Concussion - Part I: The need for a multifaceted assessment

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quantifying neurovascular coupling through a concurrent assessment of arterial, capillary, and neuronal activation in humans: A multimodal EEG-fNIRS-TCD investigation

BACKGROUND

This study explored a novel multimodal neuroimaging approach to assess neurovascular coupling (NVC) in humans using electroencephalography (EEG), functional near-infrared spectroscopy (fNIRS), and transcranial Doppler ultrasound (TCD).

METHODS

Fifteen participants (nine females; age 19-32) completed concurrent EEG-fNIRS-TCD imaging during motor (finger tapping) and visual ("Where's Waldo?") tasks, with synchronized monitoring of blood pressure, capnography, and heart rate. fNIRS assessed microvascular oxygenation within the frontal, motor, parietal, and occipital cortices, while the middle and posterior cerebral arteries (MCA/PCA) were insonated using TCD. A 16-channel EEG set-up was placed according to the 10-20 system. Wilcoxon signed-rank tests were used to compare physiological responses between the active and resting phases of the tasks, while cross-correlations with zero legs compared cerebral and systemic hemodynamic responses across both tasks.

RESULTS

Time-frequency analysis demonstrated a reduction in alpha and low beta band power in electrodes C3/C4 during finger tapping (p<0.045) and all electrodes during the Waldo task (all p<0.001). During Waldo, cross-correlation analysis demonstrated the change in oxygenated hemoglobin and cerebral blood velocity had a moderate-to-strong negative correlation with systemic physiological influences, highlighting the measured change resulted from neuronal input. Deoxygenated hemoglobin displayed the greatest negative cross-correlation with the MCA/PCA within the motor cortices and visual during the motor and visual tasks, respectively (range:0.54, -0.82).

CONCLUSIONS

This investigation demonstrated the feasibility of the proposed EEG-fNIRS-TCD response to comprehensively assess the NVC response within human, specifically quantifying the real-time temporal synchrony between neuronal activation (EEG), microvascular oxygenation changes (fNIRS), and conduit artery velocity alterations (TCD).

The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms

Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥ 84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η 2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η 2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.

Evolution of dizziness-related disability in children following concussion: a group-based trajectory analysis

OBJECTIVE

This study aimed to identify Dizziness-Related Disability (DRD) recovery trajectories in pediatric concussion and assess clinical predictors of disability groups.

MATERIALS AND METHODS

In this prospective cohort study, 81 children (8-17 years) diagnosed with an acute concussion took part in 3 evaluation sessions (baseline, 3-month, and 6-month). All sessions included the primary disability outcome, the Dizziness Handicap Inventory (DHI) to create the DRD recovery trajectories using group-based multi-trajectory modeling analysis. Each independent variable included general patients' characteristics, premorbid conditions, function and symptoms questionnaires, and clinical physical measures; and were compared between the trajectories with logistic regression models.

RESULTS

Low DRD (LD) trajectory (n = 64, 79%), and a High DRD (HD) trajectory (n = 17, 21%) were identified. The Predicting and Preventing Postconcussive Problems in Pediatrics (5P) total score (Odds Ratio (OR):1.50, 95% Confidence Interval (CI): 1.01-2.22), self-reported neck pain (OR:7.25, 95%CI: 1.24-42.36), and premorbid anxiety (OR:7.25, 95%CI: 1.24-42.36) were the strongest predictors of belonging to HD group.

CONCLUSIONS

Neck pain, premorbid anxiety, and the 5P score should be considered initially in clinical practice as to predict DRD at 3 and 6-month. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussion.

Comparison of the Buffalo Concussion Treadmill Test With a Physiologically Informed Cycle Test: Calgary Concussion Cycle Test

BACKGROUND

Sport-related concussions are a complex injury requiring multifaceted assessment, including physical exertion. Currently, concussion testing relies primarily on a treadmill-based protocol for assessing exertion-related symptoms in persons after concussion. This study compared a modified cycle protocol (Calgary Concussion Cycle Test [CCCT]) with the clinically adopted standard, the Buffalo Concussion Treadmill Test (BCTT), across multiple physiological parameters.

HYPOTHESIS

Treadmill and cycle matched workload protocols would produce similar results for cerebral blood velocity, mean arterial pressure (MAP), and end-tidal carbon dioxide partial pressure (PETCO2), but heart rate (HR) and oxygen consumption (VO2) would be higher on the treadmill than the cycle modality.

STUDY DESIGN

Crossover study design.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 17 healthy adults (8 men, 9 women; age, 26 ± 3 years; body mass index, 23.8 ± 2.7 kg/m2) completed the BCTT and CCCT protocols, 7 days apart in a randomized order. During both exertional protocols, the physiological parameters measured were middle cerebral artery mean blood velocity (MCAv), MAP, PETCO2, VO2, and HR. Analysis of variance with effect size computations, coefficient of variation, and Bland-Altman plots with 95% limits of agreement were used to compare exercise tests.

RESULTS

The BCTT and CCCT produced comparable results for both male and female participants with no significant differences for average MCAv, MAP, and PETCO2 (all P > 0.05; all generalized eta squared [η2G] < 0.02 [negligible]; P value range, 0.29-0.99) between stages. When accounting for exercise stage and modality, VO2 (P < 0.01) and HR (P < 0.01) were higher on the treadmill compared with the cycle. Aside from the final few stages, all physiology measures displayed good-to-excellent agreeability/variability.

CONCLUSION

The CCCT was physiologically similar to the BCTT in terms of MCAv, PETCO2, and MAP; however, HR and VO2 differed between modalities.

CLINICAL RELEVANCE

Providing a cycle-based modality to exertional testing after injury mayincrease accessibility to determine symptom thresholds in the future.

An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion

OBJECTIVE

Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment.

DESIGN

Secondary analysis of a published cohort study and clinician consensus.

SETTING

Three university-affiliated sports medicine centers.

PARTICIPANTS

Two hundred seventy children (14.9 ± 1.9 years).

INDEPENDENT VARIABLES

Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm.

MAIN OUTCOME MEASURES

Correlations between independent variables were calculated, and network graphs were made. k -means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes.

RESULTS

Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait).

CONCLUSIONS

Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

The balancing act - Physiotherapists' experiences of managing rugby-related concussion in the community

BACKGROUND

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP) to improve management at the community level. Physiotherapists play an important role in the CMP.

OBJECTIVE

This study explored physiotherapists' experiences in the management of community rugby-related concussion as part of the CMP.

METHODS

We adopted a pragmatic, descriptive qualitative approach to explore perceptions of twenty-four physiotherapists involved in the CMP. Thematic analysis was used to analyze data.

RESULTS

Four themes represented participants' experiences: 1) 'walking the tight rope between player welfare and performance' described the balancing act between different attitudes and priorities of the various rugby stakeholders; 2) empowering physiotherapists' authority and responsibilities, described the influence of physiotherapists' authority within the team and concussion management responsibilities; 3) multi-directional communication, described the role of communication between multiple stakeholders; and 4) the influence of context, which included the complexity of concussion, concussion knowledge of the physiotherapists and team, resource support for the physiotherapist, and access to a medical doctor.

CONCLUSION

Physiotherapists had positive attitudes toward the CMP and are well-positioned to play an active role in the pathway. Priorities of other stakeholders, authority of the physiotherapist and the communication flow influences physiotherapists' ability to optimally manage players with concussion.

Does early exercise intolerance effect time to return to play, symptom burden, neurocognition, Vestibular-Ocular-Motor (VOM) function and academic ability in acutely concussed student-athletes?

INTRODUCTION

Early Exercise Intolerance (EEI) is associated with delayed recovery and longer time to Return To Play (RTP), but this has not been established.Participants; (n = 52, male n = 30) UK university-aged rugby-union student-athletes.

METHODS

Student-athletes completed baseline screening (July-October 2021 and 2022). The test battery was repeated within 48 h, 4, 8 and 14 days after a Sports-Related Concussion (SRC) with the Buffalo Concussion Bike or Treadmill Test to set sub-symptom heart rate threshold. Student-athletes then completed a controlled early exercise protocol in-between reassessment (days 3, 5-7 and 9-13). Those with EEI were compared to those with early-exercise tolerance.

OUTCOME MEASURES

Post-Concussion Symptom Scale, Immediate Post-Concussion and Cognitive Test, Vestibular-Ocular Motor Screening Tool and the Revised Perceived Academic Impact Tool.

RESULTS

EEI was seen throughout the initial 14-days post-SRC (23.8%, 22.4%, 25.5%. 25.0%). EEI was associated with a slower reaction time within 48 h (-0.01 (-0.030-0.043) Vs 0.06 (0.033-0.24), p = 0.004) and greater VOMS scores within 48 h; (0.00 (0.00-4.00) Vs 5.50 (2.75-9.00), p = 0.016) and 4 days (0.00 (0.00-2.00) Vs 5.00 (0.00-6.00), p = 0.044). RTP was 12.5 days longer in those with EEI at 14-days post-SRC.

CONCLUSION

EEI is prevalent following an SRC in university-aged student-athletes and was associated with delayed recovery and RTP.

Advances in Neurorehabilitation: Strategies and Outcomes for Traumatic Brain Injury Recovery

Traumatic brain injury (TBI) consists of an external physical force that causes brain function impairment or pathology and globally affects 50 million people each year, with a cost of 400 billion US dollars. Clinical presentation of TBI can occur in many forms, and patients usually require prolonged hospital care and lifelong rehabilitation, which leads to an impact on the quality of life. For this narrative review, no particular method was used to extract data. With the aid of health descriptors and Medical Subject Heading (MeSH) terms, a search was thoroughly conducted in databases such as PubMed and Google Scholar. After the application of exclusion and inclusion criteria, a total of 146 articles were effectively used for this review. Results indicate that rehabilitation after TBI happens through neuroplasticity, which combines neural regeneration and functional reorganization. The role of technology, including artificial intelligence, virtual reality, robotics, computer interface, and neuromodulation, is to impact rehabilitation and life quality improvement significantly. Pharmacological intervention, however, did not result in any benefit when compared to standard care and still needs further research. It is possible to conclude that, given the high and diverse degree of disability associated with TBI, rehabilitation interventions should be precocious and tailored according to the individual's needs in order to achieve the best possible results. An interdisciplinary patient-centered care health team and well-oriented family members should be involved in every stage. Lastly, strategies must be adequate, well-planned, and communicated to patients and caregivers to attain higher functional outcomes.

A Profile of Isometric Cervical Strength in Elite Professional Male Rugby Players

OBJECTIVES: To (1) provide position-specific normative data for isometric cervical muscle strength and endurance in professional, male rugby players and (2) assess the relationship between age, height, weight, and playing position with cervical muscle strength and endurance. DESIGN: Cross-sectional study. METHODS: Professional rugby players completed peak isometric cervical strength testing followed by a test of cervical muscle endurance. Descriptive statistics for continuous variables with strength normalized to body weight were performed. Multiple linear regression was used to estimate associations between strength measurements. RESULTS: In total, 136 players participated including front-row forwards (27%), other forwards (28%), and backs (45%). Front-row forwards had significantly greater peak isometric cervical muscle strength than other position groups, with backs having the lowest strength. Extension produced the highest force for all 3 position groups (429 N ± 104 N), whereas flexion produced the least (275 N ± 65 N). Age was associated with increased isometric cervical muscle strength. There was a statistically significant relationship between peak flexion strength and flexion endurance (P = .003). The average time for the endurance tests were 55.7 (±17.1) seconds and 52.9 (±20.1) seconds for extension and flexion, respectively. Other forwards had lower cervical extension muscle endurance than backs and front-row forwards. CONCLUSIONS: Normative values for peak and endurance isometric strength in professional rugby players illustrate significant differences between playing position. Consider age, body weight, and intraindividual variability when interpreting cervical strength and endurance results. J Orthop Sports Phys Ther 2024;54(3):1-8. Epub 29 January 2024. doi:10.2519/jospt.2024.11830.

Concussion Knowledge and Self-Reported Behaviors in Youth Rugby Players and Their Coaches: A Population-Wide Cross-Sectional Survey

OBJECTIVE

To investigate concussion knowledge and self-reported behaviors in Italian youth rugby players and their coaches. To investigate predictors of lower concussion knowledge and association between athletes' self-reported knowledge and behavior.

DESIGN

Cross-sectional, population-wide, survey study.

SETTING

All rugby clubs (n = 52) of the Veneto region (Italy).

PARTICIPANTS

Players and coaches of all under 15, 17 and 19 teams. Overall, 1719 athlete surveys (92.2% male; response rate, 71.1%) and 235 coach surveys (93.6% male; response rate, 93.2%) were eligible for analysis.

INTERVENTION

Surveys circulated from September 20 to December 13, 2021.

MAIN OUTCOME MEASURES

Knowledge scores were reported as a percentage of correct answers. Descriptive statistics were reported for all answers. The primary outcomes were concussion knowledge and self-reported behaviors. The secondary outcomes were the association between knowledge and participant individual factors and self-reported behaviors.

RESULTS

Median knowledge score for athletes was 55% (IQR: 44-67) and for coaches was 60% (IQR: 52.5-69). Only 33.3% of athletes and 40% of coaches were aware of an increased risk of a second concussion after sustaining one. Athletes who had never heard of the word concussion (effect: -9.31; SE: 1.35, 95% CI: -12.0 to -6.7; P < 0.0001) and coaches with longer coaching experience (effect: -4.35; SE: 2.0, 95% CI: -8.29 to -0.41; P < 0.03) reported lower knowledge scores. There was no statistical association between knowledge scores and athlete self-reported behavior.

CONCLUSION

Athletes and coaches had a similar level of concussion knowledge. Knowledge score of athletes did not predict self-reported behaviors. Although enhanced concussion education should be undertaken, interventions to ensure appropriate concussion reporting behaviors are also required.

Examining the interdisciplinary approach for treatment of persistent post-concussion symptoms in adults: a systematic review

BACKGROUND

The objective of this review is to examine the evidence for the interdisciplinary approach in treatment of persistent post-concussion symptoms in adults.

METHODS

This systematic literature search was undertaken according to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) guidelines. Five electronic databases were searched: CINAHL, Informit, ProQuest, PubMed and Scopus. After screening and quality assessment, the review included six studies published in English and peer-reviewed journals, between 2011 and 2021 to return contemporary evidence.

RESULTS

The results revealed that there was significant variation between measures used and the timing of the pre- and post-treatment assessment. The studies found an interdisciplinary approach to be beneficial, however, the challenges of inherent heterogeneity, lack of clarity for definitions and diagnosis, and mixed results were apparent. The interdisciplinary interventions applied in all identified studies were found to reduce post-concussion symptoms across the symptom subtypes: headache/migraine, vestibular, cognitive, ocular motor and anxiety/mood.

CONCLUSIONS

The results demonstrated evidence for a reduction in persistent post-concussion symptoms following interdisciplinary intervention. This evidence will inform health services, clinicians, sports administrators and researchers with regard to concussion clinic and rehabilitation team design and service delivery.

Cerebral blood velocity during concurrent supine cycling, lower body negative pressure, and head-up tilt challenges: implications for concussion rehabilitation

Introduction. The effect of concurrent head-up tilt and lower body negative pressure (LBNP) have been examined on middle cerebral artery velocity (MCAv) at rest; however, it is unknown the superimposed effect these factors have on blunting the elevation in cerebral blood velocity associated with moderate-intensity exercise.Methods. 23 healthy adults (11 females / 12 males, 20-33 years) completed three visits. The first consisted of a maximal ramp supine cycling test to identify the wattage associated with individualized maximal MCAv. Subsequent visits included randomized no LBNP (control) or LBNP at -40 Torr (experimental) with successively increasing head-up tilt stages of 0, 15, 30, and 45 degrees during the pre-described individualized wattage. Transcranial Doppler ultrasound was utilized to quantify MCAv. Two-factorial repeated measures analysis of variance with effect sizes were used to determine differences between days and tilt stages.Results. Between-day baseline values for MCAv, heart rate, and blood pressure displayed low variability with <5% variation. With no LBNP, MCAv was above baseline on average for all participants; however, 15 degrees and 30 degrees tilt with concurrent -40 Torr LBNP was sufficient to return MCAv to 100% of baseline values in females and males, respectively. Body-weight did not impact the association between tilt and pressure (R2range: 0.01-0.12).Conclusion. Combined LBNP and tilt were sufficient to reduce the increase in MCAv associated with moderate-intensity exercise. This exercise modality shows utility to enable individuals with a concussion to obtain the positive physiological adaptions associated with exercise while minimizing symptom exacerbation due to the notion of the Monro-Kellie doctrine.

Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review

OBJECTIVES

We evaluated interventions to facilitate recovery in children, adolescents and adults with a sport-related concussion (SRC).

DESIGN

Systematic review including risk of bias (modified Scottish Intercollegiate Guidelines Network tool).

DATA SOURCES

MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, APA PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL Plus with Full Text, SPORTDiscus and Scopus searched until March 2022.

STUDY ELIGIBILITY CRITERIA

(1) Original research including randomised controlled trials (RCTs), quasi-experimental designs, cohort, comparative effectiveness studies; (2) focus on SRC; (3) English; (4) peer-reviewed and (5) evaluated treatment.

RESULTS

6533 studies were screened, 154 full texts reviewed and 13 met inclusion (10 RCTs, 1 quasi-experimental and 2 cohort studies; 1 high-quality study, 7 acceptable and 5 at high risk of bias). Interventions, comparisons, timing and outcomes varied, precluding meta-analysis. For adolescents and adults with dizziness, neck pain and/or headaches >10 days following concussion, individualised cervicovestibular rehabilitation may decrease time to return to sport compared with rest followed by gradual exertion (HR 3.91 (95% CI 1.34 to 11.34)) and when compared with a subtherapeutic intervention (HR 2.91 (95% CI 1.01 to 8.43)). For adolescents with vestibular symptoms/impairments, vestibular rehabilitation may decrease time to medical clearance (vestibular rehab group 50.2 days (95% CI 39.9 to 60.4) compared with control 58.4 (95% CI 41.7 to 75.3) days). For adolescents with persisting symptoms >30 days, active rehabilitation and collaborative care may decrease symptoms.

CONCLUSIONS

Cervicovestibular rehabilitation is recommended for adolescents and adults with dizziness, neck pain and/or headaches for >10 days. Vestibular rehabilitation (for adolescents with dizziness/vestibular impairments >5 days) and active rehabilitation and/or collaborative care (for adolescents with persisting symptoms >30 days) may be of benefit.

Active Rehabilitation Following Acute Mild Traumatic Brain Injury: A Systematic Review

Purpose:

Following mild traumatic brain injury (mTBI), patients are often advised to restrict physical activity until full symptom resolution followed by gradual return to activity. However, extended rest periods may prolong recovery and contribute to persistent symptoms. Emerging evidence suggests early active rehabilitation that increases heart rate without exacerbating symptoms may improve mTBI patient recovery. This review aims to: (1) appraise evidence on active rehabilitation intervention for mTBI recovery within one-month of injury (i.e., exercise type, duration, intensity, etc.); and (2) recommend evidence-based rehabilitation protocols.

Method:

Pubmed, CINAHL, PsychARTICLES, SportDISCUS, and AMED databases were searched using key terms “mild Traumatic Brain Injury”, “Rehabilitation”, “Acute”, and their synonyms. Evidence was appraised using Cochrane RoB-2 and ROBINS-I.

Results:

434 citations were initially identified with seven papers systematically reviewed. Within the reviewed articles, only three were randomized controlled trials with low risk of bias, and four were non-randomized trials with low to moderate risk of bias. Findings highlighted that a range of active rehabilitation protocols were used with different exercise modalities (primarily treadmills and static cycling), durations (9–20 min, or until symptomatic, for 30–50 days or symptoms resolved), and intensities (low, moderate or high). Active rehabilitation did not cause any serious adverse events (i.e., death, hospitalisation etc.), and six studies reported that it did not exacerbate mTBI symptoms in any participants (with one participant having symptom worsening in one study). Overall, the majority of reviewed studies ( n = 4) showed that active rehabilitation decreased time to mTBI symptom resolution compared to controls (strict rest/stretching exercises).

Conclusions:

Individualized active rehabilitation prescribed within one-month post-mTBI appears to be safe and effective at decreasing recovery time to symptom resolution in mTBI. However, there is a lack of consensus regarding specific intervention protocols that needs to be addressed before adoption within clinical practice.

One-year stability of preseason Sport Concussion Assessment Tool 5 (SCAT5) values in university level collision and combative sport athletes

OBJECTIVES

To determine the stability of the Sport Concussion Assessment Tool (SCAT) 5 between consecutive seasons in uninjured collision and combative varsity athletes.

METHODS

Thirty-six athletes (19 females) were recruited to participate (wrestling [n = 12], rugby [n = 14], and hockey [n = 10]). The SCAT5 was administration at the start of the 2017 and 2018 seasons. Median baseline demographics for 2017 were as follows: age (19 years [range: 17-24 years]), height (174 cm [range: 149-195 cm]), and weight (76 kg [range: 57-118 kg]). Outcome metrics included subcomponents of the SCAT5: symptom reporting, standardized assessment of concussion (SAC), neurological screening, and balance performance measured with the modified balance error scoring system (mBESS). Wilcoxon signed-rank tests and Cronbach's alpha (α) values were calculated to determine the stability between consecutive years for the SCAT5 variables in the same cohort of athletes. Bonferroni corrections were applied for Wilcoxon signed-rank tests, where alpha = 0.006 (0.05/9).

RESULTS

Between the 2017 and 2018 seasons, no differences were noted in symptom reporting (p = 0.14), SAC (p = 0.32), neurological screening (p = 0.98), and balance performance on the mBESS (p = 0.01). The Cronbach's alpha displayed unacceptable to questionable levels of within-subject stability (range: α = 0.34-0.70) for all subcomponents, except months in reverse order (α = 0.92).

CONCLUSIONS

While no statistical differences were present for all SCAT5 subcomponent metrics between 2017 and 2018 baselines, all but one displayed unacceptable to questionable stability (α ≤ 0.70) when retested one year later. Further research is needed to understand the appropriate time duration baseline SCAT5 values can reliably be utilized within longitudinal studies; as well as the normal variation of SCAT5 reporting/scoring.

Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes

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.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion

OBJECTIVE

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.

DESIGN

Cross sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients ≤14 days post concussion.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.

RESULTS

We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).

CONCLUSIONS

In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools

BACKGROUND

It can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear.

OBJECTIVE

To identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event.

DESIGN

Scoping review.

METHOD

A structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described.

RESULTS

The structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination.

CONCLUSION

Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.

Evaluation of the vestibular/ocular motor screening assessment in active combat sport athletes: an exploratory study

OBJECTIVE

The first aim of this study was to compare the results of the vestibular/ocular motor screening (VOMS) in combat sport athletes with a healthy control population. Second, to explore differences between athletes with and without a concussion history. Third, to examine the relationship between VOMS and the Post-Concussion Symptom Scale (PCSS) in combat sport athletes.

PARTICIPANTS

Forty active male combat sport athletes and 40 healthy male control participants were recruited from 4 clubs and a University in Australia.

METHODS

Participants completed the VOMS in a primary care physiotherapy clinic. Participants completed an injury questionnaire and the PCSS.

RESULTS

An "abnormal" score in at least one subtest or near point convergence (NPC) was recorded in 45% of the combat group compared with 22.5% of the control group. All VOMS scores and NPC distance were greater in the combat group compared with control group (p < 0.05). The VOMS scores were found to be moderately positively correlated with the PCSS. There was no difference in VOMS between athletes with and without a history of concussion (p > 0.05).

CONCLUSION

VOMS scores differed between combat sport athletes and control participants. The PCSS may aid clinicians in identifying athletes who have underlying vestibular/oculomotor impairment.

Pathway of care for visual and vestibular rehabilitation after mild traumatic brain injury: a critical review

PRIMARY OBJECTIVE

To review the pathway to care for treatment and management of patients receiving visual and vestibular rehabilitation after mild traumatic brain injury (mTBI).

METHODS & PROCEDURES

English scientific peer-reviewed articles from PubMed, CINAHL, Embase, and PsycINFO between 2000 and 2020 were first screened by title and abstract, then those selected underwent full-text review and analysis.

MAIN OUTCOMES & RESULTS

The database search yielded 1640 results and after title and abstract review, 75 articles were selected for full-text screening, from which 8 were included in the qualitative synthesis. Current evidence includes a limited number of retrospective cohort studies and case studies.

CONCLUSIONS

Many patients with visual and vestibular deficits following mTBI do not receive rehabilitation services until months following their injury as there is no standardized pathway to care for patients for visual and vestibular rehabilitation. Barriers to establishing a standardized pathway are the lack of natural history data for visual and vestibular function following mTBI and the lack of randomized clinical trials establishing the efficacy of rehabilitation in patients following mTBI.

Physical Activity Following Sport-Related Concussion in Adolescents: A Systematic Review

OBJECTIVE

To evaluate the evidence related to how physical activity (PA) affects recovery following a sport-related concussion (SRC) in adolescents.

DESIGN

Systematic review Data Source: PUBMED, MEDLINE, and SPORTDiscus Eligibility criteria for selecting study:(1) original research article (e.g., randomized controlled trials (RCT), quasi-experimental designs, cohort, case-control studies), (2) 66% or greater of the sample has to have a SRC diagnosed by a clinician, (4) human research, (5) evaluate the effect of a SRC on PA in adolescents only (<18 years). Participants were seen within 1-2 weeks post-SRC for acute studies and 4 weeks post-SRC for studies focused on prolonged recoveries.

RESULTS

Twenty-two studies met the inclusion criteria (i.e., 8 regarding PA (PA-daily aerobic activity including light-moderate intensities), 8 evaluating active rehabilitation/exercise programs (20 minutes of daily aerobic exercise below symptom threshold), 6 examining a single bout of exertion). The methodological quality of the literature was assessed using the Downs and Black risk of bias (ROB) checklist. The ROB scores ranged from 7-24, with only two RCTs included. Studies demonstrated single bouts of exertion testing were safe and feasible. Daily PA or active rehabilitation/exercise programs led to a reduction in symptoms present and a decrease in number of days to medical clearance.

CONCLUSION

Following a brief period of rest (24-48 hours), individuals can gradually and safely return to PA below their physical symptom exacerbation thresholds. Further research is warranted to delineate how to optimize the timing, intensity, duration, and modality of PA impacts symptom resolution and physiological recovery following SRC.

Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomised Clinical Trial

The objective of this study was to compare the effects of a cervicovestibular rehabilitation program combined with symptom-limited aerobic exercise (SLAE) program to a SLAE program alone in adults with persistent symptoms following mild traumatic brain injury (mTBI) on severity of symptoms and other indicators of clinical recovery. In this single-blind, parallel-group randomised clinical trial, 60 adults with persistent symptoms following mTBI were randomly assigned to: 1) a 6-week SLAE program or 2) a 6-week cervicovestibular rehabilitation program combined with SLAE program. All participants took part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), time to return to function, and physical cervical and vestibular measures. Nonparametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes. For PCSS, NPRS, NDI, HDI, DHI and return to function, there were no group-by-time interactions at any time-points follow-up (p>0.05); clinically significant time effects were however observed (p0.05). There were group-by-time interactions at weeks 6 and 12 for vestibulo-ocular reflex (p0.003) and the cranio-vertebral mobility (p0.001) measures in favor of the cervicovestibular rehabilitation group. The study indicates that a cervicovestibular rehabilitation program combined with SLAE was not superior to a SLAE program alone in term of symptoms and functional level improvement but resulted in improved physical cervical and vestibular function. Keywords: mild traumatic brain injury, rehabilitation, neck pain, dizziness, headache.

Sensorimotor system changes in adolescent rugby players post-concussion: A prospective investigation from the subacute period through to return-to-sport

BACKGROUND

The pathophysiology of concussion is complex. Altered sensorimotor function post-concussion may contribute to the wide range of symptoms and impairments reported. There is currently limited evidence documenting changes in sensorimotor function during the recovery period. The aim of this study was to investigate the effect of concussion on the sensorimotor system in adolescents post-concussion using a multifaceted approach.

STUDY DESIGN

Prospective nested case-control study.

METHODS

A total of 285 male adolescent rugby players underwent assessment of sensorimotor function during preseason. Players who sustained a concussion during the season and control players, matched for age and playing position, were assessed in the subacute period (3-5 days) and after return-to-sport (3 weeks). Tests of sensorimotor function included balance, cervical spine and vestibulo-ocular function, and measurement of the size and contraction of lumbopelvic muscles (ultrasound imaging).

RESULTS

Twenty-three players (8%) sustained a concussion. Of these, 20 players were assessed during the subacute period and 17 players following return-to-sport. The prevalence of vestibulo-ocular dysfunction increased from 38.9% to 72.2% during the subacute period and dysfunction was present in 83.3% of players after return-to-sport (p = 0.01). Changes in lumbar multifidus muscle size (p = 0.002) and thickness (p = 0.05) at the L5 vertebral level were observed. No statistically significant changes in balance, cervical spine proprioception, or contraction of lumbopelvic muscles were found (p > 0.05).

CONCLUSION

Changes in sensorimotor function were observed in the subacute period post-concussion, with some persisting after return-to-sport. Using symptom-based criteria for return-to-sport may not adequately reflect the sequelae of concussion on the sensorimotor system.

Prospective study with specific Re-Assessment time points to determine time to recovery following a Sports-Related Concussion in university-aged student-athletes

BACKGROUND

Time to recovery for symptom burden and neurocognition following a Sports-Related Concussion (SRC) has previously been determined by consolidating varying re-assessment time points into a singular point, and has not been established for Vestibular-Ocular-Motor (VOM) function or academic ability.

OBJECTIVES

Establish when recovery of symptom burden, neurocognition, VOM function, and academic ability occurs in university-aged student-athletes.

METHODS

Student-athletes completed an assessment battery (Post-Concussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), Vestibular Ocular-Motor Screening (VOMS), Perceived Academic Impairment Tool (PAIT)) during pre-season (n = 140), within 48 hours, 4, 8 and 14 days post-SRC and prior to Return To Play (RTP) and were managed according to the Rugby Football Union' community pathway (n = 42). Student-athletes were deemed recovered or impaired according to Reliable Change Index' (RCI) or compared to their individual baseline.

RESULTS

Symptom burden recovers by four days post-SRC on RCI and to baseline by eight days. VOM function and academic ability recovers by 8 days. Some student-athletes demonstrated worse performance at RTP on all tests by RCI and to baseline, except for on VOMS score and near point convergence by RCI change.

CONCLUSIONS

Variation in individual university-aged student-athletes requires a multi-faceted approach to establish what dysfunctions post-SRC exist and when recovery occurs.

Can the neck contribute to persistent symptoms post concussion? Long-term follow up from a prospective descriptive case series

OBJECTIVE

To describe individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment as part of multidisciplinary concussion care. A secondary objective is to report on how participants describe the outcomes of neck treatmentMethods: Long-term follow-up for a subgroup of participants in a prospective case series (n = 11). Data were collected at initial assessment, completion of neck treatment, 6 and 12 months including standard questionnaires (Rivermead post-concussion symptoms questionnaire, neck disability index, dizziness handicap inventory); patient-reported measures of headache, dizziness and neck pain and participant descriptions of the effects of neck treatmentResults: Grouped measures of post-concussion symptoms were further improved or sustained at 6 and 12 months. Ten of the 11 participants reported neck treatment as a beneficial part of their care and described the effects on the neck, multiple symptoms and their overall recovery. However, seven participants experienced recurrent headache, neck pain or dizziness at 6- or 12-month follow-up.

CONCLUSION

Long-term follow-up of individuals receiving neck treatment shows improvement across a range of patient reported outcomes, yet highlights frequent recurrence of symptoms. Neck treatment can play a valuable role in people's recovery that extends beyond local effects on the neck.

The development and the inter-rater agreement of a treatment protocol for vestibular/oculomotor rehabilitation in children and adolescents post-moderate-severe TBI

Introduction:There is limited evidence investigating the effect of vestibular/oculomotor rehabilitation programs in children and adolescents post moderate-severe TBI at the sub-acute stage.Objective:To describe the development of a treatment protocol for vestibular/oculomotor interventions in this population, and to assess the inter-rater agreement of this protocol as an initial step of a clinical trial.Method:The protocol was developed by 10 health professionals, address the high variability of balance performance, the high prevalence of vestibular/oculomotor abnormalities and the low prevalence of symptoms reported in this population.Results:The protocol enables the clinician to use the assessment during the treatment exercise selection. The training position was defined by the Pediatric Balance Scale. Vestibular/oculomotor exercises were selected using a quantified version of the Vestibular/Ocular Motor Screening. The exercise protocol was selected based on impairment in function or reproduction of symptoms. The protocol planning was implemented by two assessors in 27 children and adolescents post-moderate-severe TBI (median age 14.1 [6-18.4] years) in the sub-acute stage (median 40 [14-162] days since injury). Very high agreement was found (k > 0.72) in all the parameters.Conclusion: This protocol could reliably be used in a randomized control trial that assesses the effect of vestibular/oculomotor rehabilitation program in children and adolescents post moderate-severe TBI at the sub-acute stage.

The effect of high-intensity physical exertion on measures of cervical spine, vestibular/ocular-motor screening, and vestibulo-ocular reflex function in university level collision and combative sport athletes

OBJECTIVES

To examine how high-intensity physical exertion affects clinical measures of cervical spine (CSp), vestibular/ocular motor screen (VOMS), and vestibulo-ocular reflex (VOR) function.

DESIGN

Case series.

SETTING

Sports Medicine Centre.

PARTICIPANTS

A total of 37 athletes consented to participate (22 rugby, 15 wrestling; 9 men, 28 women; median age = 19 years [range 17-23 years]).

MAIN OUTCOME MEASURES

Outcome measures included tests of CSp (cervical flexor endurance, head perturbation test, cervical flexion rotation test and anterolateral strength), VOR (head thrust test and dynamic visual acuity [DVA]), and a quantified version of the VOMS. These metrics were assessed prior to and after completing the 30-15 Intermittent Fitness Test. Bland-Altman plots and Wilcoxon signed-rank tests were utilized to analyze the data using an alpha of p < 0.004.

RESULTS

Cervical anterolateral strength (kg) was reduced post-exertion on the left (z = 3.87; p < 0.001), but not on the right between conditions (z = -1.49; p = 0.14). Athletes reported increased dizziness (z = -3.55; p = 0.004) and had reduced DVA following exertion (z = -2.78; p < 0.001). All other metrics were not significantly different following exertion (p > 0.011).

CONCLUSION

Reduced performance on DVA, decreased left-anterolateral strength, and increased dizziness occurred following high-intensity exertion in varsity collision and combative athletes, which has implications for sideline screening for sport-related concussion.

Aerobic Exercise for Sport-related Concussion: A Systematic Review and Meta-analysis

INTRODUCTION

Approximately 25% of people with sport-related concussion (SRC) experiences persistent symptoms. The 2016 Berlin consensus on SRC recommends symptom-limited aerobic exercise as a rehabilitation option for persistent symptoms after concussion. However, this recommendation is based on a limited body of knowledge because there is uncertainty about the effectiveness of such interventions. The objective of this systematic review is to assess the effects of symptom-limited aerobic exercise programs compared with control interventions on symptom intensity in individuals with SRC.

METHODS

A structured search was conducted in MEDLINE, EMBASE, CINHAL, and EBM reviews. Randomized clinical trials (RCT) including aerobic exercise programs as an intervention for SRC were included. After selection, the risk of bias and Grading of Recommendations, Assessment, Development and Evaluation recommendations were applied to pooled studies for quantitative analysis. Standard mean differences (SMD) and 95% confidence interval (CI) were calculated. A descriptive analysis was also performed.

RESULTS

Seven RCT (326 participants) in adolescent populations were included. Three of seven RCT had a high risk of bias. Symptom-limited aerobic exercise programs have a significant beneficial effect on the perception of symptoms (6 studies, 277 participants, low-quality evidence; pooled SMD, -0.44; 95% CI, -0.68 to -0.19). When introduced in the acute phase, symptom-limited aerobic exercise programs have a significant beneficial effect on symptomatic recovery compared with control interventions (3 studies, 206 participants, moderate quality evidence, pooled SMD, -0.43; 95% CI, -0.71 to -0.15).

CONCLUSIONS

Symptom-limited aerobic exercise programs are beneficial in improving symptoms of adolescents after an SRC. Good-quality studies are needed to determine effects on adults and on other outcomes.

Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion?

Introduction: Research indicates Sports-Related Concussion (SRC) impairs Vestibular-Ocular-Motor (VOM) function. The aim was to explore if VOM impairment correlates with longer Return To Play (RTP), symptom burden, neurocognitive performance and academic capability.Participants: 40 (61.4% male) Loughborough University, UK, rugby union student-athletes who sustained 42 SRCs.Methods: Student-athletes completed an assessment battery during pre-season (baseline), 2, 4, 8 and 14 days post-SRC and prior to RTP and were managed according to the rugby Football Union' community pathway.Outcome measures: Vestibular Ocular-Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Test, Post-Concussion Symptom Scale, Perceived Academic Impairment Tool questionnaire and percentage of academic activities specifically missed due to SRC.Results: VOMS scores were significantly (p < 0.005) greater than baseline at all time points except RTP. Presence of VOM dysfunction at 14 days post-SRC significantly correlated with a longer RTP, greater symptom burden and increased odds ratio at 2, 4 and 8 days and academic time loss at 2, 4 and 8 days post-SRC.Conclusion: VOM impairment is associated with an increased symptom burden and impaired academic capability, and a longer time to RTP when present at 14 days post-SRC.

The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review

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.