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Reina Ruíz ÁJ, Quintero Cabello A. Comparison of effectiveness between different interventions in postconcussive symptoms in adolescents and young people: a literature review. Neurologia 2024; 39:372-382. [PMID: 37120109 DOI: 10.1016/j.nrleng.2023.04.006] [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: 12/14/2019] [Accepted: 08/06/2021] [Indexed: 05/01/2023] Open
Abstract
INTRODUCTION Currently, concussion considers a problem of great magnitude, adolescents and young people being the population at risk, since it is in the process of maturation. Our goal has been to compare the effectiveness of different interventions (exercise therapy, vestibular rehabilitation and rest) in adolescents and young people with concussion. DEVELOPMENT A bibliographic search was carried out in the main databases. Once the inclusion/exclusion criteria and the PEDro methodological scale were applied, 6 articles were reviewed. The results support the use of exercise and vestibular rehabilitation in the initial stages to reduce post-concussion symptoms. According to most authors, therapeutic physical exercise and vestibular rehabilitation report greater benefits, although a protocol that unifies assessment scales, study variables and analysis parameters would be needed to be able to make the inference in the target population. CONCLUSIóN: From the moment of hospital discharge, the combined application of exercise and vestibular rehabilitation could be the best option to reduce post-concussion symptoms.
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Affiliation(s)
- Á J Reina Ruíz
- Área de Fisioterapia, Centro Universitario de Osuna, Sevilla, Spain
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Kontos AP, Eagle SR, Braithwaite R, Preszler J, Manderino L, Turner RL, Jennings S, Trbovich A, Hickey RW, Collins MW, McCrea M, Nelson LD, Root J, Thomas DG. The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients. Am J Sports Med 2023; 51:3893-3903. [PMID: 36847271 DOI: 10.1177/03635465221150214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION CRD42021253060 (PROSPERO).
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rock Braithwaite
- Department of Kinesiology and Recreation Administration, Cal Poly Humboldt, Arcata, California, USA
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Lisa Manderino
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Rose L Turner
- Health Science Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alicia Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Children's Hospital of Pittsburgh Division of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeremy Root
- Pediatric Emergency Medicine, George Washington School of Medicine, Washington, DC, USA; Children's National Health System, Fairfax, Virginia, USA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Pediatric Emergency Medicine, Children's Wisconsin, Wauwatosa, Wisconsin, USA)
- Investigation performed at University of Pittsburgh Medical Center Sports Concussion Program and University of Pittsburgh Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, USA
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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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Tang AR, Wallace J, Grusky AZ, Hou BQ, Hajdu KS, Bonfield CM, Zuckerman SL, Yengo-Kahn AM. Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes. World Neurosurg 2023; 173:e755-e765. [PMID: 36898629 DOI: 10.1016/j.wneu.2023.03.009] [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: 01/26/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. METHODS Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03-1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002-1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85-1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77-1.34, P = 0.925). CONCLUSIONS Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.
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Affiliation(s)
- Alan R Tang
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jessica Wallace
- Department of Health Science, Athletic Training Program, University of Alabama, Tuscaloosa, Alabama, USA
| | - Alan Z Grusky
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Brian Q Hou
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Christopher M Bonfield
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron M Yengo-Kahn
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Thomas DG, Erpenbach H, Hickey RW, Waltzman D, Haarbauer-Krupa J, Nelson LD, Patterson CG, McCrea MA, Collins MW, Kontos AP. Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial. Contemp Clin Trials 2022; 123:106965. [PMID: 36252936 PMCID: PMC10924688 DOI: 10.1016/j.cct.2022.106965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.
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Affiliation(s)
- D G Thomas
- Medical College of Wisconsin, Department of Pediatrics, United States of America.
| | - H Erpenbach
- Medical College of Wisconsin, Department of Pediatrics, United States of America
| | - R W Hickey
- University of Pittsburgh, Department of Pediatrics, United States of America
| | - D Waltzman
- Centers for Disease Control and Prevention, United States of America
| | - J Haarbauer-Krupa
- Centers for Disease Control and Prevention, United States of America
| | - L D Nelson
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - C G Patterson
- University of Pittsburgh, Department of Physical Therapy, United States of America
| | - M A McCrea
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - M W Collins
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
| | - A P Kontos
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
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Sports-Related Concussion Is a Personalized Issue—Evaluation of Medical Assessment and Subjective Feeling of the Athlete in a German Level 1 Trauma Center. J Pers Med 2022; 12:jpm12101596. [PMID: 36294735 PMCID: PMC9605563 DOI: 10.3390/jpm12101596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes.
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Quatman-Yates CC, Miley AE, Morrison P, Hugentobler J, Wade SL, Rhine TD, Kurowski BG. Adolescent and Parent Perceptions of the Impact of Concussion/mTBI on Family Functioning and Activity Levels in Recovery. J Head Trauma Rehabil 2022; 37:E280-E291. [PMID: 34570028 DOI: 10.1097/htr.0000000000000725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery. SETTING Outpatient research setting. PARTICIPANTS Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study. DESIGN Prospective ecological study with qualitative, semistructured interviews. MAIN MEASURES Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures. RESULTS Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies. CONCLUSIONS Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions.
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Affiliation(s)
- Catherine C Quatman-Yates
- School of Health and Rehabilitation Sciences, Sports Medicine Research Institute, and Chronic Brain Injury Program, The Ohio State University, Columbus (Dr Quatman-Yates); Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital, Cincinnati, Ohio (Drs Quatman-Yates and Hugentobler); Departments of Pediatrics (DrsWade, Rhine, and Kurowski) and Neurology and Rehabilitation Medicine (Dr Kurowski), University of Cincinnati College of Medicine, Cincinnati, Ohio; Divisions of Pediatric Rehabilitation Medicine (Ms Miley and Drs Morrison, Wade, and Kurowski) and Emergency Medicine (Dr Rhine), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and Department of Psychology, University of Cincinnati, Cincinnati, Ohio (Dr Wade)
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Podolak OE, Arbogast KB, Master CL, Sleet D, Grady MF. Pediatric Sports-Related Concussion: An Approach to Care. Am J Lifestyle Med 2022; 16:469-484. [PMID: 35860366 PMCID: PMC9290185 DOI: 10.1177/1559827620984995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/18/2020] [Accepted: 12/11/2020] [Indexed: 08/14/2023] Open
Abstract
Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.
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Affiliation(s)
- Olivia E. Podolak
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Sleet
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew F. Grady
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Comparación de la efectividad entre distintas intervenciones en los síntomas posconmoción en adolescentes y jóvenes: una revisión bibliográfica. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Wiebe DJ, Bretzin AC, D'Alonzo BA. Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League-Big Ten Epidemiology of Concussion Study. Br J Sports Med 2022; 56:801-811. [PMID: 35444018 PMCID: PMC9252856 DOI: 10.1136/bjsports-2021-104451] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/24/2022]
Abstract
Objective To examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC). Methods In a multisite prospective cohort study, we identified the frequency of initial 24–48 hours physical and cognitive rest, and the sequence of (1) symptom resolution and return to (2) exertion activity, (3) limited sport, (4) full sport and (5) full academics. In resulting profiles we estimated the likelihood of return to full sport ≤14 days or prolonged >28 days and tested for variability based on timing of the stages. Results Among 1715 athletes with SRC (31.6% females), 67.9% had 24–48 hours initial physical and cognitive rest. The median was 6 days to return to full academics, 8 days to symptom resolution and 9 days to exertion. Three profiles emerged; all had the same sport-specific return progression, but varied in the relative timing of full academics. In unadjusted analyses, full academics as the first stage corresponded to the longest time to return to full sport, and initiating exertion the same day as symptom resolution resulted in the shortest time. In adjusted regression analyses, athletes initiating full academics while still symptomatic were 21.5% less likely (95% CI −27.4% to −15.5%) to return to full sport ≤14 days and, analogously, 19.1% more likely (95% CI 13.4% to 24.7%) to have prolonged return >28 days. While additionally controlling for initial rest, sex, symptom count and concussion history, the likelihood of prolonged return >28 days was 37.0% (95% CI 25.2% to 48.8%) in athletes initiating exertion considerably before symptoms resolved (ie, 7+ days), but only 3.6% (95% CI −1.4% to 8.6%) in athletes initiating exertion shortly before achieving symptom resolution (ie, 3–4 days). Conclusion We found evidence that sequential progressions were consistent with current recommendations including brief initial rest, and the initiation and relative timing of each stage impacted the final return-to-sport outcome.
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Affiliation(s)
- Douglas J Wiebe
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail C Bretzin
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Bernadette A D'Alonzo
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
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Buckley TA, Munkasy BA, Evans KM, Clouse B. Acute Physical and Mental Activity Influence on Concussion Recovery. Med Sci Sports Exerc 2022; 54:307-312. [PMID: 34559729 PMCID: PMC8760145 DOI: 10.1249/mss.0000000000002787] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Physical activity (PA) and mental activity (MA) postconcussion has received renewed attention to improve concussion management; however, most protocols start after several days and do not assess the acute window. Therefore, the purpose of this study was to assess PA and MA in the first 48 h postconcussion on the time to symptom-free status and return to play. METHODS We recruited 78 NCAA Division I athletes (male, 51.3%; age, 19.6 ± 1.4 yr; height, 173.7 ± 11.5 cm; weight, 80.1 ± 23.2 kg) who were diagnosed with a sports-related concussion. Participants completed a 0-5 PA and MA scale daily until fully cleared for return to participation (mean, 15.1 ± 6.9 d). A quadratic model regression assessed PA and MA over the first 2 d (acute) postconcussion on to time to symptom-free status and return to play. RESULTS The overall model was significant for both time to symptom free (r2 = 0.27, P = 0.004) and return to play (r2 = 0.23, P = 0.019). Reported PA was the only significant predictor for time to symptom-free (P = 0.002) and return-to-participation (P = 0.006) day. Reported MA was not associated either outcome. CONCLUSIONS The primary finding of this study was that mild to moderate PA acutely postconcussion was associated with reduced time to symptom free and return to participation as opposed to either lower or higher levels of PA. Conversely, acute MA was not associated with recovery outcomes. These results further elucidate the role of postconcussion PA.
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Affiliation(s)
- Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, Interdisciplinary program in Biomechanics and Movement Science University of Delaware, Newark, DE
| | - Barry A. Munkasy
- School of Health and Kinesiology, Georgia Southern University, Statesboro, GA
| | | | - Brandy Clouse
- Department of Intercollegiate Athletics, Georgia Southern University, Statesboro, GA
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12
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Bauer RM, Jaffee MS. Behavioral and Cognitive Aspects of Concussion. Continuum (Minneap Minn) 2021; 27:1646-1669. [PMID: 34881730 DOI: 10.1212/con.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This review provides the reader with an overview of concussion and mild traumatic brain injury (TBI). Key aspects of the pathophysiology, signs, and symptoms, treatment and rehabilitation, and recovery from concussion/mild TBI are reviewed with an emphasis on the variety of factors that may contribute to cognitive concerns following injury. RECENT FINDINGS Concussion remains a clinical diagnosis based on symptoms that occur in the immediate aftermath of an applied force and in the hours, days, and weeks thereafter. Although advances have been made in advanced diagnostics, including neuroimaging and fluid biomarkers in hopes of developing objective indicators of injury, such markers currently lack sufficient specificity to be used in clinical diagnostics. The symptoms of concussion are heterogeneous and may be seen to form subtypes, each of which suggests a targeted rehabilitation by the interdisciplinary team. Although the majority of patients with concussion recover within the first 30 to 90 days after injury, some have persistent disabling symptoms. The concept of postconcussion syndrome, implying a chronic syndrome of injury-specific symptoms, is replaced by a broader concept of persistent symptoms after concussion. This concept emphasizes the fact that most persistent symptoms have their basis in complex somatic, cognitive, psychiatric, and psychosocial factors related to risk and resilience. This framework leads to the important conclusion that concussion is a treatable injury from which nearly all patients can be expected to recover. SUMMARY Concussion/mild TBI is a significant public health problem in civilian, military, and organized athletic settings. Recent advances have led to a better understanding of underlying pathophysiology and symptom presentation and efficacious treatment and rehabilitation of the resulting symptoms. An interdisciplinary team is well-positioned to provide problem-oriented, integrated care to facilitate recovery and to advance the evidence base supporting effective practice in diagnosis, treatment, and prevention.
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Taubman B, Michael Luciani A, Gealt DB, Drake TP, Cochetti P, Farrar JT. The care of the concussed pediatric patient prior to presentation to primary care pediatrician versus concussion specialists: Implications for management. JOURNAL OF CONCUSSION 2021. [DOI: 10.1177/2059700221998921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Absent adequate randomized control trials to inform appropriate treatment for concussion in pediatric patients, guidelines have been developed based on expert opinion and observational data that may not apply to all groups. This study examines differences in the previous clinical care between concussed patients who present in pediatric practice and specialty clinics. Differences found might influence treatment recommendations for each setting. Study design Prospective data collected from a pediatric practice in 2011 to 2013 were compared to chart review data from two specialty clinics between 2015 and 2017. In all three groups patients 11–19 years of age with an ICD9 billing code for concussion were included if they met the 4th International Consensus definition of concussion. Patients were excluded if hospitalized or had abnormal CNS imaging. Results The time between injury and presentation was substantially longer in specialty clinic patients versus those seen in the primary pediatric care office. (median 10 vs. 2 days-p < 0.001) Primary care patients presenting had higher rates of immediate rest after injury, 61.4% vs 27.9% (p < 0.001). More specialty clinic patients had been seen in the emergency departments prior to presentation (47.5% vs. 18.8% p < 0.001) regardless of rest status at presentation to the office. Conclusion Several differences in previous clinical care between the groups were found. These included the time of presentation from injury, rates of cognitive rest both immediate and non-immediate, and emergency department visits. These differences may have implications for management recommendations. Accordingly, the appropriate treatment for patients seen by the primary pediatric care physicians may be different from those referred to specialty care. Given these findings randomized controlled trails should be conducted independently in both groups of patients.
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Affiliation(s)
- Bruce Taubman
- Advocare Cherry Hill Pediatric Group, Cherry Hill, New Jersey, USA
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics, Philadelphia, Pennsylvania
| | | | - David B Gealt
- Cooper Bone and Joint Institute, Division of Sports Medicine, Cooper University Hospital, Camden, USA
| | - Thomas P Drake
- Department of Pediatric Neurology, Division of Pediatric Rehabilitation, Cooper University Hospital, Camden, USA
| | - Philip Cochetti
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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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.
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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
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15
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Kim K, Priefer R. Evaluation of current post-concussion protocols. Biomed Pharmacother 2020; 129:110406. [PMID: 32768934 DOI: 10.1016/j.biopha.2020.110406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 10/23/2022] Open
Abstract
The growing number of concussions and mild traumatic brain injuries (mTBI) with the lack of evidence-based treatment options is a continuous health concern. This creates problems when evaluating and providing efficacious symptom management to patients suffering from post-concussion syndrome (PCS). Numerous pharmacological and non-pharmacological agents have been utilized in an attempt to treat PCS. Some of these approaches include physical therapy, analgesics, antidepressants, and nutraceuticals. Although these treatments have had some success, there has been inconsistent outcomes, with some examples of patients' symptoms worsening. Among pharmaceutical agents, fluoxetine has been a popular choice for the symptom management of PCS. Although some patients have had symptom resolution with the use of fluoxetine, there is still a lack of conclusive data. Of the several biochemical changes that occur in a patient's brain following a concussion, an increase in reactive oxygen species (ROS) is of particular concern. In order to counteract the responses of the brain, antioxidants, such as ascorbic acid, have been utilized to reverse the damaging cellular effects. However, this may inadvertently cause an increase in ROS, rather than a reduction. Although there is a lack of consistency in exactly when each treatment was used in the post-injury interval, it is important that we analyze the strengths and weaknesses of the most commonly used agents due to the lack of a set protocol. The studies were chosen in a non-exhaustive manner and were not consistent in patients' post-injury intervals, in addition to other baseline characteristics. However, over-arching claims that some treatments may benefit more than others can be made. This review evaluates both the pharmaceutical and non-pharmaceutical protocols that are most commonly utilized in post-concussive patients for their efficacy in treatment of post-concussive syndrome (PCS).
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Affiliation(s)
- Kristin Kim
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States.
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Abstract
Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.
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Mucha A, DeWitt J, Greenspan AI. The CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children: What Physical Therapists Need to Know. Phys Ther 2019; 99:1278-1280. [PMID: 31197370 DOI: 10.1093/ptj/pzz085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/24/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Anne Mucha
- Centers for Rehab Services, University of Pittsburgh Medical Center, 3200 South Water St, Pittsburgh, PA 15203 (USA)
| | - John DeWitt
- Physical Therapy Department, The Ohio State University, Columbus, Ohio
| | - Arlene I Greenspan
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hodges A, Ameringer S. The symptom experience of adolescents with concussion. J SPEC PEDIATR NURS 2019; 24:e12271. [PMID: 31497928 DOI: 10.1111/jspn.12271] [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: 08/01/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The incidence of concussions in adolescents has increased in recent years. Concussion causes an array of symptoms that can interfere with the daily life of an adolescent, yet the symptoms and recovery vary greatly. Concussion management is based on expert consensus guidelines but they are not specific for adolescents and it is unclear how adolescents actually manage their symptoms. This study aimed to describe the symptom experience of adolescents with a concussion and their self-management strategies. DESIGN AND METHODS The study used a qualitative design to explore the symptom experiences of adolescents. Ten adolescents aged 14-17 years were recruited from a concussion clinic. Using a semi-structured interview, adolescents were asked about their concussion symptoms, the interference with their daily life, and their symptom self-management strategies. Data were analyzed using descriptive statistics and content analysis. RESULTS Adolescents reported 17 different symptoms they experienced following their concussion. All of the adolescents reported a headache but descriptions varied. The symptoms interfered with many aspects of their daily life including school and activities. The majority of the school responses were related to difficulties attending school and learning (n = 21). The self-management strategies were organized into 11 categories. The most common strategies fell under three categories: rest (n = 20), controlling the environment (n = 20), and using motivational thoughts and activities (n = 9). PRACTICE IMPLICATIONS This study indicates that adolescents experience multiple symptoms after their concussion and use a variety of strategies to manage the symptoms. Each adolescent had a unique symptom experience, highlighting the need for developing personalized concussion management plans. Nurses can coordinate the development of management plans and provide education about managing concussion symptoms and promoting recovery.
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Affiliation(s)
- Amanda Hodges
- Virginia Commonwealth University, Richmond, Virginia
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Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med 2019; 75:471-482. [PMID: 31326205 DOI: 10.1016/j.annemergmed.2019.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
Abstract
Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.
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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]
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22
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Vestibular rehabilitation: advances in peripheral and central vestibular disorders. Curr Opin Neurol 2019; 32:137-144. [DOI: 10.1097/wco.0000000000000632] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ellis MJ, Leddy J, Cordingley D, Willer B. A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes. Front Neurol 2018; 9:1115. [PMID: 30619068 PMCID: PMC6306465 DOI: 10.3389/fneur.2018.01115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/05/2018] [Indexed: 12/29/2022] Open
Abstract
Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.
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Affiliation(s)
- Michael J. Ellis
- Section of Neurosurgery, Department of Surgery, Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Concussion Program, Winnipeg, MB, Canada
| | - John Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Buffalo, NY, United States
| | - Dean Cordingley
- Pan Am Concussion Program, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
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Halstead ME, Walter KD, Moffatt K, LaBella CR, Brooks MA, Canty G, Diamond AB, Hennrikus W, Logan K, Nemeth BA, Pengel KB, Peterson AR, Stricker PR. Sport-Related Concussion in Children and Adolescents. Pediatrics 2018; 142:peds.2018-3074. [PMID: 30420472 DOI: 10.1542/peds.2018-3074] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.
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Affiliation(s)
| | - Kevin D. Walter
- Department of Orthopaedic Surgery, Pediatric Sports Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Kody Moffatt
- Creighton University School of Medicine, Omaha, Nebraska
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Abstract
Sport-related concussion (SRC) is a physiological brain injury that produces cerebral and systemic effects, including exercise intolerance. Exercise intolerance after concussion is believed to be the result of autonomic nervous system (ANS) dysfunction. Ventilation is inappropriately low for the level of exercise intensity, raising arterial carbon dioxide (PaCO2) levels. Elevated PaCO2 increases cerebral blood flow (CBF) out of proportion to exercise intensity, which is associated with symptoms that limit exercise performance. Thus, elevated exercise PaCO2 may signal incomplete recovery from SRC. This article reviews recent observational and experimental data and presents the evidence that subthreshold aerobic exercise normalizes the cerebrovascular physiological dysfunction and is "medicine" for patients with concussion and persistent postconcussive symptoms (PPCS). It discusses the systematic evaluation of exercise tolerance after concussion using the Buffalo Concussion Treadmill Test (BCTT) and reviews the utility of the Buffalo Concussion Bike Test (BCBT), the data from which are used to establish an individualized heart rate "dose" of subthreshold exercise to safely speed recovery, which also may work in the acute recovery phase after SRC with the potential to reduce the incidence of PPCS. Evaluation and treatment approaches based on the physiology of concussion suggest that exercise is medicine for concussion, potentially adding a new dimension to concussion care to help safely speed recovery and prevent PPCS in some patients.
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Affiliation(s)
- John J Leddy
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Mohammad N Haider
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Michael Ellis
- Pan Am Concussion Program, Section of Neurosurgery, Department of Surgery and Pediatrics, University of Manitoba, Winnipeg, Manitoba, CANADA
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY
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Dobney DM, Miller MB, Tufts E. Non-pharmacological rehabilitation interventions for concussion in children: a scoping review. Disabil Rehabil 2017; 41:727-739. [PMID: 29157025 DOI: 10.1080/09638288.2017.1400595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children. METHODS An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down's and Black criteria was conducted. RESULTS Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good. CONCLUSIONS The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy. Implications for rehabilitation Few studies have examined rehabilitation interventions for youth following concussion. Research ranging from rest to exercise highlights the uncertainty of the field. Low quality research limits the generalizability of results. The use of physical activity appears to be an emerging area of interest. Individualised, aerobic exercise should be used as part of clinical management.
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Affiliation(s)
- Danielle M Dobney
- a School of Physical and Occupational Therapy, Faculty of Medicine , McGill University , Montreal , Canada
| | - Matthew B Miller
- b Department of Exercise Science, Faculty of Arts and Science , Concordia University , Montreal , Canada
| | - Emily Tufts
- c Centennial College Libraries , Toronto , Canada
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