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Konstantinides NA, Murphy S, Whelan BM, Harmon KG, Poddar S, Hernández TD, Rowe RK. Influence of pre-existing conditions and concussion history on post-concussion symptom severity and recovery time in collegiate athletes. J Neurotrauma 2024. [PMID: 39318243 DOI: 10.1089/neu.2024.0201] [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: 09/26/2024] Open
Abstract
Mental health conditions and concussion history reported by a collegiate athlete may contribute to prolonged recovery and symptom severity after concussion. This work examined the potential associations among concussion history, pre-existing conditions, and sex relative to initial symptom severity and recovery duration following sport-related concussion (SRC) in a cohort of Division 1 NCAA athletes. This prospective cohort study analyzed symptom severity, recovery and return-to-play times reported post-SRC using data collected as part of the Pac-12 CARE Affiliated Program and Health Analytics Program. Health history questionnaires which included self-reported history of pre-existing conditions were completed at baseline. When consented athletes were diagnosed with a concussion, daily post-concussion symptom scores were evaluated until an athlete was clinically determined to be asymptomatic. Generalized linear and Cox proportional hazards models were used to determine associations between pre-existing conditions and recovery and return-to-play times. 92 concussions met inclusion criteria. Notable differences in initial symptom severity existed between females and males who had mood disorders ([Cohen's d] = 0.51) and ADHD (d = 0.93). The number of previous concussions was a strong predictor of athletes reporting pre-existing mood disorders, depression, anxiety, and ADHD (p = 0.008-0.04). Females with ≥2 previous concussions required more days to return-to-play than males (d = 0.31-0.72). Weekly recovery and return-to-play probabilities substantially differed between athletes that did or did not have learning disorders (HRRecovery = 0.32, HRRTP = 0.22, d = 1.96-2.30) and ADHD (HRRecovery = 3.38, HRRTP = 2.74, d = 1.71-4.14). Although no association existed between concussion history and acute symptom severity, collegiate athletes with a history of concussion had higher probabilities of reporting depression, mood disorders, anxiety, and ADHD. Having ADHD or learning disorders likely strongly affects time to recovery and return-to-play for collegiate athletes.
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Affiliation(s)
- Niki Anthea Konstantinides
- University of Colorado Boulder, Integrative Physiology, 354 UCB, Boulder, Boulder, Colorado, United States, 80309-0574;
| | - Sean Murphy
- Cumberland Biological and Ecological Researchers, Longmont, Colorado, United States;
| | - Bridget M Whelan
- University of Washington, Family Medicine, Seattle, Washington, United States;
| | - Kimberly G Harmon
- University of Washington, Family Medicine, Seattle, Washington, United States;
| | - Sourav Poddar
- University of Colorado Anschutz Medical Campus, Family Medicine, Aurora, Colorado, United States;
| | - Theresa Dea Hernández
- University of Colorado Boulder, Psychology and Neuroscience, Boulder, Colorado, United States;
| | - Rachel K Rowe
- University of Colorado at Boulder, Department of Integrative Physiology, Boulder, Colorado, United States;
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2
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Le RK, Ortega J, Chrisman SP, Kontos AP, Buckley TA, Kaminski TW, Meyer BP, Clugston JR, Goldman JT, McAllister T, McCrea M, Broglio SP, Schmidt JD. King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes. J Athl Train 2023; 58:97-105. [PMID: 34709396 PMCID: PMC10072097 DOI: 10.4085/1062-6050-0063.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The King-Devick (K-D) test is used to identify oculomotor impairment after concussion. However, the diagnostic accuracy of the K-D test over time has not been evaluated. OBJECTIVES To (1) examine the sensitivity and specificity of the K-D test at 0 to 6 hours postinjury, 24 to 48 hours postinjury, the beginning of a return-to-play (RTP) protocol (asymptomatic), unrestricted RTP, and 6 months postconcussion and (2) compare outcomes between athletes with and those without concussion across confounding factors (sex, age, sport contact level, academic year, learning disorder, attention-deficit/hyperactivity disorder, migraine history, concussion history, and test administration mode). DESIGN Retrospective, cross-sectional design. SETTING Multiple institutions in the Concussion Assessment, Research and Education Consortium. PATIENTS OR OTHER PARTICIPANTS A total of 320 athletes with a concussion (162 men, 158 women; age = 19.80 ± 1.41 years) were compared with 1239 total collegiate athletes without a concussion (646 men, 593 women; age = 20.31 ± 1.18 years). MAIN OUTCOME MEASURE(S) We calculated the K-D test time difference (in seconds) by subtracting the baseline from the most recent time. Receiver operator characteristic (ROC) curve and area under the curve (AUC) analyses were used to determine the diagnostic accuracy across time points. We identified cutoff scores and corresponding specificity at both the 80% and 70% sensitivity levels. We repeated ROC with AUC analyses using confounding factors. RESULTS The K-D test predicted positive results at the 0- to 6-hour (AUC = 0.724, P < .001), 24- to 48-hour (AUC = 0.701, P < .001), RTP (AUC = 0.640, P < .001), and 6-month postconcussion (AUC = 0.615, P < .001) tim points but not at the asymptomatic time point (AUC = 0.513, P = .497). The 0- to 6-hour and 24- to 48-hour time points yielded 80% sensitivity cutoff scores of -2.6 and -3.2 seconds (ie, faster), respectively, but 46% and 41% specificity, respectively. The K-D test had a better AUC when administered using an iPad (AUC = 0.800, 95% CI = 0.747, 0.854) compared with the spiral-bound card system (AUC = 0.646, 95% CI = 0.600, 0.692; P < .001). CONCLUSIONS The diagnostic accuracy of the K-D test was greatest at 0 to 6 hours and 24 to 48 hours postconcussion but declined across subsequent postconcussion time points. The AUCs did not differentiate between groups across confounding factors. Our negative cutoff scores indicated that practice effects contributed to improved performance, requiring athletes to outperform their baseline scores.
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Affiliation(s)
| | - Justus Ortega
- Department of Kinesiology and Recreation Administration, Humboldt University, Arcata, CA
| | - Sara P. Chrisman
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington
| | | | - Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | - Thomas W. Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | - Briana P. Meyer
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa
| | - James R. Clugston
- Department of Community Health and Family Medicine, University Athletic Association, University of Florida, Gainesville
- Department of Neurology, University Athletic Association, University of Florida, Gainesville
- Division of Sports Health, University Athletic Association, University of Florida, Gainesville
| | | | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa
| | - Steven P. Broglio
- Michigan Concussion Center, School of Kinesiology, University of Michigan, Ann Arbor
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3
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Smith JL, Trofimova A, Ahluwalia V, Casado Garrido JJ, Hurtado J, Frank R, Hodge A, Gore RK, Allen JW. The "vestibular neuromatrix": A proposed, expanded vestibular network from graph theory in post-concussive vestibular dysfunction. Hum Brain Mapp 2021; 43:1501-1518. [PMID: 34862683 PMCID: PMC8886666 DOI: 10.1002/hbm.25737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/07/2022] Open
Abstract
Convergent clinical and neuroimaging evidence suggests that higher vestibular function is subserved by a distributed network including visuospatial, cognitive-affective, proprioceptive, and integrative brain regions. Clinical vestibular syndromes may perturb this network, resulting in deficits across a variety of functional domains. Here, we leverage structural and functional neuroimaging to characterize this extended network in healthy control participants and patients with post-concussive vestibular dysfunction (PCVD). Then, 27 healthy control subjects (15 females) and 18 patients with subacute PCVD (12 female) were selected for participation. Eighty-two regions of interest (network nodes) were identified based on previous publications, group-wise differences in BOLD signal amplitude and connectivity, and multivariate pattern analysis on affective tests. Group-specific "core" networks, as well as a "consensus" network comprised of connections common to all participants, were then generated based on probabilistic tractography and functional connectivity between the 82 nodes and subjected to analyses of node centrality and community structure. Whereas the consensus network was comprised of affective, integrative, and vestibular nodes, PCVD participants exhibited diminished integration and centrality among vestibular and affective nodes and increased centrality of visual, supplementary motor, and frontal and cingulate eye field nodes. Clinical outcomes, derived from dynamic posturography, were associated with approximately 62% of all connections but best predicted by amygdalar, prefrontal, and cingulate connectivity. No group-wise differences in diffusion metrics or tractography were noted. These findings indicate that cognitive, affective, and proprioceptive substrates contribute to vestibular processing and performance and highlight the need to consider these domains during clinical diagnosis and treatment planning.
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Affiliation(s)
- Jeremy L Smith
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anna Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vishwadeep Ahluwalia
- Georgia State University, Atlanta, Georgia, USA.,Center for Advanced Brain Imaging, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jose J Casado Garrido
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | | | | | | | - Russell K Gore
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA.,Shepherd Center, Atlanta, Georgia, USA
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine Emory University Hospital, Atlanta, Georgia, USA
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4
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Kaufman MW, Su CA, Trivedi NN, Lee MK, Nelson GB, Cupp SA, Voos JE. The Current Status of Concussion Assessment Scales: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202106000-00001. [PMID: 34101673 DOI: 10.2106/jbjs.rvw.20.00108] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness. » Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers. » The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete. » Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.
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Affiliation(s)
| | - Charles A Su
- Departments of Orthopaedic Surgery (C.A.S., N.N.T., G.B.N., S.A.C., and J.E.V.) and Family Medicine (S.A.C.), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nikunj N Trivedi
- Departments of Orthopaedic Surgery (C.A.S., N.N.T., G.B.N., S.A.C., and J.E.V.) and Family Medicine (S.A.C.), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Michelle K Lee
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Grant B Nelson
- Departments of Orthopaedic Surgery (C.A.S., N.N.T., G.B.N., S.A.C., and J.E.V.) and Family Medicine (S.A.C.), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sean A Cupp
- Departments of Orthopaedic Surgery (C.A.S., N.N.T., G.B.N., S.A.C., and J.E.V.) and Family Medicine (S.A.C.), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - James E Voos
- Departments of Orthopaedic Surgery (C.A.S., N.N.T., G.B.N., S.A.C., and J.E.V.) and Family Medicine (S.A.C.), University Hospitals Cleveland Medical Center, Cleveland, Ohio
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5
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Hurtubise JM, Gorbet DJ, Hynes LM, Macpherson AK, Sergio LE. White Matter Integrity and Its Relationship to Cognitive-Motor Integration in Females with and without Post-Concussion Syndrome. J Neurotrauma 2020; 37:1528-1536. [PMID: 31928154 DOI: 10.1089/neu.2019.6765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Fifteen percent of individuals who sustain a concussion go on to develop post-concussion syndrome (PCS). These persistent symptoms are believed to be attributed to damage to white matter tracts and impaired neurotransmission. Specifically, declines in white matter integrity after concussion have been found along the long-coursing axons underlying the frontoparietal network. This network is essential for the performance of visuomotor transformation tasks requiring cognitive-motor integration (CMI). We have previously observed deficits in performance on CMI-based tasks in those who have a history of concussion, but were asymptomatic. The aim of this study was to investigate performance on a CMI task, as well as white matter integrity differences along frontoparietal-cerebellar white matter tracts, in those with PCS compared to healthy controls. We hypothesized an association between the behavioral and brain structural measures. Twenty-six female participants (13 with PCS for ≥6 months and 13 healthy controls) completed four computer-based visuomotor CMI tasks. In addition, diffusion tensor images (DTIs) were acquired. No statistically significant differences were found in CMI performance between groups (p > 0.05). Further, there were no statistically significant differences between groups on any DTI metrics (p > 0.05). However, examination of the data collapsed across participants revealed significant associations between performance on a CMI task and white matter integrity. Further investigation into additional causes of symptoms in those with PCS (including psychological and cervicogenic factors) will strengthen our understanding of this diverse group. Nonetheless, this study demonstrates that white matter integrity is related to levels of performance in tasks that require rule-based movement control.
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Affiliation(s)
- Johanna M Hurtubise
- Centre for Sport and Exercise Education, Camosun College, Victoria, British Columbia, Canada
| | - Diana J Gorbet
- School of Kinesiology and Health Science, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada
| | - Loriann M Hynes
- School of Kinesiology and Health Science, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada
| | - Alison K Macpherson
- School of Kinesiology and Health Science, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada
| | - Lauren E Sergio
- School of Kinesiology and Health Science, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Sherman Health Science Research Centre, Toronto, Ontario, Canada
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6
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Langevin P, Fait P, Frémont P, Roy JS. Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol. BMC Sports Sci Med Rehabil 2019; 11:25. [PMID: 31737275 PMCID: PMC6844027 DOI: 10.1186/s13102-019-0139-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
Background Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated. Objective To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week). Methods In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used. Discussion Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations. Trial registration ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.
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Affiliation(s)
- Pierre Langevin
- Clinique Cortex and Physio interactive, 205-1035, avenue Wilfrid-Pelletier, QC Quebec, G1W 0C5 Canada.,2Department of Rehabilitation, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, bureau 4431, QC Quebec City, G1R 1P5 Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), 525, Boulevard Wilfrid Hamel, QC Quebec City, G1M 2S8 Canada
| | - Philippe Fait
- Clinique Cortex and Physio interactive, 205-1035, avenue Wilfrid-Pelletier, QC Quebec, G1W 0C5 Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), 525, Boulevard Wilfrid Hamel, QC Quebec City, G1M 2S8 Canada.,4Department of Human Kinetics, Université du Québec à Trois-Rivières, 3351, boul. des Forges, QC Trois-Rivières, G8Z 4M3 Canada.,5Research Center in Neuropsychology and Cognition (CERNEC), Pavillon Marie-Victorin, 90, rue Vincent d'Indy, QC Montreal, H2V 2S9 Canada
| | - Pierre Frémont
- 2Department of Rehabilitation, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, bureau 4431, QC Quebec City, G1R 1P5 Canada
| | - Jean-Sébastien Roy
- 2Department of Rehabilitation, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, bureau 4431, QC Quebec City, G1R 1P5 Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), 525, Boulevard Wilfrid Hamel, QC Quebec City, G1M 2S8 Canada
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7
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Holmes G, Clacy A, Salmon PM. Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby. ERGONOMICS 2019; 62:1485-1494. [PMID: 31390942 DOI: 10.1080/00140139.2019.1654134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 07/20/2019] [Indexed: 06/10/2023]
Abstract
The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.
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Affiliation(s)
- Glenn Holmes
- Sunshine Coast Mind & Neuroscience - Thompson Institute, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
| | - Amanda Clacy
- Sunshine Coast Mind & Neuroscience - Thompson Institute, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
| | - Paul M Salmon
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
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8
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Clacy A, Goode N, Sharman R, Lovell GP, Salmon P. A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union. APPLIED ERGONOMICS 2019; 80:256-264. [PMID: 28687400 DOI: 10.1016/j.apergo.2017.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 02/09/2017] [Accepted: 06/15/2017] [Indexed: 06/07/2023]
Abstract
AIM The aim of the present study was to utilise a systems thinking approach to explore the perceived responsibilities for identifying and treating concussion held by different actors across the community rugby system (e.g., players, coaches, parents, medics, referees, and management), as well as their role-specific concussion management strategies. METHODS A systems approach was taken to assess what different stakeholders within rugby systems perceive their roles to be regarding concussion identification and treatment. Through an online survey, 118 members of the amateur (community) rugby union system were asked about their role-specific concussion management responsibilities and strategies. Respondents included players, parents, medics, coaches, club managers, administrators, and volunteers. RESULTS The majority of respondents indicated that they were able to identify the symptoms of rugby-related concussion, however, only medics stated their responsibility to use formal concussion assessments (e.g., SCAT2). A smaller number of the respondents indicated that they were involved in treating concussion within their current role/s (majority of which were medics). CONCLUSIONS This study illustrated that the current challenges in the identification and treatment of rugby-related concussion in community sport may be due to role/responsibility confusion and possible overreliance on field-side medics. These findings offer insight into the possible limitations of the current concussion management guidelines and may offer empirically based direction for future revisions.
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Affiliation(s)
- Amanda Clacy
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Australia.
| | - Natassia Goode
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Australia
| | - Rachael Sharman
- Faculty of Arts and Business (Psychology), University of the Sunshine Coast, Australia
| | - Geoff P Lovell
- Faculty of Arts and Business (Psychology), University of the Sunshine Coast, Australia
| | - Paul Salmon
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Australia
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9
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Dessy AM, Yuk FJ, Maniya AY, Gometz A, Rasouli JJ, Lovell MR, Choudhri TF. Review of Assessment Scales for Diagnosing and Monitoring Sports-related Concussion. Cureus 2017; 9:e1922. [PMID: 29456902 PMCID: PMC5802754 DOI: 10.7759/cureus.1922] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sports-related concussion has emerged as a public health crisis due to increased diagnosis of the condition and increased participation in organized and recreational athletics worldwide. Under-recognition of concussions can lead to premature clearance for athletic participation, leaving athletes vulnerable to repeat injury and subsequent short- and long-term complications. There is overwhelming evidence that assessment and management of sports-related concussions should involve a multifaceted approach. A number of assessment criteria have been developed for this purpose. It is important to understand the available and emerging diagnostic testing modalities for sports-related concussions. The most commonly used tools for evaluating individuals with concussion are the Post-Concussion Symptom Scale (PCSS), Standard Assessment of Concussion (SAC), Standard Concussion Assessment Tool (SCAT3), and the most recognized computerized neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The strengths and limitations of each of these tools, and the Concussion Resolution Index (CRI), CogSport, and King-Devick tests were evaluated. Based on the data, it appears that the most sensitive and specific of these is the ImPACT test. Additionally, the King-Devick test is an effective adjunct due to its ability to test eye movements and brainstem function.
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Affiliation(s)
- Alexa M Dessy
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center
| | - Frank J Yuk
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center
| | - Akbar Y Maniya
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center
| | - Alex Gometz
- Concussion Management of New York, Icahn School of Medicine at Mount Sinai
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10
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Clacy A, Goode N, Sharman R, Lovell GP, Salmon PM. A knock to the system: A new sociotechnical systems approach to sport-related concussion. J Sports Sci 2016; 35:2232-2239. [DOI: 10.1080/02640414.2016.1265140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Amanda Clacy
- Centre for Human Factors and Sociotechnical Systems, Faculty of Arts, Business, and Law, University of the Sunshine Coast, Maroochydore, Queensland, Australia
| | - Natassia Goode
- Centre for Human Factors and Sociotechnical Systems, Faculty of Arts, Business, and Law, University of the Sunshine Coast, Maroochydore, Queensland, Australia
| | - Rachael Sharman
- School of Social Sciences, Faculty of Arts, Business, and Law, University of the Sunshine Coast, Maroochydore, Queensland, Australia
| | - Geoff P. Lovell
- School of Social Sciences, Faculty of Arts, Business, and Law, University of the Sunshine Coast, Maroochydore, Queensland, Australia
| | - Paul M. Salmon
- Centre for Human Factors and Sociotechnical Systems, Faculty of Arts, Business, and Law, University of the Sunshine Coast, Maroochydore, Queensland, Australia
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11
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Hurtubise J, Gorbet D, Hamandi Y, Macpherson A, Sergio L. The effect of concussion history on cognitive-motor integration in elite hockey players. Concussion 2016; 1:CNC17. [PMID: 30202559 PMCID: PMC6093836 DOI: 10.2217/cnc-2016-0006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/03/2016] [Indexed: 11/23/2022] Open
Abstract
AIM To observe the effects of concussion history on cognitive-motor integration in elite-level athletes. METHODS The study included 102 National Hockey League draft prospects (n = 51 concussion history [CH]; n = 51 no history [NC]). Participants completed two computer-based visuomotor tasks, one involved 'standard' visuomotor mapping and one involved 'nonstandard' mapping in which vision and action were decoupled. RESULTS We observed a significant effect of group on reaction time (CH slower) and accuracy (CH worse), but a group by condition interaction only for reaction time (p < 0.05). There were no other deficits found. We discussed these findings in comparison to our previous work with non-elite athletes. CONCLUSION Previously concussed elite-level athletes may have lingering neurological deficits that are not detected using standard clinical assessments.
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Affiliation(s)
- Johanna Hurtubise
- School of Kinesiology & Health Science, York University, Toronto, ON, M3J 1P3, Canada
- York University Sports Medicine Team, York University Department of Athletics and Recreation, York University, Toronto, ON, M3J 1P3, Canada
| | - Diana Gorbet
- School of Kinesiology & Health Science, York University, Toronto, ON, M3J 1P3, Canada
- Center for Vision Research, York University, Toronto, ON, M3J 1P3, Canada
| | - Yehyah Hamandi
- School of Kinesiology & Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - Alison Macpherson
- School of Kinesiology & Health Science, York University, Toronto, ON, M3J 1P3, Canada
- York University Sports Medicine Team, York University Department of Athletics and Recreation, York University, Toronto, ON, M3J 1P3, Canada
| | - Lauren Sergio
- School of Kinesiology & Health Science, York University, Toronto, ON, M3J 1P3, Canada
- York University Sports Medicine Team, York University Department of Athletics and Recreation, York University, Toronto, ON, M3J 1P3, Canada
- Center for Vision Research, York University, Toronto, ON, M3J 1P3, Canada
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12
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Morin M, Langevin P, Fait P. Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. JOURNAL OF SPORTS MEDICINE (HINDAWI PUBLISHING CORPORATION) 2016; 2016:1590161. [PMID: 27529079 PMCID: PMC4977400 DOI: 10.1155/2016/1590161] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/30/2016] [Accepted: 06/19/2016] [Indexed: 06/06/2023]
Abstract
Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.
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Affiliation(s)
- Michael Morin
- Department of Human Kinetics, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada G9A 5H7
- Research Group on Neuromusculoskeletal Dysfunctions (GRAN), UQTR, Trois-Rivières, QC, Canada G9A 5H7
| | - Pierre Langevin
- Cortex Médecine et Réadaptation Concussion Clinic, Quebec City, QC, Canada G1W 0C5
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC, Canada G1V 0A6
| | - Philippe Fait
- Department of Human Kinetics, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada G9A 5H7
- Research Group on Neuromusculoskeletal Dysfunctions (GRAN), UQTR, Trois-Rivières, QC, Canada G9A 5H7
- Cortex Médecine et Réadaptation Concussion Clinic, Quebec City, QC, Canada G1W 0C5
- Research Center in Neuropsychology and Cognition (CERNEC), Montreal, QC, Canada H3C 3J7
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13
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Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists. Phys Ther 2016; 96:1018-28. [PMID: 26637654 DOI: 10.2522/ptj.20140598] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND A concussion is considered a mild traumatic brain injury that may cause physical, cognitive, affective, and sleep dysfunction. Physical therapists have been identified as health care providers involved in the multidisciplinary care of a patient with concussion. OBJECTIVE The purpose of this study was to describe the current attitudes and beliefs, knowledge, and practice of physical therapists in the treatment of patients with concussion. METHODS A 55-question electronic survey divided into 6 sections-(1) demographics, (2) current practice in concussion, (3) youth concussion legislation, (4) attitudes and beliefs toward concussion management, (5) concussion knowledge, and (6) clinical decision making-was developed and distributed online through selected American Physical Therapy Association sections. RESULTS A total of 1,272 physical therapists completed the survey. Seventy percent of the respondents (n=894) reported having concussion training. Although supportive of the role of the physical therapist in the treatment of a person with concussion, the respondents demonstrated less confidence when making return-to-play decisions. Respondents correctly answered, on average, 13 (out of 15) concussion knowledge questions, with gaps exhibited in understanding the clinical utilization of concussion severity scales, the conservative treatment of youth who sustain a concussion, and anticipated normal computed tomography and magnetic resonance imaging after a concussion. When provided with clinical scenarios, respondents were able to recognize when a referral to a physician was indicated; however, they demonstrated variability in identifying a need for vestibular or manual physical therapy. LIMITATIONS Convenience sampling was utilized, limiting generalizability of the results of the study to the physical therapy profession as a whole. CONCLUSION Physical therapists demonstrated a solid foundation of concussion knowledge, but gaps still existed. Future professional development opportunities should be developed to target identified gaps in knowledge and current practice patterns.
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14
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Dalecki M, Albines D, Macpherson A, Sergio LE. Prolonged cognitive-motor impairments in children and adolescents with a history of concussion. Concussion 2016; 1:CNC14. [PMID: 30202556 PMCID: PMC6094154 DOI: 10.2217/cnc-2016-0001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 02/26/2016] [Indexed: 01/01/2023] Open
Abstract
Aim: We investigated whether children and adolescents with concussion history show cognitive–motor integration (CMI) deficits. Method: Asymptomatic children and adolescents with concussion history (n = 50; mean 12.84 years) and no history (n = 49; mean: 11.63 years) slid a cursor to targets using their finger on a dual-touch-screen laptop; target location and motor action were not aligned in the CMI task. Results: Children and adolescents with concussion history showed prolonged CMI deficits, in that their performance did not match that of no history controls until nearly 2 years postevent. Conclusion: These CMI deficits may be due to disruptions in fronto-parietal networks, contributing to an increased vulnerability to further injury. Current return-to-play assessments that do not test CMI may not fully capture functional abilities postconcussion.
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Affiliation(s)
- Marc Dalecki
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Toronto, Ontario, Canada.,School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Toronto, Ontario, Canada
| | - David Albines
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada
| | - Alison Macpherson
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,York University Sport Medicine Team, York University, Toronto, Ontario, Canada.,School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,York University Sport Medicine Team, York University, Toronto, Ontario, Canada
| | - Lauren E Sergio
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Toronto, Ontario, Canada.,York University Sport Medicine Team, York University, Toronto, Ontario, Canada.,School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada.,Centre for Vision Research, York University, Toronto, Ontario, Canada.,York University Sport Medicine Team, York University, Toronto, Ontario, Canada
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15
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Donnan J, Walsh S, Fortin Y, Gaskin J, Sikora L, Morrissey A, Collins K, MacDonald D. Factors associated with the onset and progression of neurotrauma: A systematic review of systematic reviews and meta-analyses. Neurotoxicology 2016; 61:234-241. [PMID: 27006002 DOI: 10.1016/j.neuro.2016.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 01/07/2023]
Abstract
Neurotrauma, including traumatic brain injury (TBI) and spinal cord injury (SCI), is a preventable condition that imposes an important burden on the Canadian society. In this study, the current evidence on risk factors for the onset and progression of neurotrauma is systematically reviewed and synthesized. Searches of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Medline and Medline in Process (via OVID), EMBASE and PsycINFO from inception to February 2013 were conducted to identify relevant systematic reviews and meta-analyses published in English or French. Two referees screened and assessed the quality of the studies using the AMSTAR tool. Thirty-two studies examined at least one risk factor for the onset of neurotrauma. Thirteen studies passed the quality assessment and the majority evaluated the impact of protective equipment in sports. Helmets effectively reduce TBI from bicycling, skiing, snowboarding, ice hockey and motorcycling. There was no evidence of a protective effect of helmets for SCI. No studies contributed evidence on risk factors for the onset of SCI. Of two studies examining risk factors for the progression of neurotrauma, only injury severity was found to be associated with poorer post-injury outcomes. Substantial evidence supports the use of helmets for the prevention of TBI in sports and motorcycling and face shields in ice hockey. Addressing bicycle helmet legislation across Canada may be an effective option for reducing TBI caused by bicycle accidents. Limited evidence on relevant risk factors for spinal cord injuries and neurotrauma progression was available.
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Affiliation(s)
- Jennifer Donnan
- School of Pharmacy, Memorial University of Newfoundland, Health Science Centre, St. John's, NL, Canada.
| | - Stephanie Walsh
- Newfoundland and Labrador Centre for Health Information, St. John's, NL, Canada
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, ON, Canada
| | - Janet Gaskin
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Andrea Morrissey
- School of Pharmacy, Memorial University of Newfoundland, Health Science Centre, St. John's, NL, Canada
| | - Kayla Collins
- School of Pharmacy, Memorial University of Newfoundland, Health Science Centre, St. John's, NL, Canada
| | - Don MacDonald
- School of Pharmacy, Memorial University of Newfoundland, Health Science Centre, St. John's, NL, Canada
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Fischer TD, Red SD, Chuang AZ, Jones EB, McCarthy JJ, Patel SS, Sereno AB. Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task. J Neurotrauma 2015; 33:1237-46. [PMID: 26398492 DOI: 10.1089/neu.2015.3990] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.
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Affiliation(s)
- Tara D Fischer
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Stuart D Red
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Alice Z Chuang
- 2 Department of Ophthalmology and Visual Science, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Elizabeth B Jones
- 3 Department of Emergency Medicine, the University of Texas Health Science Center at Houston , Houston, Texas
| | - James J McCarthy
- 3 Department of Emergency Medicine, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Saumil S Patel
- 4 Department of Neuroscience, Baylor College of Medicine , Houston, Texas
| | - Anne B Sereno
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
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17
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Burns SL. Concussion Treatment Using Massage Techniques: a Case Study. Int J Ther Massage Bodywork 2015; 8:12-7. [PMID: 26082825 PMCID: PMC4455610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Concussion, its recognition, diagnosis, and treatment is a growing public health issue. Massage practitioners who specialize in rehabilitation deal with a variety of injury cases that involve concussion, including those incurred by falls, motor vehicle incidents, and sports injuries. PURPOSE This case study presents a unique massage therapy approach to concussion trauma treatment. PARTICIPANT Male 23-year-old intramural soccer player diagnosed with postconcussion syndrome resulting from a fall. INTERVENTION Assessment and treatment were completed in two sessions of 45 minutes spaced two days apart. Massage therapy techniques were applied to injury areas by a Licensed Massage Practitioner. RESULTS Using the Balance Error Scoring System (BESS) and self-report, the outcome measures showed diminished concussion symptoms and regained ease in range of motion in the cervical area. CONCLUSION Positive results for this case highlight the potential importance of massage therapy work to reduce headache, dizziness, and nausea in concussion recovery. In the presence of such outcomes, massage therapy may also have a supportive role in a person's return to function after concussion.
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Affiliation(s)
- Sylvia L. Burns
- University of Washington Medical Center, Department of Rehabilitation, Roosevelt Center - Exercise Training Center, Seattle, WA, USA
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18
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Reneker JC, Cook CE. Dizziness after sports-related concussion: Can physiotherapists offer better treatment than just ‘physical and cognitive rest’? Br J Sports Med 2014; 49:491-2. [DOI: 10.1136/bjsports-2014-093634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Weber ML, Welch CE, Parsons JT, Valovich McLeod TC. School nurses' familiarity and perceptions of academic accommodations for student-athletes following sport-related concussion. J Sch Nurs 2014; 31:146-54. [PMID: 25015367 DOI: 10.1177/1059840514540939] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to evaluate school nurses' familiarity and perceptions regarding academic accommodations for student-athletes following sport-related concussion. School nurses (N = 1,246) accessed the survey School Nurses' Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC-SN). The BAKPAC-SN contained several questions pertaining to concussion management and academic accommodations. There were significant differences regarding personal experience as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an athletic trainer and school nurses who work at a school that does not employ an athletic trainer. There were significant weak positive relationships between years of experience and familiarity with academic accommodations (r = .210, p < .001), 504 plans (r = .243, p < .001), and individualized education plans (r = .205, p < .001). School nurses employed at a single school were significantly more familiar with academic accommodations (p = .027) and 504 plans (p = .001) than school nurses employed at multiple schools. Health care professionals should collaborate to effectively manage a concussed patient and should consider academic accommodations to ensure whole-person health care.
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Affiliation(s)
| | | | - John T Parsons
- National Collegiate Athletic Association, Indianapolis, IN, USA
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20
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Dessy A, Rasouli J, Gometz A, Choudhri T. A review of modifying factors affecting usage of diagnostic rating scales in concussion management. Clin Neurol Neurosurg 2014; 122:59-63. [PMID: 24908218 DOI: 10.1016/j.clineuro.2014.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/25/2014] [Accepted: 04/09/2014] [Indexed: 11/24/2022]
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21
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Bridging the Gap in Concussion Knowledge. J Neurol Phys Ther 2013; 37:205. [DOI: 10.1097/npt.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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