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Moser N, Gargoum S, Popovic MR, Kalsi-Ryan S. Effectiveness of Non-Pharmacological Therapy on Physical Symptoms in Patients With Persistent Concussion Symptoms: A Systematic Review. J Neurotrauma 2024. [PMID: 38149605 DOI: 10.1089/neu.2023.0474] [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: 12/28/2023] Open
Abstract
This systematic review provides a comprehensive overview on the effectiveness of rehabilitation on physical symptoms in patients of all ages with persistent concussion symptoms. PubMed, MEDLINE®, Cochrane library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase were searched from January 1, 2012 to September 1, 2023 using terms related to physical post-concussion symptoms. Eligible articles were critically appraised using the Scottish Intercollegiate Guidelines Network (SIGN) and the Quality Assessment Tool. The Grading of Recommendations Assessment, Development, and Evaluation system was applied to rate the quality of evidence. Thirty-two articles were included. Preliminary evidence suggests that transcranial magnetic stimulation improves symptoms in adults, specifically headaches. Young adults reported a significant decrease in physical symptoms following sub-symptom aerobic training as well as cervical spine manual therapy. Tentatively, adults demonstrated improvements in headache symptoms following neurofeedback sessions, and progressive muscle relaxation resulted in a decrease in monthly headaches. Multimodal therapy in adults produced significant change in physical symptoms when compared with usual care. However, no further reduction in physical symptoms was observed when adult patients received a program of care that afforded cervicovestibular rehabilitation with symptom-limited exercise compared with a symptom-limited exercise program alone. Cognitive behavioral therapy demonstrated inconsistent findings for its effects on physical symptoms, specifically headaches. Veterans had a significant change in post-concussive symptoms, specifically headaches, following 3-month use of an interactive smartphone application as compared with standard care. Finally, in a pediatric population, the use of melatonin did not produce any changes in physical persistent concussion symptoms as compared with placebo. Preliminary evidence suggests that various forms of rehabilitative therapies can improve persistent physical concussive symptoms. However, given the methodological limitations in the majority of trials, the results need to be interpreted with caution.
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Affiliation(s)
- Nicholas Moser
- KITE Research Institute-University Health Network, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Shawn Gargoum
- Private clinical practice, Apex Physiotherapy and Chiropractic, Pickering, Ontario, Canada
| | - Milos R Popovic
- KITE Research Institute-University Health Network, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
| | - Sukhvinder Kalsi-Ryan
- KITE Research Institute-University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
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De Luigi AJ, Bell KR, Bramhall JP, Choe M, Dec K, Finnoff JT, Halstead M, Herring SA, Matuszak J, Raksin PB, Swanson J, Millett C. Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury. PM R 2023; 15:1605-1642. [PMID: 37794736 DOI: 10.1002/pmrj.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions. OBJECTIVE To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice. LITERATURE SURVEY A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process. METHODOLOGY A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed. SYNTHESIS There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity. CONCLUSIONS The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.
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Affiliation(s)
- Arthur J De Luigi
- Department Chair of Physical Medicine & Rehabiltation, Medical Director of Sports Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kathleen R Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Katherine Dec
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan T Finnoff
- United States Olympic and Paralympic Committee, Colorado Springs, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, Colorado, USA
| | - Mark Halstead
- Washington University Sports Medicine, St Louis, Missouri, USA
| | - Stanley A Herring
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jason Matuszak
- Sports Medicine, Excelsior Orthopaedics, Buffalo, New York, USA
| | - P B Raksin
- John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital), Rush University Medical Center, Chicago, Illinois, USA
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Hammerle MH, Thomas LC, Swan AA, Lu LH, Treleaven JM. Sub-occipital muscle pressure pain thresholds correlate to direction of symptomatic active comfortable sustained neck rotation testing in post-concussive headache: a retrospective observational cross-sectional study. J Man Manip Ther 2023; 31:124-129. [PMID: 36102346 PMCID: PMC10013433 DOI: 10.1080/10669817.2022.2122370] [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: 10/14/2022] Open
Abstract
OBJECTIVES To compare sub-occipital muscle pressure sub pain thresholds (PPTs) in individuals with persistent-post-traumatic-headache (PPTH) in relation to the presence or not of cranial nerve and/or autonomic symptoms reported during sustained neck rotation (SNR). BACKGROUND Previously 81% of military service members with PPTH demonstrated symptoms with SNR up to 60 seconds. Of these, 54% reported symptoms in one (Uni-Symp) and 46% in both directions of rotation (Bi-Symp). Sub-occipital PPTs, in relation to SNR direction, were of interest. METHODS Retrospective review of records of 77 individuals, with PPTH with both SNR and PPTs. Average suboccipital and scalene PPTs were compared between Asymptomatic (n = 13), upon SNR testing, or Symptomatic (Uni-Symp, n = 32, Bi-Symp, n = 32), groups. RESULTS The Bi-Symp group had significantly reduced sub-occipital PPTs relative to the Asymptomatic group on both sides [p < 0.009] with no side-to-side differences in either group. The Uni-Symp group had significantly lower sub-occipital PPTs on the symptomatic SNR test direction compared to the asymptomatic side [t(31) = 3.37, p = 0.002]. There were no differences within or between groups in the scalene PPTs(p's > 0.08). CONCLUSIONS An upper cervical mechanical trigger of symptoms during SNR tests in some individuals with PPTH is possible. The direction of symptomatic SNR tests may indicate direction of guarded hypermobile dysfunction and direct treatment.
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Affiliation(s)
- Matt H. Hammerle
- Brooke Army Medical Center, Brain Injury Rehabilitation Service, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Lucy C. Thomas
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
| | - Alicia A. Swan
- Department of Psychology & South Texas Veterans Health Care System, The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Lisa H. Lu
- Defense and Veterans Brain Injury Center, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Julia M. Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
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Hammerle MH, Lu LH, Thomas LC, Swan AA, Hoppes CW, Nelson JT, Treleaven JM. Possible autonomic or cranial nerve symptoms triggered during sustained neck rotation in persistent headache post-concussion: a retrospective observational cross-sectional study. J Man Manip Ther 2023; 31:113-123. [PMID: 35695356 PMCID: PMC10013563 DOI: 10.1080/10669817.2022.2085850] [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] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To examine and categorize symptoms occurring within 60 s of vertebrobasilar-insufficiency (VBI) testing (left- and right-neck rotation) in individuals with persistent post-traumatic headache. BACKGROUND As part of routine clinical cervical screening in our patients, we found extended VBI testing often triggered additional symptoms. Therefore, we aimed to document the prevalence and precise symptoms occurring during each movement direction of this test and determine any demographic or baseline signs or symptoms associated with a positive test. METHODS A retrospective medical record review on military personnel receiving treatment for persistent post-traumatic headache was performed. Participants were grouped according to presence of non-headache related symptoms triggered during the tests. Frequency, onset, and symptom characteristics reported were categorized as potentially vascular and/or possible autonomic or cranial nerve in nature. RESULTS At least one symptom was reported by 81.3% of 123 patients. Of these, 54% reported symptoms in one and 46% in both directions of rotation, yielding 146 abnormal tests. Most reported symptoms were tear disruption (41%), altered ocular-motor-control (25%), and blepharospasm (16%). Enlisted individuals and those with altered baseline facial sensation were more likely to have a positive test. CONCLUSIONS The majority reported symptoms not typical of VBI within 60 seconds of sustained neck rotation. Further study is needed to better understand the mechanisms and clinical relevance.
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Affiliation(s)
- Matt H Hammerle
- Brain Injury Rehabilitation Service, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Lisa H Lu
- Defense and Veterans Brain Injury Center, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Lucy C Thomas
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane Queensland, Australia
| | - Alicia A Swan
- Department of Psychology & South Texas Veterans Health Care System, the University of Texas at San Antonio, San Antonio, Texas, USA
| | - Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, San Antonio, Texas, USA
| | - Jeremy T Nelson
- Department of Radiology and Imaging Sciences, Military Health Institute, the University of Texas Health Science Center at San Antonio & Indiana University, San Antonio, Texas, USA
| | - Julia M Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane Queensland, Australia
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Majcen Rosker Z, Kristjansson E, Vodicar M. How well can we detect cervical driven sensorimotor dysfunction in concussion patients? An observational study comparing patients with idiopathic neck pain, whiplash associated disorders and concussion. Gait Posture 2023; 101:21-27. [PMID: 36701850 DOI: 10.1016/j.gaitpost.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/21/2022] [Accepted: 01/16/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with mild traumatic brain injury (mTBI) suffer from sensorimotor impairments. Evidence is emerging that cervical spine plays an important role in mTBI, but it is not known how cervicocephalic kinaesthetic sensibility measured during dynamic unpredictable head movements and measures of position sense, cervical induced postural balance and eye movement control differ between mTBI, whiplash associated disorders (WAD) patients, idiopathic neck pain patients and healthy controls. RESEARCH QUESTION Are cervical sensorimotor deficits present in mTBI patients and do they differ from sensorimotor deficits found in traumatic and nontraumatic neck pain patients and whether they differ from healthy controls. METHODS Twenty idiopathic neck pain patients, 18 WAD, 17 mTBI and 20 healthy controls were enroled in the study. Frequency and velocity of centre of pressure movements were measured during parallel stance in the neutral and neck torsion positions, gain and smooth pursuit neck torsion difference of eye movements during smooth pursuit neck torsion test (SPNTT) and cervicocephalic kinaesthesia using Butterfly and head-to-neutral relocation test. RESULTS Statistically significant differences in postural balance, both tests of cervicocephalic kinaesthesia and SPNTT were observed between healthy controls and all patient groups. No differences were observed between patient groups for SPNTT, Butterfly and head-to-neutral relocation test, but differences were present in postural balance between mTBI and both groups of patients with neck pain disorders. Differences were found in the ML direction for mTBI, but not differences were found for AP direction. SIGNIFICANCE Results of our study show that mTBI present with similar impairment in cervical driven sensorimotor deficits as patients with neck pain disorders, but they differ from healthy individuals. Clinical practice would benefit from identifying cervical spine related sensorimotor impairments in patients with mTBI. This could enable to design more targeted prevention and rehabilitation programs to minimise cervical spine related disorders in concussion patients.
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Affiliation(s)
- Ziva Majcen Rosker
- Faculty of Sport, University of Ljubljana, Gortanova 22, SI-1000 Ljubljana, Slovenia.
| | | | - Miha Vodicar
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Slovenia
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Gill-Lussier J, Saliba I, Barthélemy D. Proprioceptive Cervicogenic Dizziness Care Trajectories in Patient Subpopulations: A Scoping Review. J Clin Med 2023; 12:jcm12051884. [PMID: 36902670 PMCID: PMC10003866 DOI: 10.3390/jcm12051884] [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: 01/24/2023] [Revised: 02/12/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023] Open
Abstract
Proprioceptive cervicogenic dizziness (PCGD) is the most prevalent subcategory of cervicogenic dizziness. There is considerable confusion regarding this clinical syndrome's differential diagnosis, evaluation, and treatment strategy. Our objectives were to conduct a systematic search to map out characteristics of the literature and of potential subpopulations of PCGD, and to classify accordingly the knowledge contained in the literature regarding interventions, outcomes and diagnosis. A Joanna Briggs Institute methodology-informed scoping review of the French, English, Spanish, Portuguese and Italian literature from January 2000 to June 2021 was undertaken on PsycInfo, Medline (Ovid), Embase (Ovid), All EBM Reviews (Ovid), CINAHL (Ebsco), Web of Science and Scopus databases. All pertinent randomized control trials, case studies, literature reviews, meta-analyses, and observational studies were retrieved. Evidence-charting methods were executed by two independent researchers at each stage of the scoping review. The search yielded 156 articles. Based on the potential etiology of the clinical syndrome, the analysis identified four main subpopulations of PCGD: chronic cervicalgia, traumatic, degenerative cervical disease, and occupational. The three most commonly occurring differential diagnosis categories are central causes, benign paroxysmal positional vertigo and otologic pathologies. The four most cited measures of change were the dizziness handicap inventory, visual analog scale for neck pain, cervical range of motion, and posturography. Across subpopulations, exercise therapy and manual therapy are the most commonly encountered interventions in the literature. PCGD patients have heterogeneous etiologies which can impact their care trajectory. Adapted care trajectories should be used for the different subpopulations by optimizing differential diagnosis, treatment, and evaluation of outcomes.
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Affiliation(s)
- Joseph Gill-Lussier
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC H3N 1X7, Canada
- Center for Interdisciplinary Research in Rehabilitation of Greater Montreal (IURDPM), CRIR, CIUSSS South-Center, Montreal, QC H3S 1M9, Canada
- Collège d’Études Ostéopathique de Montréal (CEOM), Montréal, QC H3G 1W7, Canada
| | - Issam Saliba
- Division of Otolaryngology, Head and Neck Surgery—Otology and Neurotology, Montreal University Hospital Center (CHUM), University of Montreal, Montreal, QC H2X 3E4, Canada
- Correspondence:
| | - Dorothy Barthélemy
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC H3N 1X7, Canada
- Center for Interdisciplinary Research in Rehabilitation of Greater Montreal (IURDPM), CRIR, CIUSSS South-Center, Montreal, QC H3S 1M9, Canada
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Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes. Clin J Sport Med 2022; 32:e556-e561. [PMID: 36315823 DOI: 10.1097/jsm.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the prevalence of acute neck pain in high school athletes following sports-related concussion (SRC) and to examine the role of acute neck pain in modifying or amplifying concurrent concussive symptoms. DESIGN Retrospective observational. SETTING High school sporting events. PARTICIPANTS High school athletes who suffered a sports-related concussion between the 2011 and 2019 academic years academic years from the National Athletic Treatment, Injury and Outcomes Network (NATION) Study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence of neck pain (yes/no) along with 33 other commonly reported concussion symptoms, number of symptoms reported, mechanism of injury (contact with person/surface or object), sport type (contact/noncontact), and injury history (first time/repeated injury). RESULTS One hundred thirty-eight of 401 athletes (33.9%) indicated acute neck pain following SRC. Those with neck pain reported significantly more symptoms overall (M = 13.53, SD = 6.89) relative to their non-neck pain counterparts (M = 8.46, SD = 5.68; t [191.35] = 7.11, P < 0.001). Athletes with SRC due to contact with a surface were significantly less likely to report neck pain than those reported contact with a person. Neck pain, repeated injury, and female sex were significantly associated with a greater number of concussion symptoms in the acute phase. CONCLUSIONS Our data suggest that acute neck pain is a frequent acute symptom following SRC and signals the necessity for additional screening to seek and identify comorbid cervical pathology. Prospective studies should seek to access the benefit of cervical therapy in the early stages in SRC patients with neck pain to reduce the risk of persistent postconcussion symptoms.
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Schlemmer E, Nicholson N. Vestibular Rehabilitation Effectiveness for Adults With Mild Traumatic Brain Injury/Concussion: A Mini-Systematic Review. Am J Audiol 2022; 31:228-242. [PMID: 35077655 DOI: 10.1044/2021_aja-21-00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Millions of people suffer from traumatic brain injuries every year with common sequelae, including dizziness, disequilibrium, compromised vision, and gait abnormalities. Individuals suffering a mild traumatic brain injury (mTBI) or concussion may be prescribed bed rest, but for some, symptoms may persist and require different treatment options. The aim of this mini-systematic review was to synthesize the best available evidence regarding the effectiveness of vestibular rehabilitation therapy (VRT) as a treatment option for adults with mTBIs. METHOD A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search term concepts were VRT and mTBI. Records meeting the inclusion criteria were extracted from the following databases: PubMed and CINAHL. A manual search of reference lists identified additional studies. Inclusion criteria were (a) participants with mTBI/concussion characterized by dizziness, balance, and/or other vestibular symptoms; (b) VRT as the primary treatment; and (c) self-reported and/or performance-based outcome measures. Data were extracted using a standardized tool, and studies were critically appraised. RESULTS Five studies were included in the systematic review: one randomized controlled trial, two retrospective chart reviews, one pre-/post-intervention study, and one case series. Four of the five studies found VRT to be effective at reducing postconcussion symptoms after head injury. Self-reported measures were included in all studies; performance-based measures were included in four out of five studies. None of the studies reported adverse effects of intervention. CONCLUSIONS Results suggest VRT is an effective treatment option for patients with persistent/lingering symptoms after concussion/mTBI, as demonstrated by self-reported and performance-based outcome measures. Results of this study emphasize the need for audiologists to be thoroughly familiar with VRT as an effective treatment for patients with persistent symptoms following mTBI.
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Affiliation(s)
- Erica Schlemmer
- Department of Audiology, Nova Southeastern University, Fort Lauderdale, FL
| | - Nannette Nicholson
- Department of Audiology, Nova Southeastern University, Fort Lauderdale, FL
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Crampton A, Garat A, Shepherd HA, Chevignard M, Schneider KJ, Katz-Leurer M, Gagnon IJ. Evaluating the Vestibulo-Ocular Reflex Following Traumatic Brain Injury: A Scoping Review. Brain Inj 2021; 35:1496-1509. [PMID: 34495773 DOI: 10.1080/02699052.2021.1972450] [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: 10/20/2022]
Abstract
Purpose:To identify the tests and tools used to evaluate vestibulo-ocular reflex (VOR) function after traumatic brain injury (TBI) in all age groups and across TBI severity.Methods: An electronic search was conducted to include relevant peer-reviewed literature published up to November 2019. Studies included those done with humans, of all ages, and had assessments of oculomotor and/or vestibulo-ocular function in TBI.Results: Of the articles selected (N = 48), 50% were published in 2018/2019. A majority targeted mild TBI, with equal focus on non-computerized versus computerized measures of VOR. Computerized assessment tools used were videonystagmography, dynamic visual acuity/gaze stability, rotary chair, and caloric irrigation. Non-computerized tests included the head thrust, dynamic visual acuity, gaze stability, head shaking nystagmus, rotary chair tests and the vestibular/oculomotor screening tool. High variability in administration protocols were identified. Namely: testing environment, distances/positioning/equipment used, active/passive state, procedures, rotation frequencies, and variables observed.Conclusions: There is a rapid growth of literature incorporating VOR tests in mild TBI but moderate and severe TBI continues to be under-represented. Determining how to pair a clinical test with a computerized tool and developing standardized protocols when administering tests will help in developing an optimal battery assessing the VOR in TBI.
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Affiliation(s)
- Adrienne Crampton
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - A Garat
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France.,Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation, Paris, France
| | - H A Shepherd
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada
| | - M Chevignard
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France.,Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation, Paris, France.,Rehabilitation Department for Children with Acquired Neurological Injury and Outreach Team for Children and Adolescents with Acquired Brain Injury, Saint Maurice Hospitals, Saint Maurice, France
| | - K J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - M Katz-Leurer
- Physical Therapy Department, University of Tel-Aviv, Tel-Aviv, Israel
| | - I J Gagnon
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada.,Montreal Children's Hospital-McGill University Health Centre, Montreal, Canada
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Cheever K, McDevitt J, Phillips J, Kawata K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports Med 2021; 51:1875-1891. [PMID: 33891292 DOI: 10.1007/s40279-021-01469-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with cervicogenic symptoms following a concussion have shown a disproportionate rate of delayed symptom resolution. However, the prevalence of cervicogenic symptoms in the acute stages following a concussion and the percentage of those patients who continue on to suffer delayed symptom resolution is poorly described in the literature. OBJECTIVES To provide a comprehensive report on the clinical prevalence, diagnostic methods, and potential treatment options for cervicogenic symptoms that are elicited during acute and chronic phases following a concussion. METHODS Electronic searches were conducted in PubMed, SPORTDiscus, ICL, CINAHL and PEDro, from inception to May 2020, to identify original research articles on concussion involving cervicogenic symptoms. We assessed each included article for risk of bias, methodological quality, level of evidence and evidence quality. The articles were categorized into three topics: (1) prevalence of post-concussion cervicogenic symptoms; (2) diagnostic testing for cervicogenic symptoms, and (3) treatment techniques for cervicogenic symptoms. RESULTS The initial review resulted in 1443 abstracts, of which 103 abstracts met the inclusion criteria of our research. After the review of full text, 80 articles were excluded, which resulted in a total of 23 articles for this systematic review. Prevalence of cervicogenic symptoms in the acute stages ranged from 7 to 69% and increased to 90% in patients experiencing persistent post-concussive symptoms. Neck pain at initial evaluation increased risk of developing persistent post-concussive symptoms (PPCS) by 2.58-6.38 times. Patient-reported outcome measures (e.g., Neck Disability Index, Dizziness Handicap Inventory, and Rivermead Post-Concussion Questionnaire) can identify patients with cervicogenic symptoms that should be further differentiated by clinical testing. Lastly, treatment using graded cervical manual therapy has shown to reduce time to symptom resolution and medical clearance. CONCLUSIONS Cervicogenic symptoms are prevalent in the acute and chronic stages following concussion, which if not diagnosed appropriately increase the likelihood of PPCS. Several clinical tests are available to help differentiate cervicogenic symptoms; however, lack of awareness and hesitation by practitioners limits their use. More randomized controlled trials are necessary to evaluate the effectiveness of cervical specific treatment programs for PPCS.
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Affiliation(s)
- Kelly Cheever
- Department of Kinesiology, College for Health, Community and Policy, University of Texas at San Antonio, One UTSA cir, San Antonio, TX, 78429, USA.
| | - Jane McDevitt
- Depart of Health and Rehabilitation Science, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Jacqueline Phillips
- Department of Kinesiology, College of Public, Health Temple University, Philadelphia, PA, USA
| | - Keisuke Kawata
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, USA
- Program in Neuroscience, College of Arts and Sciences, Indiana University, Bloomington, IN, USA
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11
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Certified Athletic Trainers' Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion. J Sport Rehabil 2021; 30:926-934. [PMID: 33771946 DOI: 10.1123/jsr.2020-0394] [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: 08/31/2020] [Revised: 12/22/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Despite evidence implicating cervicogenic symptoms in the development of persistent postconcussion symptoms, factors that influence utilization of cervical clinical tests to identify cervicogenic symptoms following concussion are poorly understood. OBJECTIVE Explore barriers to the utilization of cervical clinical testing in multifaceted concussion evaluation. DESIGN Cross-sectional. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS A total of 122 athletic trainers (AT) (age = 42.6 [6.4] y; female = 51.6%; 52% >10 y of clinical practice; 68% master's degree or greater; 35% treated a minimum of 15 concussions/y). MAIN OUTCOME MEASURE(S) Perceived importance, clinical experience, number of concussions treated, utilization of cervical clinical tests following nonspecific cervical pathology and following concussion, comfort with cervical treatment modalities following a concussion, and recommendation for cervical-specific therapy to treat persistent postconcussion symptoms. RESULTS Ordinal logistic regression revealed perceived importance had the strongest positive impact on AT's likelihood of high utilization of cervical clinical testing following concussion (95% CI, .17 to .99; P = .005), while clinical experience (95% CI, -.43 to .29; P = .71) and number of concussions treated/y (95% CI, -.21 to .31; P = .71) had no bearing. Moreover, low comfort with cervical treatments following a concussion (95% CI, -2.86 to -.26; P = .018) and low utilization of cervical clinical testing following nonspecific cervical pathology (95% CI, -7.01 to -3.39; P ≤ .001) had a strong positive impact on high utilization of cervical clinical testing following concussion. Two logistic regression models demonstrated how recommendations for cervical-specific therapy in persistent post-concussion symptom patients could be predicted based on (1) cervical test utilization and (2) perceptions and clinical experience with 79% and 78%, respectively. CONCLUSIONS Perceived importance played a major role in utilization of cervical clinical test following concussion. ATs who utilized common cervical treatments when dealing with non-concussive injuries were more likely to utilize those same treatments to treat comorbid cervical pathology following a concussion.
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Carrick FR, Pagnacco G, Hunfalvay M, Azzolino S, Oggero E. Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers. Brain Sci 2020; 10:brainsci10121003. [PMID: 33348759 PMCID: PMC7766169 DOI: 10.3390/brainsci10121003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/01/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB). However, the mCTSIB is a standard group of tests relying largely on eyes-open and -closed standing positions with the head in a neutral position, associated with probability of missing postural instabilities associated with head positions off the neutral plane. Postural stability scores are compromised with changes in head positions after concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores than the standardized head neutral position of the mCTSIB in Post-Concussion Syndrome (PCS) subjects but not in normal healthy controls. This phenomenon may serve as a diagnostic biomarker to differentiate PCS subjects from normal ones as well as serving as a measurement with which to quantify function or the success or failure of a treatment. Head positions off the neutral plane provide novel biomarkers that identify and differentiate subjects suffering from PCS from healthy normal subjects.
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Affiliation(s)
- Frederick Robert Carrick
- Department of Neurology, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
- Department of Health Professions Education, MGH Institute of Health Professions, Boston, MA 02129, USA
- Department of Research, Centre for Mental Health Research in Association with University of Cambridge, Cambridge CB3 9AJ, UK
- Department of Neurology, Carrick Institute, Cape Canaveral, FL 32920, USA; (G.P.); (M.H.); (S.A.); (E.O.)
- Correspondence:
| | - Guido Pagnacco
- Department of Neurology, Carrick Institute, Cape Canaveral, FL 32920, USA; (G.P.); (M.H.); (S.A.); (E.O.)
- Electrical and Computer Engineering Department, University of Wyoming, Laramie, WY 82071, USA
| | - Melissa Hunfalvay
- Department of Neurology, Carrick Institute, Cape Canaveral, FL 32920, USA; (G.P.); (M.H.); (S.A.); (E.O.)
| | - Sergio Azzolino
- Department of Neurology, Carrick Institute, Cape Canaveral, FL 32920, USA; (G.P.); (M.H.); (S.A.); (E.O.)
| | - Elena Oggero
- Department of Neurology, Carrick Institute, Cape Canaveral, FL 32920, USA; (G.P.); (M.H.); (S.A.); (E.O.)
- Electrical and Computer Engineering Department, University of Wyoming, Laramie, WY 82071, USA
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Clinical Changes in Cervical Neuromuscular Control Following Subconcussive Impacts. J Sport Rehabil 2020; 30:467-474. [PMID: 33075749 DOI: 10.1123/jsr.2020-0228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/09/2020] [Accepted: 08/09/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Increased injury rates following concussive injury have been attributed to decreased neuromuscular coordination frequently documented following a concussion. However, altered integration between the vestibular system and oculomotor pathways following impacts at subconcussive thresholds implicate all sports-related impacts not just those at a concussive threshold in future musculoskeletal injury. While, several studies have explored the utility of vestibular and oculomotor clinical testing to detect altered neuromuscular control and then correlated those alterations to future injury risk, no research has explored the use of cervical clinical tests in the same capacity. OUTCOME MEASURES Cervical joint position error test, Neck Disability Index and head acceleration. INTERVENTIONS Soccer headers, fatigue protocol, soccer headers + fatigue. OBJECTIVE To explore the clinical utility of a novel clinical approach to measuring changes in cervical neuromuscular control following subconcussive impacts in a controlled lab environment. PARTICIPANTS 40 current female colligate club soccer athletes were recruited. Inclusion criteria included between the age of 18 and 25 and a minimum of 4-year soccer heading experience. SETTING Laboratory. Design: A repeated-measures design with 4 groups was utilized to test the hypothesis. RESULTS A 65%, 54%, and 49% increased error was observed following the soccer heading, fatigue only, and soccer heading + fatigue interventions, respectively. Meanwhile, the controls saw a 6% decrease in neck position error. Concussion: While, cervical joint position error testing was sensitive to decreased neuromuscular coordination following soccer heading, it was not specific enough to rule out an exercise effect in the absence of subconcussive impacts. Further research is warranted to explore the clinical utility and specificity of cervical joint position error testing to measured alterations in supraspinal processing following subconcussive impacts, and how these alterations may lead to decreased coordination and movement of the body during sports-related task.
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Barton JJS, Ranalli PJ. Vision therapy: Occlusion, prisms, filters, and vestibular exercises for mild traumatic brain injury. Surv Ophthalmol 2020; 66:346-353. [PMID: 32827496 DOI: 10.1016/j.survophthal.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/04/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
A number of treatment approaches have been advocated for persistent visual complaints following mild traumatic brain injury. These include devices such as binasal occlusion, yoked prisms, vertical prisms, and filters, as well as vestibular training. We discuss the rationale and the evidence for each of these approaches. Binasal occlusion has been advocated for visual motion sensitivity, but it is not clear why this should help, and there is no good evidence for its symptomatic efficacy. Base-in prisms can help manage convergence insufficiency, but there are few data on their efficacy. Midline shift is an unproven concept, and while the yoked prisms advocated for its treatment may have some effect on egocentric neglect, their use in mild traumatic brain injury is more questionable. A wide variety of posttraumatic symptoms have been attributed to vertical heterophoria, but this is an unproven concept and there are no controlled data on the use of vertical prisms for mild traumatic brain injury symptoms. Filters could plausibly ameliorate light intolerance but studies are lacking. Better evidence is emerging for the effects of vestibular therapy, with a few randomized controlled trials that included blinded assessments and appropriate statistical analyses. Without more substantial evidence, the use of many of these techniques cannot be recommended and should be regarded as unproven and in some cases implausible.
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Affiliation(s)
- Jason J S Barton
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, Psychology, University of British Columbia, Vancouver, Canada.
| | - Paul J Ranalli
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, Otolaryngology, University of Toronto, Toronto, Canada
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Register-Mihalik JK, Callahan CE. Postconcussion Exertion Evolution: Clinical and Behavioral Considerations. Curr Sports Med Rep 2020; 19:151-156. [PMID: 32282461 DOI: 10.1249/jsr.0000000000000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The philosophy and practices concerning concussion management have evolved from passive to active strategies that incorporate immediate, guided rest followed by early integration of physical and cognitive activity as tolerated by symptoms. Recent research and clinical evidence support guidance that symptom tolerable and clinically guided activity is beneficial postconcussion both acutely and in the longer term. Furthermore, recent studies illustrate benefits of targeted deficit-based therapies (vestibular, cervicogenic, visual, psychological, etc.) postconcussion subacutely and in those with persistent symptoms. The dissemination of this new information occurs at a fast pace and is often difficult to rapidly integrate into clinical practice due to necessary policy and behavior changes. This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes.
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Hoppes CW, Romanello AJ, Gaudette KE, Herron WK, McCarthy AE, McHale CJ, Bares J, Turner R, Whitney SL. Physical therapy interventions for cervicogenic dizziness in a military-aged population: protocol for a systematic review. Syst Rev 2020; 9:62. [PMID: 32293544 PMCID: PMC7087372 DOI: 10.1186/s13643-020-01335-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 03/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic cervicogenic dizziness is dizziness that is temporally associated with neck pain and injury after other causes of dizziness have been excluded. It can lead to activity limitations and participation restrictions that may include lost duty or work days. The objective of this systematic review is to determine which interventions are most effective in decreasing dizziness or vertigo and neck pain in military-aged adults with traumatic cervicogenic dizziness. METHODS The literature will be systematically searched using the following online databases: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, CENTRAL, Cochrane Methodology Register), CINAHL, SCOPUS, Web of Science, and J-STAGE. The review will include randomized controlled trials (RCTs), including cluster RCTs and controlled (non-randomized) clinical trials or cluster trials, and observational studies (including prospective and retrospective comparative cohort and case-control or nested case-control studies) and determine the effectiveness of physical therapy interventions for the treatment of traumatic cervicogenic dizziness in military-aged adults. Assessment of methodological quality will be performed by two independent, blinded reviewers using the PEDro scale. The level of evidence will be determined using the GRADE scale. The primary outcome measures will be change in dizziness and neck pain and disability from baseline to the last available follow-up, measured using the Dizziness Handicap Inventory and Neck Disability Index. Other relevant outcome measures will include self-reported change in symptoms, time to return to duty or work, and quality of life. DISCUSSION This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for cervicogenic dizziness in a military-aged population. We anticipate our findings may inform individual treatment and future research. Clinical recommendations generated from this systematic review may inform military physical therapy treatment of individuals with cervicogenic dizziness. SYSTEMATIC REVIEW REGISTRATION In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 21 January 2020 (registration number CRD42020150853). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.
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Affiliation(s)
- Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA.
| | - Anthony J Romanello
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA
| | - Kathryn E Gaudette
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA
| | - William K Herron
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA
| | - Anne E McCarthy
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA
| | - Catherine J McHale
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, 78234, USA
| | - Joan Bares
- Stimson Library, U.S. Army Medical Center of Excellence, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - Rose Turner
- Falk Library, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
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