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Panzera JC, Podolak OE, Master CL. Contemporary diagnosis and management of mild TBI (concussions): What you need to know. J Trauma Acute Care Surg 2024; 96:865-869. [PMID: 38696496 DOI: 10.1097/ta.0000000000004297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
ABSTRACT Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.
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Affiliation(s)
- Joseph C Panzera
- From the Sports Medicine and Performance Center, (J.C.P.); Center for Injury Research and Prevention (O.E.P.); and Sports Medicine and Performance Center, Center for Injury Research and Prevention (C.L.M.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Huang PC, Shaw JS, Kentis S, Young L, Bryant BR, Esagoff AI, White J, Peters ME. A systematic review of pre-injury anxiety disorder and post-concussion outcomes in youth and young adult athletes. Int Rev Psychiatry 2024; 36:219-232. [PMID: 39255025 DOI: 10.1080/09540261.2024.2370875] [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: 05/03/2024] [Accepted: 06/17/2024] [Indexed: 09/11/2024]
Abstract
Pre-injury anxiety disorder may be a risk factor for poor outcomes following sportsrelated concussion. A systematic review was performed to characterize the relationship between pre-injury anxiety disorder and post-concussion symptom presentation and recovery time after sports-related concussions among children, adolescents, and young adults. A PRISMA-compliant literature search was conducted in Ovid MEDLINE, PsycINFO, EMBASE, and Scopus for articles published up to 25 January 2024. The initial query yielded 1358 unique articles. Articles that analyzed the relationship between pre-injury anxiety disorder and post-concussion symptoms and recovery time were included. A final cohort of 11 articles was extracted, comprising a total of 8390 study participants, of whom 921 had a history of pre-injury anxiety disorder. Pre-injury anxiety disorder was associated with prolonged time to return to sports activity and an increased incidence of physical, emotional, cognitive, and sleep-related symptoms. While the results of this review suggest an association between pre-injury anxiety disorder and post-concussion symptoms and recovery time, future studies should be more stringent regarding standardized anxiety disorder definitions, longitudinal assessment of post-concussion symptoms, anxiety disorder subtypes, and anxiety treatment history.
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Affiliation(s)
- Philip C Huang
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacob S Shaw
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Lisa Young
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Barry R Bryant
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron I Esagoff
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacob White
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew E Peters
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wingerson MJ, Hunt DL, Wilson JC, Mannix RC, Meehan WP, Howell DR. Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion. Med Sci Sports Exerc 2024; 56:783-789. [PMID: 38109187 PMCID: PMC11018463 DOI: 10.1249/mss.0000000000003358] [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: 12/19/2023]
Abstract
BACKGROUND Aerobic exercise facilitates postconcussion symptom resolution at the group level, but patient-level characteristics may affect the likelihood of treatment efficacy. PURPOSE This study aimed to investigate demographic and clinical characteristics, which differentiate postconcussion aerobic exercise treatment efficacy from nonefficacy in the intervention arm of a randomized clinical trial. METHODS Adolescent and young adult participants initiated a standardized aerobic exercise intervention within 14 d of concussion, consisting of self-selected exercise for 100 min·wk -1 at an individualized heart rate (80% of heart rate induced symptom exacerbation during graded exercise testing). Treatment efficacy was defined as symptom resolution within 28-d postconcussion. Treatment efficacy and nonefficacy groups were compared on demographics, clinical characteristics, intervention adherence, and persistent symptom risk using the Predicting Persistent Postconcussive Problems in Pediatrics (5P) clinical risk score. RESULTS A total of 27 participants (16.1 ± 2.3 yr old; range, 11-21 yr; 52% female) began the intervention, with a mean of 9.5 ± 3.7 d after concussion; half ( n = 13; 48%) demonstrated treatment efficacy (symptom resolution within 28 d postconcussion). Those whose symptoms resolved within 28 d had significantly lower preintervention postconcussion symptom inventory scores (21.2 ± 13.2 vs 41.4 ± 22.2; P < 0.01), greater adherence to the intervention (77% vs 36%; P = 0.05), and longer average exercise duration (median [interquartile range], 49.7 [36.8-68.6] vs 30.4 [20.7-34.7] min; P < 0.01) than those whose symptoms lasted more than 28 d. Groups were similar in age, sex, timing of intervention, and preintervention 5P risk score. CONCLUSIONS A standardized aerobic exercise intervention initiated within 14 d of concussion demonstrated efficacy for approximately half of participants, according to our definition of treatment efficacy. This multisite aerobic exercise intervention suggests that lower symptom severity, higher intervention adherence, and greater exercise duration are factors that increase the likelihood of symptoms resolving within 28 d of concussion.
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Affiliation(s)
- Mathew J. Wingerson
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
| | - Danielle L. Hunt
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - Julie C. Wilson
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
| | - Rebekah C. Mannix
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - William P. Meehan
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - David R. Howell
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
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Hageman G, Hageman I, Nihom J. Chronic Traumatic Encephalopathy in Soccer Players: Review of 14 Cases. Clin J Sport Med 2024; 34:69-80. [PMID: 37403989 DOI: 10.1097/jsm.0000000000001174] [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: 09/30/2022] [Accepted: 05/22/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Exposure to repetitive sports-related concussions or (sub)concussive head trauma may lead to chronic traumatic encephalopathy (CTE). Which impact (heading or concussion) poses the greatest risk of CTE development in soccer players? DESIGN Narrative review. SETTING Teaching hospital and University of Applied sciences. PATIENTS A literature search (PubMed) was conducted for neuropathologic studies in the period 2005-December 2022, investigating soccer players with dementia and a CTE diagnosis, limited to English language publications. 210 papers were selected for final inclusion, of which 7 papers described 14 soccer players. ASSESSMENT Magnetic resonance imaging studies in soccer players show that lifetime estimates of heading numbers are inversely correlated with cortical thickness, grey matter volume, and density of the anterior temporal cortex. Using diffusion tensor imaging-magnetic resonance imaging, higher frequency of headings-particularly with rotational accelerations-are associated with impaired white matter integrity. Serum neurofilament light protein is elevated after heading. MAIN OUTCOME MEASURES Chronic traumatic encephalopathy pathology, history of concussion, heading frequency. RESULTS In 10 of 14 soccer players, CTE was the primary diagnosis. In 4 cases, other dementia types formed the primary diagnosis and CTE pathology was a concomitant finding. Remarkably, 6 of the 14 cases had no history of concussion, suggesting that frequent heading may be a risk for CTE in patients without symptomatic concussion. Rule changes in heading duels, management of concussion during the game, and limiting the number of high force headers during training are discussed. CONCLUSIONS Data suggest that heading frequency and concussions are associated with higher risk of developing CTE in (retired) soccer players. However based on this review of only 14 players, questions persist as to whether or not heading is a risk factor for CTE or long-term cognitive decline.
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Affiliation(s)
- Gerard Hageman
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
| | - Ivar Hageman
- Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Jik Nihom
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
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Wang X, Yu H, Dong L, Wang D. Discussion of "Efficacy of aerobic exercise following concussion: a narrative review". Appl Physiol Nutr Metab 2023; 48:550-551. [PMID: 37222399 DOI: 10.1139/apnm-2023-0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Xuanqi Wang
- Department of Neurosurgery, Dandong Central Hospital, 118002, PR China
- Dalian Medical University, Dalian, 116000, PR China
| | - Hui Yu
- Department of Neurosurgery, Dandong Central Hospital, 118002, PR China
| | - Lei Dong
- Department of Neurosurgery, Dandong Central Hospital, 118002, PR China
- China Medical University, Shenyang, 110122, PR China
| | - Dechen Wang
- Department of Neurosurgery, Dandong Central Hospital, 118002, PR China
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Gaudet CE, Iverson GL, Kissinger-Knox A, Van Patten R, Cook NE. Clinical Outcome Following Concussion Among College Athletes with a History of Prior Concussion: A Systematic Review. SPORTS MEDICINE - OPEN 2022; 8:134. [PMID: 36308612 PMCID: PMC9617993 DOI: 10.1186/s40798-022-00528-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is long-standing interest in, and concern about, whether collegiate athletes with a history of concussion will experience worse clinical outcomes, or prolonged recovery, should they sustain a subsequent concussion. OBJECTIVES This systematic review examined the association between prior concussion history and clinical outcomes following a subsequent sport-related concussion among college-age student athletes. STUDY DESIGN Systematic review. METHODS We screened 5,118 abstracts and 619 full-text articles that were appraised to determine whether they met inclusion criteria. We utilized a likelihood heuristic to assess the probability of observing a specific number of statistically significant and nonsignificant studies reporting an association between concussion history and clinical outcomes. We conducted a narrative synthesis of the study findings. RESULTS Sixteen studies met the inclusion criteria. Thirteen studies reported the number of participants with a history of prior concussions (≥ 1), which totaled 1690 of 4573 total participants (on average 37.0% of study participants; median = 46.0%, range 5.6-63.8%). On the Newcastle-Ottawa Quality Assessment Scale, the risk of bias ratings ranged from 3 to 9 (mean = 5.4, SD = 1.4). Across all studies, 43.8% (k = 7/16) reported at least one statistically significant result among primary analyses showing an association between concussion history and worse clinical outcome. A minority of studies reporting on symptom duration (4/13, 30.8%) and time to return to play (2/7, 28.6%) found an association between concussion history and worse outcome. Studies included in the review reported limited information pertaining to the characteristics of prior concussions, such as presence or duration of loss of consciousness or posttraumatic amnesia, age at first lifetime concussion, time since most recent past concussion, or length of recovery from prior concussions. CONCLUSION The question of whether college athletes with a prior history of concussion have worse clinical outcome from their next sport-related concussion remains unresolved. The published results are mixed and in aggregate show modest evidence for an association. Many studies have small samples, and only three studies were designed specifically to address this research question. Important outcomes, such as time to return to academics, have not been adequately studied. Larger hypothesis-driven studies considering the number of prior concussions (e.g., 3 or more) are needed. TRIAL REGISTRATION PROSPERO CRD42016041479, CRD42019128300.
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Affiliation(s)
- Charles E. Gaudet
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924MassGeneral Hospital for Children Sports Concussion Program, Waltham, MA USA ,grid.416228.b0000 0004 0451 8771Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA USA
| | - Grant L. Iverson
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924MassGeneral Hospital for Children Sports Concussion Program, Waltham, MA USA ,grid.416228.b0000 0004 0451 8771Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA USA ,Center for Health and Rehabilitation Research, Charlestown, MA 02129 USA
| | - Alicia Kissinger-Knox
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924MassGeneral Hospital for Children Sports Concussion Program, Waltham, MA USA ,grid.416228.b0000 0004 0451 8771Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA USA
| | - Ryan Van Patten
- grid.413904.b0000 0004 0420 4094Providence Veterans Administration Medical Center, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI USA
| | - Nathan E. Cook
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924MassGeneral Hospital for Children Sports Concussion Program, Waltham, MA USA ,grid.416228.b0000 0004 0451 8771Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA USA
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