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Pyndiura KL, Di Battista AP, Richards D, Reed N, Lawrence DW, Hutchison MG. A Multimodal Exertional Test for concussion: a pilot study in healthy athletes. Front Neurol 2024; 15:1390016. [PMID: 38699052 PMCID: PMC11063232 DOI: 10.3389/fneur.2024.1390016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction Exertional tests have become a promising tool to assist clinicians in the management of concussions, however require expensive equipment, extensive spaces, and specialized clinician expertise. As such, we developed a test with minimal resource requirements encompassing key elements of sport and physical activity. The purpose of this study was to pilot test the Multimodal Exertional Test (MET) protocol in a sample of healthy interuniversity athletes. Methods The MET comprises four stages, each featuring three distinct tasks. The test begins with engaging in squats, alternating reverse lunges, and hip hinges (Stage 1). The next stage progressively evolves into executing these tasks within specified time limits (Stage 2). Following this, the test advances to a stage that incorporates cognitive tasks (Stage 3), and the final stage demands greater levels of physical exertion, cognition, and multi-directional movements (Stage 4). Heart rate (HR) was obtained during each stage of the MET and participants' symptom severity scores were recorded following each task. Results Fourteen healthy interuniversity athletes (n = 8 female, n = 6 male) participated in the study. HR was obtained for 10 of the 14 athletes (females: n = 6, males: n = 4). Increases in average and maximum HR were identified between pre-MET and Stage 1, and between Stages 3 and 4. Consistent with the tasks in each stage, there were no increases in average and maximum HR observed between MET Stages 1 to 3. Female athletes exhibited higher average and maximum HRs compared to male athletes during all four stages. All 14 athletes reported minimal changes in symptom severity following each task. Conclusion Among healthy athletes, the MET elicits an increase in average and maximum HR throughout the protocol without symptom provocation. Female athletes exhibit higher HRs during all four stages in comparison to male athletes.
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Affiliation(s)
- Kyla L. Pyndiura
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Alex P. Di Battista
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Doug Richards
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Nick Reed
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - David W. Lawrence
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Michael G. Hutchison
- Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON, Canada
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McLoughlin J. Concussion Rehabilitation and the Application of Ten Movement Training Principles. Cureus 2023; 15:e46520. [PMID: 37927640 PMCID: PMC10625311 DOI: 10.7759/cureus.46520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Concussion awareness continues to grow in all aspects of healthcare, including the areas of prevention, acute care, and ongoing rehabilitation. Most of the concussion research to date has focussed on the challenges around screening and diagnosing what can be a complex mix of brain impairments that overlay with additional pre-existing comorbidities. While we expect further progress in concussion diagnosis, progress also continues to be made around proactive rehabilitation, with the emergence of interventions that can enhance the recovery process, maximise function and independence with a return to study, work, and play. Traditionally, optimal multimodal assessments of concussion have treated the physical, cognitive, and psychological domains of brain injury separately, which supports diagnosis, and informs appropriate follow-up care. Due to the complex nature of brain injury, multimodal assessments direct care toward professionals from many different disciplines including medicine, physiotherapy, psychology, neuropsychology, ophthalmology, and exercise physiology. In addition, these professionals may work in different fields such as sports, neurorehabilitation, vestibular, musculoskeletal, community, vocational, and general practice clinical settings. Rehabilitation interventions for concussions employed in practice are also likely to use a blend of theoretical principles from motor control, cognitive, and psychological sciences. This scale of diversity can make information dissemination, collaboration, and innovation challenging. The Ten Movement Training Principles (MTPs) have been proposed as a usable and relevant concept to guide and support clinical reasoning in neurorehabilitation. When applied to concussion rehabilitation, these same 10 principles provide a comprehensive overview of key rehabilitation strategies for current and future practice. Future collaborations can use these training principles to support clinical and research innovations including the rapid rise of technologies in this growing field of rehabilitation practice.
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Affiliation(s)
- James McLoughlin
- College of Nursing and Health Sciences, Flinders University, Adelaide, AUS
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Lalji R, Hincapié CA, Macpherson A, Howitt S, Marshall C, Tamim H. Association Between First Attempt Buffalo Concussion Treadmill Test and Days to Recovery in 855 Children With Sport-Related Concussion: A Historical Cohort Study and Prognostic Factors Analysis. Clin J Sport Med 2023; 33:505-511. [PMID: 36881442 PMCID: PMC10467809 DOI: 10.1097/jsm.0000000000001134] [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] [Received: 06/30/2022] [Accepted: 01/19/2023] [Indexed: 03/08/2023]
Abstract
OBJECTIVE Little is known about the prognostic value of the Buffalo Concussion Treadmill Test (BCTT) after the acute phase of sport-related concussion (SRC). We examined the added prognostic value of the BCTT performed 10 to 21 days after SRC in children, in addition to participant, injury, and clinical process characteristics on days to recovery. DESIGN Historical clinical cohort study. SETTING Network of approximately 150 Canadian multidisciplinary primary-care clinics. PARTICIPANTS 855 children (mean age 14 years, range 6-17 years, 44% female) who presented between January 2016, and April 2019 with SRC. ASSESSMENT OF RISK FACTORS Participant, injury, and clinical process characteristics, with focus on BCTT exercise intolerance assessed 10 to 21 days after injury. OUTCOME Days to clinical recovery. RESULTS Children who were exercise intolerant experienced an increase of 13 days to recovery (95% CI, 9-18 days). Each additional day between SRC and first BCTT was associated with a recovery delay of 1 day (95% CI, 1-2 days), and prior history of concussion was associated with a recovery delay of 3 days (95% CI, 1-5 days). Participant, injury, and clinical process characteristics, and the first attempt BCTT result explained 11% of the variation in recovery time, with 4% accounted for by the BCTT. CONCLUSION Exercise-intolerance assessed 10 to 21 days after SRC was associated with delayed recovery. However, this was not a strong prognostic factor for days to recovery.
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Affiliation(s)
- Rahim Lalji
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Switzerland
| | - Cesar A. Hincapié
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Switzerland
| | - Alison Macpherson
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Scott Howitt
- Canadian Memorial Chiropractic College (CMCC), Toronto, Canada; and
| | | | - Hala Tamim
- School of Kinesiology and Health Science, York University, Toronto, Canada
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Fisher M, Wiseman-Hakes C, Obeid J, DeMatteo C. Does Sleep Quality Influence Recovery Outcomes After Postconcussive Injury in Children and Adolescents? J Head Trauma Rehabil 2023; 38:240-248. [PMID: 35997760 DOI: 10.1097/htr.0000000000000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether objective parameters of sleep quality differ throughout recovery between children and adolescents who experienced an early return to school (RTS) and those who had a delayed RTS or did not return at all during the study period. SETTING Sleep parameters reflective of sleep quality were evaluated in participants' natural sleeping habitat throughout 9 weeks postinjury. PARTICIPANTS Ninety-four children and adolescents (aged 5-18 years) with diagnosed concussion. DESIGN Prospective cohort. Participants followed RTS protocols. MAIN MEASURES Actigraphy-derived estimates of total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), average arousal length (AAL), and number of arousals (NOAs) per hour were assessed. The length of time from injury until RTS was determined for each participant. Participants were categorized into an early RTS or delayed RTS group based on their time to RTS. RESULTS Both TST and SE were significantly greater in the early RTS group. WASO duration, AAL, and NOAs were significantly greater in the delayed RTS group. Differences between RTS groups were most apparent during weeks 1 to 5 postinjury. CONCLUSIONS AND CLINICAL IMPLICATIONS Participants who returned to school earlier had significantly better objective sleep quality than participants who experienced a delayed RTS. This study provides evidence in support of a relationship between sleep quality and time to RTS in children and adolescents with concussion. Considering early monitoring of sleep, education regarding sleep hygiene, and access to age-appropriate sleep interventions may be helpful in pediatric concussion recovery.
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Affiliation(s)
- Michael Fisher
- School of Rehabilitation Science (Mr Fisher and Ms DeMatteo), Department of Speech Language Pathology (Dr Wiseman-Hakes), and Department of Pediatrics (Dr Obeid), McMaster University, Hamilton, Ontario, Canada
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Terpstra AR, Louie DR, Iverson GL, Yeates KO, Picon E, Leddy JJ, Silverberg ND. Psychological Contributions to Symptom Provocation Testing After Concussion. J Head Trauma Rehabil 2023; 38:E146-E155. [PMID: 35687896 DOI: 10.1097/htr.0000000000000796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes. SETTING Two outpatient concussion clinics in British Columbia, Canada. PARTICIPANTS Adults with persistent symptoms following concussion ( N = 79; 62% women). DESIGN In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge. MAIN MEASURES Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test. RESULTS We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB. CONCLUSION Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.
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Affiliation(s)
- Alex R Terpstra
- Departments of Psychology (Mr Terpstra, Ms Picon, and Dr Silverberg) and Physical Therapy (Dr Louie), University of British Columbia, Vancouver, British Columbia, Canada; Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada (Drs Louie and Silverberg); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (Dr Iverson); Spaulding Rehabilitation Hospital and Spaulding Research Institute, Boston, Massachusetts (Dr Iverson); MassGeneral Hospital for Children Sports Concussion Program, Boston, Massachusetts (Dr Iverson); and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts (Dr Iverson); Department of Psychology, University of Calgary (Dr Yeates), Alberta Children's Hospital Research Institute (Dr Yeates), and Hotchkiss Brain Institute (Dr Yeates), Calgary, Alberta, Canada; and UBMD Orthopaedics and Sports Medicine, SUNY Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (Dr Leddy)
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Sinnott AM, Eagle SR, Kochick V, Preszler J, Collins MW, Sparto PJ, Flanagan SD, Elbin RJ, Connaboy C, Kontos AP. The Role of Age, Sex, Body Mass Index, and Sport Type on the Dynamic Exertion Test in Healthy Athletes: A Cross-Sectional Study. Clin J Sport Med 2022; 32:e499-e507. [PMID: 35350035 DOI: 10.1097/jsm.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The dynamic exertion test (EXiT) was developed to help inform return to play after sport-related concussion, but some factors may threaten the internal validity of EXiT and affect clinical interpretation. OBJECTIVE To compare age, sex, BMI, and sport types across EXiT physiological [pre-EXiT and post-EXiT percentage of maximum heart rate (HR %max) and blood pressure (BP)], performance (change-of-direction task completion time and committed errors), and clinical [symptoms and rating of perceived exertion (RPE)] outcomes among healthy adolescents and adults. STUDY DESIGN Cross-sectional. METHODS Eighty-seven participants ( F = 55, 37.4%) reported symptoms and RPE during the EXiT, which consists of a 12-minute treadmill running protocol, and the dynamic circuit, ball toss, box shuffle (SHUF) and carioca (CAR), zig zag (ZZ), proagility (PA), and arrow agility (AA) tasks. Independent samples t tests were conducted for pre-EXiT and post-EXiT HR %max and BP and change-of-direction task completion time and Mann-Whitney U tests for errors, symptoms, and RPE. A series of 1-way analysis of variance (ANOVAs) and Kruskal-Wallis H tests were conducted to compare collision, contact, and noncontact sport types. RESULTS Adolescents had lower completion time across AA ( P = 0.01) and male athletes lower than female athletes on CAR, ZZ, PA, and AA ( P < 0.04). Male athletes reported greater RPE after the SHUF, CAR, and AA ( P < 0.03). HR %max , errors, and symptoms were equivocal across all subgroups ( P > 0.05). CONCLUSION Age and sex should be considered in the interpretation of performance and clinical, but not physiological, EXiT outcomes. The EXiT is a standardized exercise assessment and generalizable to healthy athletes.
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Affiliation(s)
- Aaron M Sinnott
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shawn R Eagle
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Victoria Kochick
- Centers for Rehabilitation Services-Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael W Collins
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J Sparto
- Department of Physical Therapy University of Pittsburgh, Pennsylvania; and
| | - Shawn D Flanagan
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas
| | - Christopher Connaboy
- Neuromuscular Research Laboratory-Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony P Kontos
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Sinnott AM, Eagle SR, Kochick V, Bricker IR, Collins MW, Sparto PJ, Flanagan SD, Elbin RJ, Connaboy C, Kontos AP. Test-Retest, Interrater Reliability, and Minimal Detectable Change of the Dynamic Exertion Test (EXiT) for Concussion. Sports Health 2022; 15:410-421. [PMID: 35678147 PMCID: PMC10170234 DOI: 10.1177/19417381221093556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Dynamic Exertion Test (EXiT) was developed to inform return-to-play (RTP) decision-making following clinical recovery from sport-related concussion (SRC). The purpose of the current study was to document intrarater and test-retest reliability and minimal detectable change (MDC) scores for physiological [heart rate (HR) and blood pressure], performance (change-of-direction task completion time and errors), and clinical outcomes (endorsed symptoms, perceived exertion) of EXiT, and interrater reliability of performance outcomes. HYPOTHESIS Healthy athletes would exhibit stable physiological responses to the EXiT across visits, demonstrate consistent change-of-direction task completion time between consecutive trials at each visit, and the fastest time (of 2 trials) across visits, and endorse equivocal symptoms and effort across visits. STUDY DESIGN Cross-sectional, test-retest. LEVEL OF EVIDENCE Level 3. METHODS Seventy-nine (female: 34 [43%], 19.6 ± 5.0 years) athletes completed the EXiT at 2 study visits (8.7 ± 4.7 days between visits). Two-way, mixed, intraclass correlation coefficients (ICCs) were used to evaluate intrarater and test-retest reliability. Cronbach's alpha was used to document the internal consistency of symptoms at each visit, and MDC scores were calculated on the physiological, performance, and clinical outcomes. RESULTS Measured and percentage of age-estimated maximum HR were reliable following EXiT (ICC = 0.579-0.618). Change-of-direction task completion time (MDC range = 0.75-8.70 s) had good-to-excellent test-retest (ICC = 0.703-0.948) and interrater (ICC = 0.932-0.965) reliability. Symptoms had a high internal consistency at visits 1 (α = 0.894) and 2 (α = 0.805) and were reliable across visits (ICC = 0.588). CONCLUSION The current investigation established test-retest reliability in addition to MDC scores of an objective dynamic exercise assessment among healthy adolescent and adult athletes. The EXiT may be an objective approach to inform RTP decision-making following SRC recovery. CLINICAL RELEVANCE The EXiT is a clinically feasible exertion-based assessment that can be readily administered in a variety of outpatient clinical settings.
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Pratile T, Marshall C, DeMatteo C. Examining how time from sport-related concussion to initial assessment predicts return-to-play clearance. PHYSICIAN SPORTSMED 2022; 50:132-140. [PMID: 33475440 DOI: 10.1080/00913847.2021.1879603] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE (i) To analyze data of adolescents who have sustained a sport-related concussion (SRC) through the use of Complete Concussion Management Inc. (CCMI) concussion database system; and (ii) to determine an optimal time to assess and manage an athlete with an SRC by prospectively analyzing data from CCMI concussion database system. METHOD A cohort of patients, ages 8-18 years, who sustained an SRC, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada were prospectively followed. The primary outcome measure was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski-Goodman test without symptom exacerbation. RESULTS 1213 athletes (482 female) were included for analysis. Days between injury and initial assessment (p = 0.00), male sex (p = 0.00), and previous concussion history (p = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (p = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5, 24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7, 40.5). Athletes who were assessed at 0 to 9 days from injury were two times more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, p = 0.00). CONCLUSION Time from SRC to initial assessment significantly predicted time to discharge, with those being evaluated earlier experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following an SRC in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.
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Affiliation(s)
- Taylor Pratile
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Cameron Marshall
- Department of research, Complete Concussion Management Inc, Oakville, Ontario, Canada
| | - Carol DeMatteo
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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Fisher M, Wiseman-Hakes C, Obeid J, DeMatteo C. Examining the trajectory and predictors of post-concussion sleep quality in children and adolescents. Brain Inj 2022; 36:166-174. [PMID: 35213283 DOI: 10.1080/02699052.2022.2043439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES This study aimed to 1) determine if post-concussion sleep quality of children and adolescents differed from healthy sleep estimates; 2) describe the trajectory of parameters of sleep quality; 3) determine factors that predict sleep quality outcomes; and 4) compare sleep parameter outcomes between asymptomatic and symptomatic participants at 4 weeks post-concussion. METHODS Nightly actigraphy estimates of sleep in 79 children and adolescents were measured throughout 4 weeks post-concussion. Total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), number of arousals (NOA), and average arousal length (AAL) were measured. RESULTS Child and adolescent participants experienced significantly poorer SE and longer WASO duration throughout 4 weeks of recovery and adolescents experienced significantly longer TST. SE significantly improved with time post-injury (p = .047). Older age was associated with longer TST (p = .003) and female sex was associated with longer WASO (p = .025) and AAL duration (p = .044). Week 4 sleep parameter outcomes were not significantly different between asymptomatic and symptomatic participants. CONCLUSIONS The sleep quality of youth is adversely affected by concussion, particularly in females. Sleep quality appears to improve with time but may require more than 4 weeks to return to normal.
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Affiliation(s)
- M Fisher
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - C Wiseman-Hakes
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - J Obeid
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - C DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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The Dynamic Exertion Test for Sport-Related Concussion: A Comparison of Athletes at Return-to-Play and Healthy Controls. Int J Sports Physiol Perform 2022; 17:834-843. [PMID: 35213824 DOI: 10.1123/ijspp.2021-0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/06/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To describe the Dynamic Exertion Test (EXiT) by comparing physiological, performance, and clinical outcomes between athletes medically cleared following sport-related concussion (SRC) and healthy controls. METHODS One hundred four (female = 41, 39.4%) participants (14-21 y of age) including 52 medically cleared for return to play at 21.48 (15.40) days following SRC and 52 healthy athletes completed the EXiT involving (1) 12-minute aerobic component and (2) 18-minute dynamic component including 2 functional movement and 5 change-of-direction (COD) tasks. Physiological (heart rate and blood pressure), clinical (endorsed symptoms and rating of perceived exertion), and performance (COD-task completion time and errors) outcomes were collected throughout EXiT. Participants also completed the Postconcussion Symptom Scale and vestibular/ocular motor screening before EXiT. Independent-samples t tests were used to compare groups on resting heart rate and blood pressure, COD-task completion time, and Mann-Whitney U tests on Postconcussion Symptom Scale, vestibular/ocular motor screening, and EXiT symptoms, rating of perceived exertion, and errors. RESULTS COD-task completion time and resting systolic blood pressure and heart rate were similar between groups (P > .05). SRC reported greater rating of perceived exertion during the aerobic component (P < .05) and lower total dizziness (P = .003) and total symptoms (P = .021) during EXiT and had lower near point of convergence distance (P < .001) and total symptoms (P = .007) for vestibular/ocular motor screening than healthy athletes. CONCLUSION Physiological, performance, and clinical EXiT outcomes were equivocal between athletes at medical clearance following SRC and healthy controls. The multidomain EXiT may help to inform safe return-to-play decision making post-SRC.
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Picon EL, Perez DL, Burke MJ, Debert CT, Iverson GL, Panenka WJ, Silverberg ND. Unexpected symptoms after concussion: Potential links to functional neurological and somatic symptom disorders. J Psychosom Res 2021; 151:110661. [PMID: 34739941 DOI: 10.1016/j.jpsychores.2021.110661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Reporting of unexpected symptoms after concussion might, in some people, reflect a Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD), or exaggeration (feigning). This study aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for FND/SSD, exaggeration, or both. METHOD Adults with persistent symptoms following concussion (N = 77; 61% women) rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing FND and/or SSD (e.g., fear avoidance behavior). RESULTS When adjusting for all covariates, fear avoidance behavior was most strongly related to unexpected neurological symptoms (B = 0.11, 95% confidence interval = 0.05-0.18, p < .001), while current anxiety scores were most strongly related to unexpected somatic symptoms (B = 0.34, 95% confidence interval = 0.15-0.52, p < .001). Performance validity test failure and litigation were not significant predictors in either model. CONCLUSION Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate FND and SSD (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion. More research is needed at the intersection of FND, SSD, and persistent post-concussive symptoms.
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Affiliation(s)
- Edwina L Picon
- Department of Psychology, University of British Columbia, Canada.
| | - David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School; USA.
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto; Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, USA.
| | - Chantel T Debert
- Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, University of Calgary, Canada.
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital and Spaulding Research Institute; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, USA.
| | - William J Panenka
- Department of Psychiatry, University of British Columbia; BC Mental Health and Substance Use Research Institute; BC Neuropsychiatry Program, Canada.
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Canada.
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Does Exercise Increase Vestibular and Ocular Motor Symptom Detection After Sport-Related Concussion? J Neurol Phys Ther 2021; 45:214-220. [PMID: 33782346 DOI: 10.1097/npt.0000000000000356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Postconcussive vestibular and ocular motor symptoms are common and contribute to longer recovery. The Vestibular/Ocular Motor Screening (VOMS) is used to detect such symptoms, but a VOMS performed at rest may miss symptoms that are only provoked by exertion. Supervised exercise challenges (SECs) have been shown to detect concussion-related symptoms provoked by physical exertion. The purpose of this study was to determine whether athletes undergoing an SEC will exhibit greater symptom provocation with the VOMS compared to a VOMS performed at rest prior to an SEC. METHODS Thirty-six athletes (58.3% male) between ages 10 and 18 years and within 30 days of concussion were included. All participants completed VOMS assessments at rest and immediately after an SEC. VOMS total symptom score increases were calculated for both pre- and post-SEC assessments compared using Wilcoxon ranked sum tests. The frequencies of positive assessments for each VOMS item were compared using McNemar's test. RESULTS There were significant increases in post-SEC symptom provocation scores compared with pre-SEC scores for all VOMS items. The post-SEC VOMS identified 29 participants (80.6%) as positive in at least 1 VOMS item compared with 21 participants (58.3%) identified as positive pre-SEC (P = 0.008). For all VOMS items, the post-SEC VOMS identified participants who were previously negative on a pre-SEC VOMS but became positive after the SEC. DISCUSSION AND CONCLUSIONS An SEC performed prior to a VOMS assessment may increase the detection of vestibular and ocular motor symptoms that may be missed if the VOMS was performed only at rest.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A342).
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Sicard V, Caron G, Moore RD, Ellemberg D. Post-exercise cognitive testing to assess persisting alterations in athletes with a history of concussion. Brain Inj 2021; 35:978-985. [PMID: 34223775 DOI: 10.1080/02699052.2021.1944668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary Objective: To determine whether a physical exercise protocol could reveal persistent cognitive alterations in university athletes with a history of concussion (HOC). Thirty-four HOC and 34 controls participated in this study.Research Design: Cross-sectional.Methods and Procedures: The exercise protocol consisted of a 20-min bout on a stationary bike at 80% of the theoretical maximal heart rate. Before and after the exercise, participants performed a computerized switch task designed specifically to recruit executive functions. Group × Condition (pre- and post-exercise) repeated measures of ANCOVAs for accuracy, reaction time, and inverse efficiency score on the switch task were conducted. Chi-square tests were run to determine if the proportion of HOC and controls who underperformed (at least 2SD lower than the control group's average score) at rest and post-exercise were similar. Whilst no interaction or main effects were found with ANCOVAs, significantly more HOC athletes (21%) underperformed following exercise than at rest (3%) on the switch task, p = .02. The current results indicate that an acute bout of exercise can reveal persistent alterations that are not present at rest in the protracted phase of concussion. They also highlight the importance of considering inter-individual differences in recovery trajectories.
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Affiliation(s)
- Veronik Sicard
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
| | - Gabriel Caron
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
| | - Robert Davis Moore
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Dave Ellemberg
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
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Popovich M, Sas A, Almeida AA, Freeman J, Alsalaheen B, Lorincz M, Eckner JT. Symptom Provocation During Aerobic and Dynamic Supervised Exercise Challenges in Adolescents With Sport-Related Concussion. J Athl Train 2021; 56:148-156. [PMID: 33428736 DOI: 10.4085/1062-6050-0072.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Supervised exercise challenges (SECs) have been shown to be safe and beneficial in the early symptomatic period after concussion. Thus far, most in-clinic SECs studied have included a form of basic aerobic exercise only. An SEC that also includes dynamic forms of exercise mimics all steps of a standard return-to-play progression and may enhance the detection of concussion symptoms to guide in-clinic management decisions. OBJECTIVE To determine whether an SEC that includes a dynamic SEC (DSEC) uncovered symptoms that would not have been identified by an SEC involving an aerobic SEC (ASEC) alone in adolescent patients with sport-related concussion. DESIGN Retrospective case series. SETTING Multidisciplinary sport concussion clinic at a tertiary care center. PATIENTS OR OTHER PARTICIPANTS A total of 65 adolescent athletes (mean age = 14.9 ± 2.0 years, 72.3% males) who underwent an in-clinic SEC within 30 days of concussion. MAIN OUTCOME MEASURE(S) Presence of pre-exercise symptoms and symptom provocation during the SEC were recorded, with exercise-provoked symptoms categorized as occurring during ASEC or DSEC. RESULTS Of the total patient sample, 69.2% (n = 45/65) experienced symptom provocation at some point during the SEC. Symptoms were provoked in 20 patients during the ASEC, whereas 25 completed the ASEC without symptom provocation before becoming symptomatic during the subsequent DSEC and 20 completed the SEC without any symptom provocation. Of the 65 patients in the total sample, 46 were asymptomatic immediately before the SEC. Of these previously asymptomatic patients, 23.9% (n = 11/46) experienced symptom provocation during the ASEC, and an additional 37.0% (n = 17/46) remained asymptomatic during the ASEC but then developed symptoms during the DSEC. CONCLUSIONS The ASEC alone may not detect symptom provocation in a significant proportion of concussion patients who otherwise would develop symptoms during a DSEC.
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Affiliation(s)
| | - Andrew Sas
- Department of Neurology, The Ohio State University, Columbus
| | | | - Jeremiah Freeman
- Department of Sports Medicine and Physical Therapy, University of Michigan, Ann Arbor
| | | | | | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
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