughout 90 seconds of the CPT (peak increase at 60 seconds = 16 ± 13 beats/min; P < .001) in healthy control participants but remained unchanged in concussed athletes (peak increase at 60 seconds = 7 ± 10 beats/min; P = .08). We observed no differences between groups for the heart rate response (P > .28). Mean arterial pressure was elevated throughout the CPT starting at 30 seconds (5 ± 7 mm Hg; P = .048) in healthy control individuals (peak increase at 120 seconds = 26 ± 9 mm Hg; P < .001). Mean arterial pressure increased in concussed athletes at 90 seconds (8 ± 8 mm Hg; P = .003) and 120 seconds (12 ± 8 mm Hg; P < .001). Healthy control participants had a greater increase in mean arterial pressure starting at 60 seconds (P < .001) and throughout the CPT than concussed athletes (peak difference at 90 seconds = 25 ± 10 mm Hg and 8 ± 8 mm Hg, respectively; P < .001). CONCLUSIONS Recently concussed athletes had blunted cardiovascular responses to the CPT, which indicated sympathetic dysfunction.
Collapse
Affiliation(s)
- Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, NY
| | - James R Sackett
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, NY
| | - Zachary J Schlader
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, NY
| | - John J Leddy
- Department of Orthopaedics and Sports Medicine, University at Buffalo, NY
| |
Collapse
|
30
|
Pediatric Traumatic Brain Injury and Exercise Medicine: A Narrative Review. Pediatr Exerc Sci 2019; 31:393-400. [PMID: 30955443 DOI: 10.1123/pes.2017-0286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/10/2019] [Accepted: 01/28/2019] [Indexed: 11/18/2022]
Abstract
The multidisciplinary field of pediatric traumatic brain injury (TBI) and exercise medicine is of growing importance. There is active study into the diagnostic and therapeutic potential of exercise in pediatric TBI as well as the effects of TBI on postinjury fitness. With the evidence-based growing, a literature review can help establish the state of the science and inform future research. Therefore, the authors performed a narrative review (based on a search of 6 health sciences databases) to summarize evidence on pediatric TBI and cardiorespiratory fitness, muscular fitness and neuromotor control, and obesity. To date, studies related to cardiorespiratory fitness have centered on exercise tolerance and readiness to return to play, and indicate that protracted rest may not facilitate symptom recovery; this suggests a role for exercise in concussion management. Furthermore, strength and gait may be impaired following pediatric brain injury, and interventions designed to train these impairments may lead to their improvement. Pediatric brain injury can also lead to changes in body composition (which may be related to poorer cognitive recovery), but additional research is required to better understand such associations. This narrative review of pediatric TBI and exercise medicine can serve as a reference for researchers and clinicians alike.
Collapse
|
31
|
Weil ZM, Karelina K. Lifelong consequences of brain injuries during development: From risk to resilience. Front Neuroendocrinol 2019; 55:100793. [PMID: 31560884 PMCID: PMC6905510 DOI: 10.1016/j.yfrne.2019.100793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/23/2019] [Accepted: 09/23/2019] [Indexed: 10/26/2022]
Abstract
Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.
Collapse
Affiliation(s)
- Zachary M Weil
- Department of Neuroscience, Group in Behavioral Neuroendocrinology, Center for Brain and Spinal Cord Repair, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
| | - Kate Karelina
- Department of Neuroscience, Group in Behavioral Neuroendocrinology, Center for Brain and Spinal Cord Repair, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| |
Collapse
|
32
|
Is There an Optimal Time to Initiate an Active Rehabilitation Protocol for Concussion Management in Children? A Case Series. J Head Trauma Rehabil 2019; 33:E11-E17. [PMID: 28926482 DOI: 10.1097/htr.0000000000000339] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the time frame during which initiating an active rehabilitation intervention (aerobic exercise, balance, and sport specific skills) after concussion contributed to improvement in symptoms at follow-up in children and adolescents who are slow to recover (symptoms persisting beyond 2 weeks) from concussion. SETTING Concussion clinic at a tertiary care pediatric teaching hospital. PARTICIPANTS A total of 677 children and adolescents with concussion aged 7 to 18 years. DESIGN Case series of participants starting active rehabilitation less than 2, 2, 3, 4, 5, or 6 or more weeks postconcussion. MAIN MEASURE Symptom severity measured by the 22-item Post-Concussion Scale (PCS)-revised. RESULTS All patients experienced significant improvement of symptoms while participating in active rehabilitation, irrespective of the start time postonset. Patients initiating active rehabilitation at 2 (P < .001) or 3 (P = .039) weeks postinjury demonstrated lower symptom severity at follow-up than those starting at 6 weeks or later. Patients starting at 2 weeks had lower symptom severity than patients starting less than 2 (P = .02), 4 (P = .20), or 5 weeks postinjury (P = .04). Lastly, patients starting less than 2 and 6 weeks or more postinjury yielded equivalent outcomes. CONCLUSIONS The findings support the use of active rehabilitation in children and adolescents who are slow to recover from concussion. Participants starting active rehabilitation less than 2 weeks and up to 6 or more weeks postconcussion demonstrated significant symptom improvements, but improvement was observed in all groups, regardless of the time to start active rehabilitation.
Collapse
|
33
|
Johnson BD, O'Leary MC, McBryde M, Sackett JR, Schlader ZJ, Leddy JJ. Face cooling exposes cardiac parasympathetic and sympathetic dysfunction in recently concussed college athletes. Physiol Rep 2019; 6:e13694. [PMID: 29741235 PMCID: PMC5941219 DOI: 10.14814/phy2.13694] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 12/24/2022] Open
Abstract
We tested the hypothesis that concussed college athletes (CA) have attenuated parasympathetic and sympathetic responses to face cooling (FC). Eleven symptomatic CA (age: 20 ± 2 years, 5 women) who were within 10 days of concussion diagnosis and 10 healthy controls (HC; age: 24 ± 4 years, 5 women) participated. During FC, a plastic bag filled with ice water (~0°C) was placed on the forehead, eyes, and cheeks for 3 min. Heart rate (ECG) and blood pressure (photoplethysmography) were averaged at baseline and every 60 sec during FC. High‐frequency (HF) power was obtained from spectral analysis of the R‐R interval. Data are presented as a change from baseline. Baseline heart rate (HC: 61 ± 12, CA: 57 ± 12 bpm; P = 0.69), mean arterial pressure (MAP) (HC: 94 ± 10, CA: 96 ± 13 mmHg; P = 0.74), and HF (HC: 2294 ± 2314, CA: 2459 ± 2058 msec2; P = 0.86) were not different between groups. Heart rate in HC decreased at 2 min (−7 ± 11 bpm; P = 0.02) but did not change in CA (P > 0.43). MAP increased at 1 min (HC: 12 ± 6, CA: 6 ± 6 mmHg), 2 min (HC: 21 ± 7, CA: 11 ± 7 mmHg), and 3 min (HC: 20 ± 6, CA: 13 ± 7 mmHg) in both groups (P < 0.01 for all) but the increase was greater at each interval in HC (P < 0.02). HF increased at 1 min (12354 ± 11489 msec2; P < 0.01) and 2 min (5832 ± 8002 msec2; P = 0.02) in HC but did not change in CA (P > 0.58). The increase in HF at 1 min was greater in HC versus CA (P < 0.01). These data indicate that symptomatic concussed patients have impaired cardiac parasympathetic and sympathetic activation.
Collapse
Affiliation(s)
- Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Morgan C O'Leary
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Muhamed McBryde
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - James R Sackett
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - Zachary J Schlader
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, New York
| | - John J Leddy
- UBMD, Department of Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, New York
| |
Collapse
|
34
|
Li KHC, White FA, Tipoe T, Liu T, Wong MC, Jesuthasan A, Baranchuk A, Tse G, Yan BP. The Current State of Mobile Phone Apps for Monitoring Heart Rate, Heart Rate Variability, and Atrial Fibrillation: Narrative Review. JMIR Mhealth Uhealth 2019; 7:e11606. [PMID: 30767904 PMCID: PMC6396075 DOI: 10.2196/11606] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/06/2018] [Accepted: 11/25/2018] [Indexed: 12/19/2022] Open
Abstract
Background Mobile phone apps capable of monitoring arrhythmias and heart rate (HR) are increasingly used for screening, diagnosis, and monitoring of HR and rhythm disorders such as atrial fibrillation (AF). These apps involve either the use of (1) photoplethysmographic recording or (2) a handheld external electrocardiographic recording device attached to the mobile phone or wristband. Objective This review seeks to explore the current state of mobile phone apps in cardiac rhythmology while highlighting shortcomings for further research. Methods We conducted a narrative review of the use of mobile phone devices by searching PubMed and EMBASE from their inception to October 2018. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) mobile phone monitoring, (2) AF, (3) HR, and (4) HR variability (HRV). Results The findings of this narrative review suggest that there is a role for mobile phone apps in the diagnosis, monitoring, and screening for arrhythmias and HR. Photoplethysmography and handheld electrocardiograph recorders are the 2 main techniques adopted in monitoring HR, HRV, and AF. Conclusions A number of studies have demonstrated high accuracy of a number of different mobile devices for the detection of AF. However, further studies are warranted to validate their use for large scale AF screening.
Collapse
Affiliation(s)
- Ka Hou Christien Li
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).,Faculty of Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Timothy Tipoe
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Martin Cs Wong
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Aaron Jesuthasan
- Faculty of Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kington, ON, Canada
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).,Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong)
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong).,Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China (Hong Kong).,Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, China (Hong Kong)
| |
Collapse
|
35
|
Worts PR, Burkhart SO, Kim JS. A Physiologically Based Approach to Prescribing Exercise Following a Sport-Related Concussion. Sports Med 2019; 49:683-706. [DOI: 10.1007/s40279-019-01065-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
36
|
La Fountaine MF. An anatomical and physiological basis for the cardiovascular autonomic nervous system consequences of sport-related brain injury. Int J Psychophysiol 2018; 132:155-166. [DOI: 10.1016/j.ijpsycho.2017.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 11/14/2017] [Accepted: 11/23/2017] [Indexed: 01/11/2023]
|
37
|
Abstract
CONTEXT Baseline testing is a common strategy for concussion assessment and management. Research continues to evaluate novel measures for potential to improve baseline testing methods. OBJECTIVES The primary objective was to (1) determine the feasibility of including physiological, neuromuscular, and mood measures as part of baseline concussion testing protocol, (2) describe typical values in a varsity athlete sample, and (3) estimate the influence of concussion history on these baseline measures. DESIGN Prospective observational study. SETTING Ryerson University Athletic Therapy Clinic. PARTICIPANTS One hundred varsity athletes. MAIN OUTCOME MEASURES Frequency and domain measures of heart rate variability, blood pressure, grip strength, profile of mood states-short form, and the Sport Concussion Assessment Tool-2. RESULTS Physiological, neuromuscular performance, and mood measures were feasible at baseline. Participants with a history of 2 or more previous concussions displayed significantly higher diastolic blood pressure. Females reported higher total mood disturbance compared with males. CONCLUSIONS Physiological and neuromuscular performance measures are safe and feasible as baseline concussion assessment outcomes. History of concussion may have an influence on diastolic blood pressure.
Collapse
|
38
|
Cerebral Hemodynamic Influences in Task-Related Functional Magnetic Resonance Imaging and Near-Infrared Spectroscopy in Acute Sport-Related Concussion: A Review. J Imaging 2018. [DOI: 10.3390/jimaging4040059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
39
|
Pertab JL, Merkley TL, Cramond AJ, Cramond K, Paxton H, Wu T. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review. NeuroRehabilitation 2018; 42:397-427. [PMID: 29660949 PMCID: PMC6027940 DOI: 10.3233/nre-172298] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms. OBJECTIVE This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning. METHODS The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN. RESULTS Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations. CONCLUSIONS The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.
Collapse
Affiliation(s)
- Jon L. Pertab
- Neurosciences Institute, Intermountain Healthcare, Murray, UT, USA
| | - Tricia L. Merkley
- Department of Clinical Neuropsychology, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Kelly Cramond
- Summit Neuropsychology, Reno, NV, USA
- VA Sierra Nevada Healthcare System, Reno, NV, USA
| | - Holly Paxton
- Hauenstein Neurosciences of Mercy Health and Department of Translational Science and Molecular Medicine, Michigan State University, MI, USA
| | - Trevor Wu
- Hauenstein Neurosciences of Mercy Health and Department of Translational Science and Molecular Medicine, Michigan State University, MI, USA
| |
Collapse
|
40
|
Bishop SA, Dech RT, Guzik P, Neary JP. Heart rate variability and implication for sport concussion. Clin Physiol Funct Imaging 2017; 38:733-742. [PMID: 29144026 DOI: 10.1111/cpf.12487] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Finding sensitive and specific markers for sports-related concussion is both challenging and clinically important. Such biomarkers might be helpful in the management of patients with concussion (i.e. diagnosis, monitoring and risk prediction). Among many parameters, blood flow-pressure metrics and heart rate variability (HRV) have been used to gauge concussion outcomes. Reports on the relation between HRV and both acute and prolonged concussion recovery are conflicting. While some authors report on differences in the low-frequency (LF) component of HRV during postural manipulations and postexercise conditions, others observe no significant differences in various HRV measures. Despite the early success of using the HRV LF for concussion recovery, the interpretation of the LF is debated. Recent research suggests the LF power is a net effect of several intrinsic modulatory factors from both sympathetic and parasympathetic branches of the autonomic nervous system, vagally mediated baroreflex and even some respiratory influences at lower respiratory rate. There are only a few well-controlled concussion studies that specifically examine the contribution of the autonomic nervous system branches with HRV for concussion management. This study reviews the most recent HRV- concussion literature and the underlying HRV physiology. It also highlights cerebral blood flow studies related to concussion and the importance of multimodal assessment of various biological signals. It is hoped that a better understanding of the physiology behind HRV might generate cost-effective, repeatable and reliable protocols, all of which will improve the interpretation of HRV throughout concussion recovery.
Collapse
Affiliation(s)
- Scott A Bishop
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - Ryan T Dech
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - Przemyslaw Guzik
- Department of Cardiology-Intensive Care Therapy & Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - J Patrick Neary
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| |
Collapse
|
41
|
Lai E, Boyd K, Albert D, Ciocca M, Chung EH. Heart rate variability in concussed athletes: A case report using the smartphone electrocardiogram. HeartRhythm Case Rep 2017; 3:523-526. [PMID: 29204350 PMCID: PMC5688238 DOI: 10.1016/j.hrcr.2017.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ernest Lai
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kenny Boyd
- Division of Sports Medicine, Campus Heath Services, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - David Albert
- AliveCor™ Corporation, San Francisco, California
| | - Mario Ciocca
- Division of Sports Medicine, Campus Heath Services, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eugene H Chung
- Division of Cardiology, Cardiac Electrophysiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
42
|
Bishop SA, Neary JP. Assessing prefrontal cortex oxygenation after sport concussion with near-infrared spectroscopy. Clin Physiol Funct Imaging 2017. [DOI: 10.1111/cpf.12447] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Scott A. Bishop
- Faculty of Kinesiology and Health Studies; University of Regina; Regina SK Canada
| | - J. Patrick Neary
- Faculty of Kinesiology and Health Studies; University of Regina; Regina SK Canada
| |
Collapse
|
43
|
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.
Collapse
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
| | | |
Collapse
|
44
|
Psychological and Physiological Markers of Stress in Concussed Athletes Across Recovery Milestones. J Head Trauma Rehabil 2017; 32:E38-E48. [DOI: 10.1097/htr.0000000000000252] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
45
|
Abstract
OBJECTIVE To assess heart rate variability (HRV) in athletes with concussion across three phases of recovery. DESIGN A prospective matched control group design included the collection of HRV and symptoms measured by the Rivermead Post-Concussion Questionnaire. These measures were taken at 3 phases of recovery [(1) symptomatic; (2). asymptomatic; and (3) one-week after return-to-play (RTP)]. The same protocol was completed by noninjured athletes. SETTING Interuniversity sports teams at a single institution. PARTICIPANTS 11 athletes, across 7 sports, diagnosed with concussion, and 11 matched-athlete controls volunteered for the study. INTERVENTION Physician diagnosed concussion and a sitting to standing protocol for HRV monitoring. MAIN OUTCOME MEASURES The frequency, time, and nonlinear domains of HRV were assessed along with the absolute difference between sitting and standing for each. RESULTS A 2 x 3 (group x phase) repeated-measures analysis of variance revealed significant interactions for sitting High Frequency (HF) norm, sitting Low Frequency (LF) norm, the difference between sitting and standing HF norm, and difference between sitting and standing LF norm. Acutely, athletes with concussion displayed increased LF norm and decreased HF norm while sitting and a decreased change in their HF and LF norm measures between sitting and standing. A significant group effect for sample entropy when standing was detected, with the concussed group displaying decreased values compared with the matched controls. CONCLUSIONS Athletes with concussion displayed autonomic dysfunction in some measures of HRV that persisted beyond RTP and were related to a previous history of concussion.
Collapse
|
46
|
Kamins J, Bigler E, Covassin T, Henry L, Kemp S, Leddy JJ, Mayer A, McCrea M, Prins M, Schneider KJ, Valovich McLeod TC, Zemek R, Giza CC. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med 2017; 51:935-940. [DOI: 10.1136/bjsports-2016-097464] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 12/14/2022]
|
47
|
Dobson JL, Yarbrough MB, Perez J, Evans K, Buckley T. Sport-related concussion induces transient cardiovascular autonomic dysfunction. Am J Physiol Regul Integr Comp Physiol 2017; 312:R575-R584. [DOI: 10.1152/ajpregu.00499.2016] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 12/14/2022]
Abstract
Recent evidence suggests that concussions may disrupt autonomic cardiovascular control. This study investigated the initial effects of concussion on cardiovascular function using three autonomic reflex tests. Twenty-three recreational athletes (12 women, 11 men) were divided into concussed ( n = 12) and control ( n = 11) groups. Concussed participants performed forced breathing, standing, and Valsalva autonomic tests four times: 1) within 48 h of injury; 2) 24 h later; 3) 1 wk after injury; and 4) 2 wk after injury. The controls performed the same tests on the same schedule. Differences in heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) responses to the tests were continuously measured using finger photoplethysmography and were analyzed using repeated-measures multivariate ANOVAs and ANOVAs. Within 48 h of injury, the concussed group had significantly greater resting SBP ( t21= 2.44, P = 0.02, d = 1.03), HR ( t21= 2.33, P = 0.03, d = 1.01), and SBP responses to standing ( t21= 2.98, P = 0.01, d = 1.24), and 90% SBP normalization times ( t21= 2.64, P = 0.02, d = 1.10) after the Valsalva, but those group differences subsided 24 h later. There was also a significant interaction with the HR responses to forced breathing ( F3,60= 4.13, P = 0.01, ηp2= 0.17), indicating the concussed responses declined relative to the control’s over time. The results demonstrate that concussion disrupted autonomic cardiovascular control, and that autonomic reflex tests are practical means by which to evaluate that dysfunction.
Collapse
Affiliation(s)
- John L. Dobson
- School of Health and Kinesiology, Georgia Southern University, Statesboro, Georgia
| | - Mary Beth Yarbrough
- School of Health and Kinesiology, Georgia Southern University, Statesboro, Georgia
| | - Jose Perez
- School of Health and Kinesiology, Georgia Southern University, Statesboro, Georgia
| | - Kelsey Evans
- School of Health and Kinesiology, Georgia Southern University, Statesboro, Georgia
| | - Thomas Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware
| |
Collapse
|
48
|
Bishop S, Dech R, Baker T, Butz M, Aravinthan K, Neary JP. Parasympathetic baroreflexes and heart rate variability during acute stage of sport concussion recovery. Brain Inj 2017; 31:247-259. [DOI: 10.1080/02699052.2016.1226385] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Scott Bishop
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - Ryan Dech
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - Taylor Baker
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - Matthew Butz
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kaishan Aravinthan
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| | - J. Patrick Neary
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada
| |
Collapse
|
49
|
Hinds A, Leddy J, Freitas M, Czuczman N, Willer B. The Effect of Exertion on Heart Rate and Rating of Perceived Exertion in Acutely Concussed Individuals. ACTA ACUST UNITED AC 2016; 7. [PMID: 27812398 PMCID: PMC5089811 DOI: 10.4172/2155-9562.1000388] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective Research suggests that one physiological effect of concussion is a disruption in regulation of autonomic nervous system control that affects the balance between parasympathetic and sympathetic output. While changes in heart rate after concussion have been observed, the nature of the heart rate change during progressive exercise has not been well evaluated in acutely symptomatic patients. Additionally, little is known about the relationship between HR and RPE in this population. Methods We compared changes in heart rate and perceived effort during graded treadmill exertion in recently concussed patients to elucidate the effect of brain injury on cardiovascular response to exercise. Resting HR, HR on exercise initiation, and changes in HR and RPE during the Buffalo Concussion Treadmill Test (BCTT) were compared on two test visits: When patients were symptomatic (acute) and after recovery. Results were compared with the test-retest results obtained from a control group consisting of healthy, non-concussed individuals. Results Patients had a significantly lower HR at onset of exercise when acutely concussed as compared to when recovered and reported greater perceived exertion at every exercise intensity level when symptomatic, despite exercising at lower workloads, than when recovered. Sympathetic response to increased exertion was not affected by concussion - HR increased in response to exercise at a comparable rate in both tests. These differences observed in response to exercise between the first BCTT and follow-up evaluation in initially concussed patients were not present in non-concussed individuals. Conclusion Our results suggest that during the acute phase after concussion, acutely concussed patients demonstrated an impaired ability to shift from parasympathetic to sympathetic control over heart rate at the onset of exercise. Changes in the autonomic nervous system after concussion may be more complex than previously reported. Continued evaluation of autonomic regulatory effects in the acute phase after concussion is warranted.
Collapse
Affiliation(s)
- Andrea Hinds
- Department of Psychiatry, University Sports Medicine, Buffalo New York, USA
| | - John Leddy
- UBMD Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, New York, USA
| | - Michael Freitas
- UBMD Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, New York, USA
| | | | - Barry Willer
- Department of Psychiatry, University Sports Medicine, Buffalo New York, USA
| |
Collapse
|
50
|
Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R 2016; 8:S91-S100. [PMID: 26972272 DOI: 10.1016/j.pmrj.2015.10.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/06/2015] [Accepted: 10/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- John Leddy
- UBMD Orthopaedics and Sports Medicine, SUNY Buffalo, 160 Farber Hall, Buffalo, NY 14214
| | - Andrea Hinds
- Department of Psychiatry, SUNY Buffalo, Buffalo, NY
| | - Dan Sirica
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Barry Willer
- Department of Psychiatry, SUNY Buffalo, Buffalo, NY
| |
Collapse
|