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Jack AI, Digney HT, Bell CA, Grossman SN, McPherson JI, Saleem GT, Haider MN, Leddy JJ, Willer BS, Balcer LJ, Galetta SL, Busis NA, Torres DM. Testing the Validity and Reliability of a Standardized Virtual Examination for Concussion. Neurol Clin Pract 2024; 14:e200328. [PMID: 38895642 PMCID: PMC11182663 DOI: 10.1212/cpj.0000000000200328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/27/2024] [Indexed: 06/21/2024]
Abstract
Background and Objectives We determined inter-modality (in-person vs telemedicine examination) and inter-rater agreement for telemedicine assessments (2 different examiners) using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a standardized concussion examination designed for remote use. Methods Patients referred for an initial evaluation for concussion were invited to participate. Participants had a brief initial assessment by the treating neurologist. After a patient granted informed consent to participate in the study, the treating neurologist obtained a concussion-related history before leaving the examination room. Using the Tele-BCPE, 2 virtual examinations in no specific sequence were then performed from nearby rooms by the treating neurologist and another neurologist. After the 2 telemedicine examinations, the treating physician returned to the examination room to perform the in-person examination. Intraclass correlation coefficients (ICC) determined inter-modality validity (in-person vs remote examination by the same examiner) and inter-rater reliability (between remote examinations done by 2 examiners) of overall scores of the Tele-BCPE within the comparison datasets. Cohen's kappa, κ, measured levels of agreement of dichotomous ratings (abnormality present vs absent) on individual components of the Tele-BCPE to determine inter-modality and inter-rater agreement. Results For total scores of the Tele-BCPE, both inter-modality agreement (ICC = 0.95 [95% CI 0.86-0.98, p < 0.001]) and inter-rater agreement (ICC = 0.88 [95% CI 0.71-0.95, p < 0.001]) were reliable (ICC >0.70). There was at least substantial inter-modality agreement (κ ≥ 0.61) for 25 of 29 examination elements. For inter-rater agreement (2 telemedicine examinations), there was at least substantial agreement for 8 of 29 examination elements. Discussion Our study demonstrates that the Tele-BCPE yielded consistent clinical results, whether conducted in-person or virtually by the same examiner, or when performed virtually by 2 different examiners. The Tele-BCPE is a valid indicator of neurologic examination findings as determined by an in-person concussion assessment. The Tele-BCPE may also be performed with excellent levels of reliability by neurologists with different training and backgrounds in the virtual setting. These findings suggest that a combination of in-person and telemedicine modalities, or involvement of 2 telemedicine examiners for the same patient, can provide consistent concussion assessments across the continuum of care.
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Affiliation(s)
- Alani I Jack
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Helena T Digney
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Carter A Bell
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Scott N Grossman
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Jacob I McPherson
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Ghazala T Saleem
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Mohammad N Haider
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - John J Leddy
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Barry S Willer
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Laura J Balcer
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Steven L Galetta
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Neil A Busis
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
| | - Daniel M Torres
- Department of Neurology (AIJ, HTD, CAB, SNG, LJB, SLG, NAB), New York University Grossman School of Medicine, NY; Department of Rehabilitation Sciences (JIM, GTS), School of Public Health and Health Professions, State University of New York at Buffalo; UBMD Department of Orthopaedics and Sports Medicine (MNH, JJL) and Department of Psychiatry (BSW), Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo; Departments of Population Health (LJB) and Ophthalmology (LJB, SLG), New York University Grossman School of Medicine, NY; and Department of Neurology (DMT), Lenox Hill Hospital at Northwell Health, New York, NY
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Sharma B, Koelink E, DeMatteo C, Noseworthy MD, Timmons BW. The Concussion, Exercise, and Brain Networks (ConExNet) study: a cohort study aimed at understanding the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. BMC Sports Sci Med Rehabil 2024; 16:133. [PMID: 38886815 PMCID: PMC11184857 DOI: 10.1186/s13102-024-00926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Recent scientific evidence has challenged the traditional "rest-is-best" approach for concussion management. It is now thought that "exercise-is-medicine" for concussion, owing to dozens of studies which demonstrate that sub-maximal, graded aerobic exercise can reduce symptom burden and time to symptom resolution. However, the primary neuropathology of concussion is altered functional brain activity. To date, no studies have examined the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. In addition, although exercise is now more widely prescribed following concussion, its cardiopulmonary response is not yet well understood in this population. Our study has two main goals. The first is to understand whether there are exercise-induced resting state functional brain activity differences in children with concussion vs. healthy controls. The second is to profile the physiological response to exercise and understand whether it differs between groups. METHODS We will perform a single-center, controlled, prospective cohort study of pediatric concussion at a large, urban children's hospital and academic center. Children with sport-related concussion (aged 12-17 years) will be recruited within 4-weeks of injury by our clinical study team members. Key inclusion criteria include: medical clearance to exercise, no prior concussion or neurological history, and no implants that would preclude MRI. Age- and sex-matched healthy controls will be required to meet the same inclusion criteria and will be recruited through the community. The study will be performed over two visits separated by 24-48 h. Visit 1 involves exercise testing (following the current clinical standard for concussion) and breath-by-breath gas collection using a metabolic cart. Visit 2 involves two functional MRI (fMRI) scans interspersed by 10-minutes of treadmill walking at an intensity calibrated to Visit 1 findings. To address sub-objectives, all participants will be asked to self-report symptoms daily and wear a waist-worn tri-axial accelerometer for 28-days after Visit 2. DISCUSSION Our study will advance the growing exercise-concussion field by helping us understand whether exercise impacts outcomes beyond symptoms in pediatric concussion. We will also be able to profile the cardiopulmonary response to exercise, which may allow for further understanding (and eventual optimization) of exercise in concussion management. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Bhanu Sharma
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Imaging Research Centre, St. Joseph's Healthcare, Hamilton, ON, Canada
- Department of Electrical & Computer Engineering, McMaster University, Hamilton, ON, Canada
| | - Eric Koelink
- Department of Pediatric Emergency Medicine, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Carol DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - Michael D Noseworthy
- Imaging Research Centre, St. Joseph's Healthcare, Hamilton, ON, Canada
- Department of Electrical & Computer Engineering, McMaster University, Hamilton, ON, Canada
- McMaster School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
- Department of Medical Imaging, McMaster University, Hamilton, ON, Canada
| | - Brian W Timmons
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada.
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Streicher NS, Popovich M, Almeida A, Alsalaheen B, Ichesco IK, Freeman J, Lorincz M, Eckner JT. Understanding Abnormal Examination Findings During Concussion Recovery: A Retrospective Chart Review. Neurol Clin Pract 2024; 14:e200284. [PMID: 38699600 PMCID: PMC11065325 DOI: 10.1212/cpj.0000000000200284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 01/22/2024] [Indexed: 05/05/2024]
Abstract
Background and Objective Physical examination findings in athletes with sport-related concussion (SRC) are not well described in the literature. The objective of this study was to describe physical examination findings during the first month following concussion in athletes, with a focus on the effect of sex, age, and time since injury. Methods This was a retrospective electronic medical record (EMR) review of physical examination findings in 500 patients aged 6-24 who were initially seen within 15 days of SRC at a multidisciplinary outpatient academic concussion clinic between 2017 and 2019. A standardized concussion examination built in the EMR recorded mental status, cranial nerve, vestibulo-ocular motor screen, and balance findings for all patients. The primary outcome was the frequency of abnormal examination findings during the first 30 days postinjury, which was further analyzed by sex, age, and time since injury using mixed logistic regression models. Results The most common abnormal examination findings overall were eyes-closed single-leg stance, vestibular-ocular reflex, visual motion sensitivity, the neck examination, and eyes-closed tandem stance. Abnormal findings were more frequent in female athletes for vestibular ocular reflex and visual motion sensitivity. The frequency of abnormal findings increased with age for vestibulo-ocular reflex, visual motion sensitivity, the neck examination, convergence testing, and eyes-open single-leg stance, whereas abnormalities decreased in frequency with age for eyes-open tandem stance and tandem gait. The frequency of abnormal findings generally decreased with time over the first 4 weeks following injury. Discussion A comprehensive physical examination is pivotal for evaluation of athletes with concussion. These findings highlight high-yield components of the concussion examination and support use of these examination components as injury markers. Future work should investigate associations between physical examination findings and postconcussion symptoms and recovery outcomes. Classification of Evidence This retrospective cohort study provides Class IV evidence that neurologic examination with specifically designed clinical tests are helpful for diagnosis of traumatic brain injury in young athletes at age 6-24.
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Affiliation(s)
- Nicholas S Streicher
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Michael Popovich
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Andrea Almeida
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Bara Alsalaheen
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Ingrid K Ichesco
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Jeremiah Freeman
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - Matt Lorincz
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
| | - James T Eckner
- Department of Neurology (NSS, MP, AA, IKI, ML, JTE), University of Michigan, Ann Arbor; Department of Neurology (NSS), Georgetown University, Washington, DC; Department of Physical Therapy (BA), University of Michigan-Flint; and Sports Medicine and Physical Therapy (JF), University of Michigan, Ann Arbor
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Broglio SP, Register-Mihalik JK, Guskiewicz KM, Leddy JJ, Merriman A, Valovich McLeod TC. National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion. J Athl Train 2024; 59:225-242. [PMID: 38530653 DOI: 10.4085/1062-6050-0046.22] [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: 03/28/2024]
Abstract
OBJECTIVE To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport. BACKGROUND Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice. RECOMMENDATIONS These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.
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Affiliation(s)
| | - Johna K Register-Mihalik
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science and Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | - Kevin M Guskiewicz
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science and Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
| | | | - Tamara C Valovich McLeod
- Athletic Training Program, A.T. Still University, Mesa, AZ. Dr Guskiewicz is now at the Department of Kinesiology, Michigan State University, East Lansing
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McPherson JI, Marsh AC, Cunningham A, Leddy JJ, Corrado C, Cheema ZD, Nazir MSZ, Nowak AS, Farooq O, Willer BS, Haider MN. An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion. Clin J Sport Med 2024:00042752-990000000-00173. [PMID: 38329287 DOI: 10.1097/jsm.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Abstract
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.
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Affiliation(s)
- Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York
| | | | - Adam Cunningham
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - John J Leddy
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Cathlyn Corrado
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - Zaheerud D Cheema
- Department of Neurology, Division of Pediatric Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Muhammad S Z Nazir
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - Andrew S Nowak
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan; and
| | - Osman Farooq
- Department of Neurology, Division of Pediatric Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Mohammad N Haider
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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Barnhart M, McLeod TV, Bay RC. The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature. J Athl Train 2024; 59:49-65. [PMID: 36913634 PMCID: PMC10783467 DOI: 10.4085/1062-6050-0429.22] [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: 03/14/2023]
Abstract
OBJECTIVE The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion. DATA SOURCES Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles. STUDY SELECTION Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool. DATA EXTRACTION After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies. DATA SYNTHESIS Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not. CONCLUSIONS Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery.
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Affiliation(s)
- Mitchell Barnhart
- Athletic Training Programs, A.T. Still University, Mesa, AZ; Phoenix Country Day School, Paradise Valley, AZ
| | - Tamara Valovich McLeod
- Department of Athletic Training, Athletic Training Programs and School of Osteopathic Medicine, A.T. Still University, Mesa, AZ
| | - R. Curtis Bay
- Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, AZ
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Haider MN, Lutnick E, Nazir MSZ, Nowak A, Chizuk HM, Miecznikowski JC, McPherson JI, Willer BS, Leddy JJ. Sensitivity and Specificity of Exercise Intolerance on Graded Exertion Testing for Diagnosing Sport-Related Concussion: A Systematic Review and Exploratory Meta-Analysis. J Neurotrauma 2023; 40:1524-1532. [PMID: 37014078 DOI: 10.1089/neu.2022.0331] [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: 04/05/2023] Open
Abstract
Abstract There is no single gold standard test to diagnose sport-related concussion (SRC). Concussion-related exercise intolerance, that is, inability to exercise to the individual's appropriate level due to exacerbation of concussion-like symptoms, is a frequent finding in athletes early after SRC that has not been systematically evaluated as a diagnostic test of SRC. We performed a systematic review and proportional meta-analysis of studies that evaluated graded exertion testing in athletes after SRC. We also included studies of exertion testing in healthy athletic participants without SRC to assess specificity. Pubmed and Embase were searched in January 2022 for articles published since 2000. Eligible studies included those that performed graded exercise tolerance tests in symptomatic concussed participants (> 90% of subjects had an SRC, seen within 14 days of injury), at the time of clinical recovery from SRC, in healthy athletes, or both. Study quality was assessed using the Newcastle-Ottawa Scale. Twelve articles met inclusion criteria, most of which were of poor methodological quality. The pooled estimate of incidence of exercise intolerance in participants with SRC equated to an estimated sensitivity of 94.4% (95% confidence interval [CI]: 90.8, 97.2). The pooled estimate of incidence of exercise intolerance in participants without SRC equated to an estimated specificity of 94.6% (95% CI: 91.1, 97.3). The results suggest that exercise intolerance measured on systematic testing within 2 weeks of SRC may have excellent sensitivity for helping to rule in the diagnosis of SRC and excellent specificity for helping to rule out SRC. A prospective validation study to determine the sensitivity and specificity of exercise intolerance on graded exertion testing for diagnosing SRC after head injury as the source of symptoms is warranted.
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Affiliation(s)
- Mohammad N Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York, USA
| | - Ellen Lutnick
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Muhammad S Z Nazir
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York, USA
| | - Andrew Nowak
- College of Medicine, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Haley M Chizuk
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York, USA
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Jeffrey C Miecznikowski
- Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York, USA
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8
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Echemendia RJ, Burma JS, Bruce JM, Davis GA, Giza CC, Guskiewicz KM, Naidu D, Black AM, Broglio S, Kemp S, Patricios JS, Putukian M, Zemek R, Arango-Lasprilla JC, Bailey CM, Brett BL, Didehbani N, Gioia G, Herring SA, Howell D, Master CL, Valovich McLeod TC, Meehan WP, Premji Z, Salmon D, van Ierssel J, Bhathela N, Makdissi M, Walton SR, Kissick J, Pardini J, Schneider KJ. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med 2023; 57:722-735. [PMID: 37316213 DOI: 10.1136/bjsports-2022-106661] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6). DATA SOURCES Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation. ELIGIBILITY CRITERIA (1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC. DATA EXTRACTION Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool. RESULTS Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children. CONCLUSION Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes. PROSPERO REGISTRATION NUMBER CRD42020154787.
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Affiliation(s)
- Ruben J Echemendia
- Concussion Care Clinic, University Orthopedics, State College, Pennsylvania, USA
- University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Joel S Burma
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jared M Bruce
- Biomedical and Health Informatics, University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Christopher C Giza
- Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Kevin M Guskiewicz
- Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dhiren Naidu
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | | | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Christopher M Bailey
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Benjamin L Brett
- Neurosurgery/ Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Gerry Gioia
- Depts of Pediatrics and Psychiatry & Behavioral Sciences, Children's National Health System, Washington, District of Columbia, USA
| | - Stanley A Herring
- Department of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Howell
- Orthopedics, Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Tamara C Valovich McLeod
- Department of Athletic Training and School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona, USA
| | - William P Meehan
- Sports Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
- Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | | | | | - Neil Bhathela
- UCLA Health Steve Tisch BrainSPORT Program, Los Angeles, California, USA
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Samuel R Walton
- Department of Physical Medicine and Rehabilitation, School of Medicine, Richmond, Virginia, USA
| | - James Kissick
- Dept of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Haider MN, Nowak A, Sandhur M, Leddy JJ. Sport-Related Concussion and Exercise Intolerance. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Leddy JJ, Haider MN, Noble JM, Rieger B, Flanagan S, McPherson JI, Shubin-Stein K, Saleem GT, Corsaro L, Willer B. Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists. Curr Neurol Neurosci Rep 2021; 21:72. [PMID: 34817719 DOI: 10.1007/s11910-021-01160-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS). RECENT FINDINGS Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.
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Affiliation(s)
- John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
| | - Mohammad Nadir Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,Department of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - James M Noble
- Department of Neurology, Taub Institute for Research On Alzheimer's Disease and the Aging Brain, and G.H. Sergievsky Center, Columbia University, New York, NY, USA
| | - Brian Rieger
- Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Steven Flanagan
- Department of Rehabilitation Medicine, Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | | | - Ghazala T Saleem
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Louis Corsaro
- Northern Westchester and Southern Putnam County School Districts, New York, NY, USA
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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11
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Haider MN, Cunningham A, Darling S, Suffoletto HN, Freitas MS, Jain RK, Willer B, Leddy JJ. Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms. Br J Sports Med 2021; 55:1427-1433. [PMID: 34510003 DOI: 10.1136/bjsports-2020-103690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days). METHODS This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived. RESULTS Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation. CONCLUSION The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.
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Affiliation(s)
- Mohammad Nadir Haider
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adam Cunningham
- Biostatistics, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Scott Darling
- Family Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Invision Health, Amherst, New York, USA
| | - Heidi N Suffoletto
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Emergency Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Michael S Freitas
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Family Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Rajiv K Jain
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Barry Willer
- Psychiatry, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - John J Leddy
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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12
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Neurosensory Screening and Symptom Provocation in Pediatric Mild Traumatic Brain Injury. J Head Trauma Rehabil 2021; 35:270-278. [PMID: 32108710 DOI: 10.1097/htr.0000000000000560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate diagnostic/prognostic implications of neurosensory testing during the subacute stage in patients with pediatric mild traumatic brain injury (pmTBI). SETTING Recruitment from pediatric emergency department and urgent care clinics, assessment in a controlled environment. PARTICIPANTS In total, 146 pmTBI patients evaluated 7.4 ± 2.3 days and approximately 4 months postinjury; 104 age/sex-matched healthy controls (HCs) at equivalent time points. DESIGN Prospective cohort study. MAIN MEASURES Neurosensory examination based on sequence of 10 established tests of vestibular-ocular, oculomotor, vestibulospinal, and visual functioning. RESULTS The amount of symptom provocation (positive change from pretest symptomatology) was significantly increased in pmTBI relative to HCs on every subtest 1 week postinjury, as were deficits in monocular accommodative amplitude and King-Devick Test errors. However, symptom provocation did not meaningfully alter diagnostic sensitivity/specificity relative to more easily obtained pretest symptom ratings. Evidence of clinically significant symptom provocation 1 week postinjury improved sensitivity (Δ = +12.9%) of identifying patients with persistent postconcussive symptoms 4 months postinjury on an independent symptom measure. CONCLUSIONS The diagnostic sensitivity/specificity of neurosensory testing in acutely concussed youth may be limited at 1 week postinjury as a function of natural recovery occurring in most emergency department cohorts. Neurosensory screening may have greater utility for identifying patients who experience delayed recovery.
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13
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Haider MN, Bezherano I, Wertheimer A, Siddiqui AH, Horn EC, Willer BS, Leddy JJ. Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms. Sports Health 2021; 13:154-160. [PMID: 33147117 PMCID: PMC8167349 DOI: 10.1177/1941738120946015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
CONTEXT Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS. EVIDENCE ACQUISITION PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value. CONCLUSION Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes. STRENGTH OF RECOMMENDATION TAXONOMY 2.
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Affiliation(s)
- Mohammad Nadir Haider
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Itai Bezherano
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Alex Wertheimer
- Department of Emergency Medicine, State University of New York at Buffalo, Buffalo, New York
| | | | - Emily C Horn
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, New York
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
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14
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Haider MN, Worts PR, Viera KB, Villarrubia B, Wilber CG, Willer BS, Leddy JJ. Postexercise Slowing on the King-Devick Test and Longer Recovery From Sport-Related Concussion in Adolescents: A Validation Study. J Athl Train 2020; 55:482-487. [PMID: 32320625 PMCID: PMC7249288 DOI: 10.4085/1062-6050-264-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT The King-Devick (KD) test is a rapid number-reading test that has emerging use in the assessment of sport-related concussion (SRC). Previous research suggested that healthy individuals and patients with acute concussions who had shorter recovery times (<3 weeks) demonstrated a learning effect on the KD test after mild to moderate exertion, whereas patients with longer recovery times did not. OBJECTIVE To assess if the absence of postexertional improvement on the KD test within 10 days of concussive head injury was associated with a longer duration of recovery. DESIGN Prospective cohort study. SETTING University concussion-management clinics. PATIENTS OR OTHER PARTICIPANTS Male and female adolescent athletes (n = 99, aged 13-18 years) presenting within 10 days of SRC. MAIN OUTCOME MEASURE(S) The KD test was administered before and after the Buffalo Concussion Treadmill Test (BCTT). Days from injury to recovery, with recovery defined as being asymptomatic, confirmed by the assessment of a physician who was blinded to the treatment group, and the return of normal exercise tolerance on the BCTT were recorded. RESULTS Participants with postexertional slowing (PES group, n = 33) had a longer duration of recovery (17 days versus 13.5 days, P = .033) than participants without PES (no-PES group, n = 66). At any clinic visit, PES was also associated with a relative risk of 2.36 (95% confidence interval = 1.55, 3.61; P < .001) of not recovering within the following week. CONCLUSIONS The current study validates our prior work showing that acutely concussed adolescents who did not display the typical learning effect on the KD test after the BCTT took longer to recover from SRC than those who exhibited the typical learning effect.
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Affiliation(s)
- Mohammad N Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo
| | - Phillip R Worts
- Tallahassee Orthopedic Clinic, FL
- Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee
- Institute of Sports Sciences and Medicine, Florida State University, Tallahassee
| | - Kaitlin B Viera
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo
| | - Brendan Villarrubia
- Department of Exercise and Nutrition Sciences, State University of New York at Buffalo
| | - Charles G Wilber
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo
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15
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Willer BS, Haider MN, Bezherano I, Wilber CG, Mannix R, Kozlowski K, Leddy JJ. Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents. Arch Phys Med Rehabil 2019; 100:2267-2275. [PMID: 31377190 PMCID: PMC6879855 DOI: 10.1016/j.apmr.2019.07.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/10/2019] [Accepted: 07/15/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To compare a sample of adolescents with sport-related concussion (SRC) who were prescribed rest with 2 arms of a randomized controlled trial comparing aerobic exercise with placebo-like stretching. We also compared sex differences across the 3 approaches to treatment. DESIGN Quasi-experimental trial. SETTING University concussion management clinics. PARTICIPANTS Adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG], n=48, 15.4±1y, 25% female). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG], n=52, 15.3±2y, 46% female) or placebo-like stretching (placebo group [PG], n=51, 15.4±2y, 47% female) (N=151). MAIN OUTCOME MEASURES The primary outcome was median days from injury to recovery. The secondary outcome was proportion classified as normal recovery (<30d) or delayed recovery (≥30d). RESULTS The RG recovered in 16 days (interquartile range, 9.25-23.25d), which was significantly delayed (P=.020) compared with EG (13d; interquartile range, 10-18.5d). The PG recovered in 17 days (interquartile range, 13-23d). Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery (P=.190). There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups (P=.013). CONCLUSION Relative rest and a placebo-like stretching program were very similar in days to recovery and symptom improvement pattern after SRC. Both conditions were less effective than subsymptom threshold aerobic exercise. Female adolescents appear to be susceptible to symptom increase when prescribed rest.
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Affiliation(s)
- Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States.
| | - Mohammad N Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States; PhD Program in Biomedical Science, Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States
| | - Itai Bezherano
- Department of Nutrition and Exercise Science, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States
| | - Charles G Wilber
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Katherine Kozlowski
- Department of Nutrition and Exercise Science, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States
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16
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Haider MN, Johnson SL, Mannix R, Macfarlane AJ, Constantino D, Johnson BD, Willer B, Leddy J. The Buffalo Concussion Bike Test for Concussion Assessment in Adolescents. Sports Health 2019; 11:492-497. [PMID: 31486715 DOI: 10.1177/1941738119870189] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The Buffalo Concussion Treadmill Test (BCTT) is a graded exertion test for assessing exercise tolerance after concussion, but its utility is limited for certain populations. HYPOTHESIS We developed the Buffalo Concussion Bike Test (BCBT) and tested its comparability with the BCTT. We hypothesize that heart rate (HR) at symptom exacerbation on the BCBT will be equivalent to the BCTT. STUDY DESIGN Case-control study. LEVEL OF EVIDENCE Level 3. METHODS Adolescents with acute concussion (AC) (n = 20; mean age, 15.9 ± 1.1 years; 60% male) presenting to a concussion clinic within 10 days of injury and age- and sex-matched healthy controls (n = 20; mean age, 15.9 ± 1.1 years; 60% male) performed the BCTT at first visit and returned within 3 days to perform the BCBT. Test duration, HR, symptom severity (measured using a visual analog scale), and exertion (measured using the Borg Rating of Perceived Exertion) were collected during each test. RESULTS Adolescents with AC who were exercise intolerant on the BCTT were also intolerant on the BCBT, with symptom exacerbation occurring at a mean 8.1 ± 2.8 minutes on the BCTT versus 14.6 ± 6.0 minutes on the BCBT (P < 0.01). Two 1-sided t tests showed that the HR at symptom exacerbation in AC patients (137 ± 28 bpm on BCTT vs 135 ± 25 bpm on BCBT; 95% CI, <0.01-0.03) and at voluntary exhaustion for controls (175 ± 13 bpm on BCTT vs 175 ± 13 bpm on BCBT; 95% CI, 0.03-0.03) on each test were statistically equivalent. CONCLUSION The HR at symptom exacerbation on BCBT is equivalent to the BCTT for the assessment of exercise tolerance after concussion in adolescents. CLINICAL RELEVANCE The BCBT can be used in patients with limited mobility or for research interventions that require limited participant motion.
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Affiliation(s)
- Mohammad N Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York.,Department of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Samantha L Johnson
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Alexander J Macfarlane
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Dylan Constantino
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Blair D Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - John Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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