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Brown JC, Goldszer IM, Brooks MC, Milano NJ. An Evaluation of the Emerging Techniques in Sports-Related Concussion. J Clin Neurophysiol 2023; 40:384-390. [PMID: 36930205 PMCID: PMC10329722 DOI: 10.1097/wnp.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
SUMMARY Sports-related concussion is now in public awareness more than ever before. Investigations into underlying pathophysiology and methods of assessment have correspondingly increased at an exponential rate. In this review, we aim to highlight some of the evidence supporting emerging techniques in the fields of neurophysiology, neuroimaging, vestibular, oculomotor, autonomics, head sensor, and accelerometer technology in the setting of the current standard: clinical diagnosis and management. In summary, the evidence we reviewed suggests that (1) head impact sensors and accelerometers may detect possible concussions that would not otherwise receive evaluation; (2) clinical diagnosis may be aided by sideline vestibular, oculomotor, and portable EEG techniques; (3) clinical decisions on return-to-play eligibility are currently not sensitive at capturing the neurometabolic, cerebrovascular, neurophysiologic, and microstructural changes that biomarkers have consistently detected days and weeks after clinical clearance. Such biomarkers include heart rate variability, quantitative electroencephalography, as well as functional, metabolic, and microstructural neuroimaging. The current challenge is overcoming the lack of consistency and replicability of any one particular technique to reach consensus.
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Affiliation(s)
- Joshua C. Brown
- Dept. of Neurology, Medical University of South Carolina
- Dept. of Psychiatry and Behavioral Sciences, Medical University of South Carolina
- Department of Psychiatry and Human Behavior, Department of Neurology, Alpert Medical School of Brown University
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The effects of slow breathing on postural muscles during standing perturbations in young adults. Exp Brain Res 2022; 240:2623-2631. [PMID: 35962803 DOI: 10.1007/s00221-022-06437-0] [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: 05/09/2022] [Accepted: 08/04/2022] [Indexed: 11/04/2022]
Abstract
Maintaining standing balance is vital to completing activities in daily living. Recent findings suggest an interaction between cardiovascular and postural control systems. Volitional slow breathing can modulate the cardiovascular response and affect postural control during quiet standing. However, the effects of slow breathing during threats to standing balance have not been studied. The study examined the effect of slow breathing on the latency and amplitude of postural muscle responses to perturbations of the base of support in healthy, young adults. Twenty-seven participants completed two balance perturbation tasks in standing on an instrumented split-belt treadmill while breathing spontaneously and breathing at 6 breaths per minute. Each perturbation task consisted of 25 posteriorly directed translations of the treadmill belts every 8-12 s. Muscle latency and muscle burst amplitude were measured using surface electromyography from the right limb for the quadriceps (QUADS), medial hamstring (MH), gastrocnemii (GASTROC), soleus (SOL), and tibialis anterior (TA) muscle groups, while a respiratory belt was used to record respiratory rate. Results indicated that during the slow breathing task both muscle latency (p = 0.022) and muscle burst amplitude (p = 0.011) decreased compared to spontaneous breathing. The EMG pre-perturbation activation was not significantly different in any muscle group between conditions (p > 0.167). The study found that reducing respiratory rate to approximately 6 breaths per minute affects the neuromuscular responses in the lower limb muscles to perturbations.
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Wu L, Chan ST, Edmiston WJ, Jin G, Levy ES, Kwong KK, Mannix R, Meehan WP, Chifamba FF, Lipton JO, Whalen MJ, Chen YCI. Persistent CO 2 reactivity deficits are associated with neurological dysfunction up to one year after repetitive mild closed head injury in adolescent mice. J Cereb Blood Flow Metab 2021; 41:3260-3272. [PMID: 34229511 PMCID: PMC8669283 DOI: 10.1177/0271678x211021771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cerebrovascular reactivity (CVR) deficits in adolescents with concussion may persist after resolution of neurological symptoms. Whether or not CVR deficits predict long term neurological function is unknown. We used adolescent mice closed head injury (CHI) models (54 g, 107 cm or 117 cm drop height), followed by blood oxygenation level dependent (BOLD)-functional MRI with CO2 challenge to assess CVR and brain connectivity. At one week, 3HD 107 cm mice showed delayed BOLD responses (p = 0.0074), normal striatal connectivity, and an impaired respiratory rate response to CO2 challenge (p = 0.0061 in ΔRmax). The 107 cm group developed rotarod deficits at 6 months (p = 0.02) and altered post-CO2 brain connectivity (3-fold increase in striatum to motor cortex correlation coefficient) by one year, but resolved their CVR and respiratory rate impairments, and did not develop cognitive or circadian activity deficits. In contrast, the 117 cm group had persistent CVR (delay time: p = 0.016; washout time: p = 0.039) and circadian activity deficits (free-running period: 23.7 hr in sham vs 23.9 hr in 3HD; amplitude: 0.15 in sham vs 0.2 in 3HD; peak activity: 18 in sham vs 21 in 3HD) at one year. Persistent CVR deficits after concussion may portend long-term neurological dysfunction. Further studies are warranted to determine the utility of CVR to predict chronic neurological outcome after mild traumatic brain injury.
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Affiliation(s)
- Limin Wu
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Suk-Tak Chan
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - William J Edmiston
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gina Jin
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily S Levy
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth K Kwong
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Rebekah Mannix
- Department of Emergency Medicine, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA
| | - William P Meehan
- Department of Emergency Medicine, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedics, Division of Sports Medicine, Boston, MA, USA
| | - Fortunate F Chifamba
- Department of Neurology, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan O Lipton
- Department of Neurology, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Michael J Whalen
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yin-Ching I Chen
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Howell DR, Hunt DL, Aaron SE, Hamner JW, Meehan WP, Tan CO. Association of Hemodynamic and Cerebrovascular Responses to Exercise With Symptom Severity in Adolescents and Young Adults With Concussion. Neurology 2021; 97:e2204-e2212. [PMID: 34635563 DOI: 10.1212/wnl.0000000000012929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Aerobic exercise has become a useful method to assist with post-concussion management. Exercise can exacerbate concussion symptoms even when symptoms are not apparent at rest. Few studies have examined the reasons for symptom exacerbation during exercise following a concussion. We had two primary objectives. 1) To delineate cardiopulmonary and cerebrovascular responses to exercise in adolescents and young adults with a concussion and healthy controls. 2) To determine the association between cerebrovascular responses and symptom burden. METHODS We recruited participants with a recent concussion from a sport concussion clinic between 9/1/2018-2/22/2020. They were included if their concussion occurred <3 weeks before initial testing and if they were symptomatic at rest. Participants were excluded if they sustained a concussion in the past year (excluding index injury), reported history of neurological disorders, or were using medications/devices that may alter neurological function. Participants completed a progressive, symptom-limited, sub-maximal exercise protocol on a stationary bike. We assessed heart rate, blood pressure, fraction of end tidal CO2 (FETCO2) and middle cerebral artery blood flow velocity (CBF) and cerebrovascular function (vasoreactivity and autoregulation) at seated rest and during exercise. RESULTS We conducted 107 exercise tests (40 concussed, 37 healthy participants initially; 30 concussed at follow-up). Concussed participants were tested initially (mean=17.6±2.2 [SD] years old; 55% female; mean=12.5±4.7 days post-concussion) and again 8 weeks later (mean=73.3±9.5 days post-concussion). Control participants (mean=18.3±2.4 years; 62% female) were tested once. FETCO2 increased throughout the exercise protocol as heart rate increased, reached a plateau, and declined at higher exercise intensities. CO2 explained >25% of the variation in resting CBF (R2>0.25; p<0.01) in most (73% individuals). Within the concussion group, resting symptom severity and the heart rate at which FETCO2 reached a plateau explained ∼two-thirds of variation in exercise-induced symptom exacerbation (R 2 =0.65; FETCO2 β=-1.210±0.517[S.E.], p<0.05). There was a moderate, statistically significant relationship between cerebrovascular responses to CO2 at rest (cerebral vasoreactivity) and cerebrovascular responses to exercise-induced changes in FETCO2 (R2=0.13, p=0.01). DISCUSSION The arterial CO2 response and symptom exacerbation relationship during post-concussion aerobic exercise may be mediated by increased sensitivity of cerebral vasculature to exercise-related increase in CO2.
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Affiliation(s)
- David R Howell
- Sports Medicine Center, Childrens Hospital Colorado, Aurora, CO, USA .,Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Danielle L Hunt
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.,Division of Sports Medicine, Boston Childrens Hospital, Boston, MA, USA
| | - Stacey E Aaron
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, USA.,Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Jason W Hamner
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, USA.,Cardiovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.,Division of Sports Medicine, Boston Childrens Hospital, Boston, MA, USA.,Departments of Orthopedic Surgery and Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Can Ozan Tan
- Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, USA.,Cardiovascular Research Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, USA.,Division of Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
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Snyder A, Sheridan C, Tanner A, Bickart K, Sullan M, Craske M, Choe M, Babikian T, Giza C, Asarnow R. Cardiorespiratory Functioning in Youth with Persistent Post-Concussion Symptoms: A Pilot Study. J Clin Med 2021; 10:561. [PMID: 33546148 PMCID: PMC7913264 DOI: 10.3390/jcm10040561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/22/2021] [Accepted: 01/30/2021] [Indexed: 12/15/2022] Open
Abstract
Dysregulation of the autonomic nervous system (ANS) may play an important role in the development and maintenance of persistent post-concussive symptoms (PPCS). Post-injury breathing dysfunction, which is influenced by the ANS, has not been well-studied in youth. This study evaluated cardiorespiratory functioning at baseline in youth patients with PPCS and examined the relationship of cardiorespiratory variables with neurobehavioral outcomes. Participants were between the ages of 13-25 in two groups: (1) Patients with PPCS (concussion within the past 2-16 months; n = 13) and (2) non-injured controls (n = 12). Capnometry was used to obtain end-tidal CO2 (EtCO2), oxygen saturation (SaO2), respiration rate (RR), and pulse rate (PR) at seated rest. PPCS participants exhibited a reduced mean value of EtCO2 in exhaled breath (M = 36.3 mmHg, SD = 2.86 mmHg) and an altered inter-correlation between EtCO2 and RR compared to controls. Neurobehavioral outcomes including depression, severity of self-reported concussion symptoms, cognitive catastrophizing, and psychomotor processing speed were correlated with cardiorespiratory variables when the groups were combined. Overall, results from this study suggest that breathing dynamics may be altered in youth with PPCS and that cardiorespiratory outcomes could be related to a dimension of neurobehavioral outcomes associated with poorer recovery from concussion.
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Affiliation(s)
- Aliyah Snyder
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
| | - Christopher Sheridan
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Alexandra Tanner
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
| | - Kevin Bickart
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Departments of Neurology and Neuropsychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Molly Sullan
- Department of Psychiatry, Psychology Service, University of California, San Diego, CA 92093, USA;
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Michelle Craske
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
| | - Meeryo Choe
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- UCLA Mattel Children’s Hospital, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Talin Babikian
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
| | - Christopher Giza
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- UCLA Mattel Children’s Hospital, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Robert Asarnow
- Department of Psychiatry, University of California, Los Angeles, CA 90095, USA; (T.B.); (R.A.)
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA 90095, USA; (C.S.); (K.B.); (M.C.); (C.G.)
- Department of Psychology, University of California, Los Angeles, CA 90095, USA; (A.T.); (M.C.)
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