1
|
Mikolic A, Klotz T, Brasher P, Yeates K, Vranceanu AM, Kendall KD, Snell DL, Debert CT, Bayley M, Panenka W, Cairncross M, Hunt C, Burke M, Tartaglia MC, Silverberg N. Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial. BMJ Open 2024; 14:e086602. [PMID: 38950993 PMCID: PMC11218021 DOI: 10.1136/bmjopen-2024-086602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024] Open
Abstract
INTRODUCTION Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments. METHODS AND ANALYSIS We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire). ETHICS AND DISSEMINATION Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians. TRIAL REGISTRATION NUMBER ClinicalTrials.gov #NCT05365776.
Collapse
Affiliation(s)
- Ana Mikolic
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Tasha Klotz
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Penelope Brasher
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Keith Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Univeristy of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen D Kendall
- School of Kinesiology, Acadia University, Wolfville, Nova Scotia, Canada
| | - Deborah L Snell
- Department of Orthopedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Chantel T Debert
- Alberta Children's Hospital Research Institute, Univeristy of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Univeristy of Calgary, Calgary, Alberta, Canada
| | - Mark Bayley
- Hull-Ellis Concussion Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Medicine, University of Toronto, Toronto, Ontario, Canada
| | - William Panenka
- Department of Psychiatry, UBC, Vancouver, British Columbia, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada
- British Columbia Provincial Neuropsychiatry Program, Vancouver, British Columbia, Canada
| | - Molly Cairncross
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Cindy Hunt
- Head Injury Clinic, Department of Trauma and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Concussion Ontario Network: Neuroinformatics to Enhance Clinical Care and Translation, Toronto, British Columbia, Canada
| | - Matthew Burke
- Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Hurvitz Brain Sciences Program and Tory Trauma Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- Tanz Centre for Research in Neurodegenerative Diseases, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Noah Silverberg
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| |
Collapse
|
2
|
Kontos AP, Eagle SR, Braithwaite R, Preszler J, Manderino L, Turner RL, Jennings S, Trbovich A, Hickey RW, Collins MW, McCrea M, Nelson LD, Root J, Thomas DG. The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients. Am J Sports Med 2023; 51:3893-3903. [PMID: 36847271 DOI: 10.1177/03635465221150214] [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] [Indexed: 03/01/2023]
Abstract
BACKGROUND Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION CRD42021253060 (PROSPERO).
Collapse
Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rock Braithwaite
- Department of Kinesiology and Recreation Administration, Cal Poly Humboldt, Arcata, California, USA
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Lisa Manderino
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Rose L Turner
- Health Science Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alicia Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Children's Hospital of Pittsburgh Division of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeremy Root
- Pediatric Emergency Medicine, George Washington School of Medicine, Washington, DC, USA; Children's National Health System, Fairfax, Virginia, USA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Pediatric Emergency Medicine, Children's Wisconsin, Wauwatosa, Wisconsin, USA)
- Investigation performed at University of Pittsburgh Medical Center Sports Concussion Program and University of Pittsburgh Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Jaganathan KS, Sullivan KA, Greenslade J, McMahon KL, Mitchell G, Kerr G. Understanding the Sociocognitive Determinants Underlying Intentions to Exercise for Postconcussion Symptom Relief: An Application of the Theory of Planned Behavior. J Sport Rehabil 2023; 32:873-883. [PMID: 37591504 DOI: 10.1123/jsr.2023-0017] [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] [Received: 01/17/2023] [Revised: 05/19/2023] [Accepted: 06/19/2023] [Indexed: 08/19/2023]
Abstract
CONTEXT This study investigated individual sociocognitive factors from the theory of planned behavior and their relationship to exercise for postconcussion recovery. DESIGN AND METHODS Four hundred and fifty-nine Australian adults, two-thirds of whom had no concussion history (66%), completed an online survey of their beliefs and attitudes toward exercise for postconcussion recovery. Secondary questions evaluated program design features that could affect engagement (eg, session frequency). RESULTS Structured equation modeling found that subjective norms were the strongest significant predictor of intention to participate in exercise for postconcussion recovery. Perceived behavioral control was also a significant predictor of intention to participate but to a lesser extent. Attitude did not predict participation intention. The design features identified as key were personalization and being supervised during the program. CONCLUSIONS This study found that people's intention to participate in a program of exercise postconcussion recovery is shaped by individual psychological factors and identified program design features that could be adjusted for increased engagement. Program success could be maximized through strategies such as supporting individuals to have a stronger sense of control over their participation through the choice of session timing or frequency and harnessing the influence of significant others via supportive messaging from key professionals.
Collapse
Affiliation(s)
| | - Karen A Sullivan
- School of Psychology & Counselling, Centre for Biomedical Technologies, Queensland University of Technology, Brisbane,Australia
| | - Jamie Greenslade
- School of Public Health and Social Work, Queensland University of Technology, Brisbane,Australia
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane,Australia
| | - Katie L McMahon
- School of Clinical Sciences, Centre for Biomedical Technologies, Queensland University of Technology, Brisbane,Australia
| | - Gary Mitchell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane,Australia
| | - Graham Kerr
- School of Exercise & Nutrition Sciences, Centre for Biomedical Technologies, Queensland University of Technology, Brisbane,Australia
| |
Collapse
|
4
|
Vuu S, Barr CJ, Killington M, Howie J, Hutchins S, van den Berg MEL. The Buffalo Concussion Treadmill and Bike Tests in People With Mild-to-Moderate Traumatic Brain Injury: An Exploratory Clinical Audit. J Head Trauma Rehabil 2023; 38:E414-E423. [PMID: 37115938 DOI: 10.1097/htr.0000000000000879] [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: 04/30/2023]
Abstract
OBJECTIVE To assess the performance on the Buffalo Concussion Treadmill and Bike Tests in nonathletic people following a mild-to-moderate traumatic brain injury. SETTING An outpatient rehabilitation clinic. PARTICIPANTS Forty-nine patients with mild-to-moderate traumatic brain injury who underwent the Buffalo Concussion Treadmill or Bike Test as usual clinical care. DESIGN A retrospective clinical audit. MAIN MEASURES Demographics and brain injury-specific clinical data, Depression Anxiety Stress Scale; Rivermead Post-Concussion Symptom Questionnaire, and performance outcomes on the Buffalo Concussion Treadmill or Bike Test. RESULTS Forty-nine patients (mean age: 33.7 ± 13.0 years), on average 56.2 ± 36.4 days post-injury, completed the Buffalo Concussion Treadmill or Bike Test. Fourteen patients stopped the test due to symptom exacerbation with a mean test duration of 8.1 ± 4.5 minutes, reaching an age-predicted maximum heart rate of 72.9% ± 12.4% and reporting a rating of perceived exertion of 13.4 ± 2.2. Those who terminated the test for other reasons had a significantly longer test duration (14.0 ± 4.7 minutes, P = .01), with a higher age-predicted maximum heart rate (83.3% ± 12.8%, P = .01) and rating of perceived exertion (17.0 ± 2.5, P = .01). Within the group who stopped for other reasons, 10 were due to symptoms deemed unrelated to the injury at the time of the test and 2 were stopped by the therapist for safety reasons. A significant but weak correlation between heart rate and rating of perceived exertion existed only for those who terminated the test for other reasons ( r = 0.38, P = .02). Overall, a shorter test duration was associated with higher scores of both self-reported depression ( r = -0.41, P < .01) and late postconcussion symptoms ( r = -0.40, P < .01). CONCLUSION The Buffalo Concussion Treadmill or Bike Test can be used in the nonathletic mild-to-moderate traumatic brain injury population to differentiate between those who experience symptom exacerbation during exercise and those who do not based on symptom exacerbation, test duration, and poor perception of exertion. Further research is required to determine whether other reasons for test termination are related to the injury.
Collapse
Affiliation(s)
- Sally Vuu
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia (Ms Vuu and Drs Barr and van den Berg); Brain Injury Rehabilitation Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia (Dr Killington and Ms Hutchins); and Physiotherapy, Brain Injury Rehabilitation Services, Adelaide, Australia (Ms Howie)
| | | | | | | | | | | |
Collapse
|
5
|
Cordingley DM, Cornish SM. Reply to the discussion by Wang et al. of "Efficacy of aerobic exercise following concussion: a narrative review". Appl Physiol Nutr Metab 2023; 48:552-553. [PMID: 37222426 DOI: 10.1139/apnm-2023-0161] [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)
- Dean M Cordingley
- Pan Am Clinic Foundation, Winnipeg, MB R3M 3E4, Canada
- Applied Health Sciences, Winnipeg, MB R3T 2N2, Canada
| | - Stephen M Cornish
- Applied Health Sciences, Winnipeg, MB R3T 2N2, Canada
- Faculty of Kinesiology and Recreation Management, Winnipeg, MB R3T 2N2, Canada
- Centre for Aging, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| |
Collapse
|
6
|
Valaas LJV, Soberg HL, Rasmussen MS, Steenstrup SE, Andelic N, Kleffelgård I. Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury - a study protocol with a nested feasibility study for a randomized controlled trial. BMC Neurol 2023; 23:179. [PMID: 37138202 PMCID: PMC10155435 DOI: 10.1186/s12883-023-03221-7] [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: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI. MAIN PURPOSE The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation. DESIGN Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1. METHODS Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance-the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity. DISCUSSION This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT. TRIAL REGISTRATION Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021.
Collapse
Affiliation(s)
- Lars-Johan V Valaas
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.
- Center for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Helene L Soberg
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Mari S Rasmussen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Sophie E Steenstrup
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Center for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ingerid Kleffelgård
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
7
|
Pelo R, Suttman E, Fino PC, McFarland MM, Dibble LE, Cortez MM. Autonomic dysfunction and exercise intolerance in concussion: a scoping review. Clin Auton Res 2023; 33:149-163. [PMID: 37038012 PMCID: PMC10812884 DOI: 10.1007/s10286-023-00937-x] [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] [Received: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE Concussion commonly results in exercise intolerance, often limiting return to activities. Improved understanding of the underlying mechanisms of post-concussive exercise intolerance could help guide mechanism-directed rehabilitation approaches. Signs of altered cardiovascular autonomic regulation-a potential contributor to exercise intolerance-have been reported following concussion, although it is not clear how these findings inform underlying mechanisms of post-concussive symptoms. Systematic summarization and synthesis of prior work is needed to best understand current evidence, allowing identification of common themes and gaps requiring further study. The purpose of this review was to (1) summarize published data linking exercise intolerance to autonomic dysfunction, and (2) summarize key findings, highlighting opportunities for future investigation. METHODS The protocol was developed a priori, and conducted in five stages; results were collated, summarized, and reported according to PRISMA guidelines. Studies including injuries classified as mild traumatic brain injury (mTBI)/concussion, regardless of mechanism of injury, were included. Studies were required to include both autonomic and exercise intolerance testing. Exclusion criteria included confounding central or peripheral nervous system dysfunction beyond those stemming from the concussion, animal model studies, and case reports. RESULTS A total of 3116 publications were screened; 17 were included in the final review. CONCLUSION There was wide variability in approach to autonomic/exercise tolerance testing, as well as inclusion criteria/testing timelines, which limited comparisons across studies. The reviewed studies support current clinical suspicion of autonomic dysfunction as an important component of exercise intolerance. However, the specific mechanisms of impairment and relationship to symptoms and recovery require additional investigation.
Collapse
Affiliation(s)
- Ryan Pelo
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Erin Suttman
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Peter C Fino
- Department of Health and Kinesiology, University of Utah, Salt Lake City, UT, USA
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT, USA
| | - Leland E Dibble
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
8
|
Jaganathan KS, Sullivan KA, Kinmond S, Berndt S, Street S, Haden C, Greenslade J, McMahon K, Mitchell G, Kerr G. Exercise Parameters for Postconcussion Symptom Rehabilitation: A Systematic Review. J Sport Rehabil 2023:1-10. [PMID: 36940683 DOI: 10.1123/jsr.2022-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 12/04/2022] [Accepted: 12/21/2022] [Indexed: 03/23/2023]
Abstract
CONTEXT Exercise rehabilitation for postconcussion symptoms (PCS) has shown some benefits in adolescent athletes; but a synthesis of evidence on exercise per se has been lacking. OBJECTIVE This systematic review aimed to determine if unimodal exercise interventions are useful to treat PCS and if so, to identify a set of clearly defined and effective exercise parameters for further research. EVIDENCE ACQUISITION Relevant health databases and clinical trial registries were searched from inception to June 2022. The searches used a combination of subject headings and keywords related to mild traumatic brain injury (mTBI), PCSs, and exercise. Two independent reviewers screened and appraised the literature. The Cochrane Collaboration's Risk of Bias-2 tool for randomized controlled trials was used to assess methodological quality of studies. EVIDENCE SYNTHESIS Seven studies were included in the review. Four studies were assessed to have a low overall risk of bias, 2 with low risk and 1 with some concerns. Participants in the studies comprised mostly adolescents with sports-related concussion. The review found exercise to be more beneficial than control conditions in 2 studies investigating acute PCS and 2 studies investigating persistent PCS. Within-group differences showing symptom improvement over time were observed in all 7 studies. In general, the review found support for programmatic exercise that commences after an initial period of rest for 24 to 48 hours. Recommendations for exercise parameters that can be explored in subsequent research include progressive aerobic exercise starting from 10 to 15 minutes at least 4 times a week, at a starting intensity of 50% HR of the subsymptom threshold, with length of program depending on recovery. CONCLUSION The evidence in support of exercise rehabilitation for PCSs is moderate based on the small pool of eligible studies. Further research can be guided by the exercise parameters identified in this review.
Collapse
Affiliation(s)
| | - Karen A Sullivan
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Sally Kinmond
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Sara Berndt
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Steve Street
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Catherine Haden
- QUT Library, Academic Division, Queensland University of Technology, Brisbane, QLD,Australia
| | - Jaimi Greenslade
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD,Australia
- Emergency and Trauma Centre, RBWH Brisbane, QLD,Australia
| | - Katie McMahon
- School of Clinical Sciences, Center for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD,Australia
| | - Gary Mitchell
- Emergency and Trauma Centre, RBWH Brisbane, QLD,Australia
| | - Graham Kerr
- School of Exercise & Nutrition Sciences, Queensland University of Technology, Brisbane, QLD,Australia
| |
Collapse
|
9
|
Commentary: "Inflammation and the role of infection: Complications and treatment options following neurotrauma". J Clin Neurosci 2023:S0967-5868(23)00005-X. [PMID: 36669992 DOI: 10.1016/j.jocn.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023]
|
10
|
Cordingley DM, Cornish SM. Efficacy of aerobic exercise following concussion: a narrative review. Appl Physiol Nutr Metab 2023; 48:5-16. [PMID: 36423352 DOI: 10.1139/apnm-2022-0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Concussion is a type of mild traumatic brain injury which results in symptoms within the physical, cognitive, emotional, and sleep domains. Historically, guidelines established by expert opinion have recommended rest during the initial stages of recovery following a concussion until symptom resolution. However, recent recommendations have shifted to advise an initial period of 24-48 h of rest immediately following concussion with the gradual introduction of light-to-moderate intensity aerobic exercise thereafter. Given the relatively recent transition in recommendations, the aim of this review is to provide an overview of the current literature on the efficacy of aerobic exercise following concussion. The current literature is limited to studies assessing the impact of standardized aerobic exercise following concussion. Upon review, literature suggests participating in aerobic exercise below the point of symptom exacerbation is safe in both the acute and chronic post-concussion symptom stages of recovery and does not delay time to medical clearance. Future large-scale randomized controlled trials assessing the impact of aerobic exercise and differences between males and females would help support the current evidence suggesting aerobic exercise could improve time to recovery following concussion and identify any sex differences in response. As well, future studies with the purpose of identifying optimal aerobic exercise volume and intensity in the treatment of concussion could improve the specificity of the current guidelines.
Collapse
Affiliation(s)
- Dean M Cordingley
- Pan Am Clinic Foundation, Winnipeg, MB R3M 3E4 Canada
- Applied Health Sciences, Winnipeg, MB R3T 2N2, Canada
| | - Stephen M Cornish
- Applied Health Sciences, Winnipeg, MB R3T 2N2, Canada
- Faculty of Kinesiology and Recreation Management, Winnipeg, MB R3T 2N2, Canada
- Centre for Aging, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| |
Collapse
|
11
|
Hutchison MG, Di Battista AP, Loenhart M. A Continuous Aerobic Resistance Exercise (CARE) Protocol for Concussion Rehabilitation Delivered Remotely via a Mobile App: Feasibility Study (Preprint). JMIR Form Res 2022. [DOI: 10.2196/45321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
|
12
|
Mucha A, Pardini JE, Herring SA, Murphy J, Elbin RJ, Bauer RM, Schmidt JD, Resch JE, Broshek DK. Persisting symptoms after concussion: Considerations for active treatment. PM R 2022; 15:663-673. [PMID: 36507616 DOI: 10.1002/pmrj.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anne Mucha
- UPMC Centers for Rehab Services, UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Jamie E Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Justin Murphy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas, USA
| | - Russell M Bauer
- Department of Clinical & Health Psychology, University of Florida Department of Clinical & Health Psychology, Gainesville, Florida, USA
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, Georgia, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Donna K Broshek
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| |
Collapse
|
13
|
Vuu S, Barr CJ, Killington M, Jill G, van den Berg ME. Physical exercise for people with mild traumatic brain injury: A systematic review of randomized controlled trials. NeuroRehabilitation 2022; 51:185-200. [DOI: 10.3233/nre-220044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Recent research recommends physical exercise rather than rest following a mild traumatic brain injury (mTBI). OBJECTIVE: To determine the effect of physical exercise on persistent symptoms in people with mTBI. METHODS: A search of randomized controlled trials was conducted in CINAHL, Cochrane Library, EMBASE, MEDLINE, SportDiscus and Web of Science, from 2010 to January 2021. Studies were included if they described the effects of a physical exercise intervention in people with mTBI on persistent symptoms. Study quality, intervention reporting, and confidence in review findings were assessed with the CASP, TIDieR and GRADE respectively. RESULTS: 11 eligible studies were identified for inclusion. Study interventions broadly comprised of two categories of physical exercise, i.e., aerobic (n = 8) and vestibular (n = 3). A meta-analysis (n = 3) revealed the aerobic exercise group improvement was significantly larger compared to the usual care group –0.39 (95% CI: –0.73 to –0.05, p = 0.03). Only three studies using vestibular exercise reported on persistent symptoms and yielded mixed results. CONCLUSIONS: This study demonstrated that the use of aerobic exercise is supported by mixed quality evidence and moderate certainty of evidence, yet there is limited evidence for the use of vestibular exercise for improving persistent symptoms in people with mTBI.
Collapse
Affiliation(s)
- Sally Vuu
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Christopher J. Barr
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Maggie Killington
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Garner Jill
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | | |
Collapse
|
14
|
Quatman-Yates CC, Miley AE, Morrison P, Hugentobler J, Wade SL, Rhine TD, Kurowski BG. Adolescent and Parent Perceptions of the Impact of Concussion/mTBI on Family Functioning and Activity Levels in Recovery. J Head Trauma Rehabil 2022; 37:E280-E291. [PMID: 34570028 DOI: 10.1097/htr.0000000000000725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery. SETTING Outpatient research setting. PARTICIPANTS Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study. DESIGN Prospective ecological study with qualitative, semistructured interviews. MAIN MEASURES Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures. RESULTS Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies. CONCLUSIONS Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions.
Collapse
Affiliation(s)
- Catherine C Quatman-Yates
- School of Health and Rehabilitation Sciences, Sports Medicine Research Institute, and Chronic Brain Injury Program, The Ohio State University, Columbus (Dr Quatman-Yates); Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital, Cincinnati, Ohio (Drs Quatman-Yates and Hugentobler); Departments of Pediatrics (DrsWade, Rhine, and Kurowski) and Neurology and Rehabilitation Medicine (Dr Kurowski), University of Cincinnati College of Medicine, Cincinnati, Ohio; Divisions of Pediatric Rehabilitation Medicine (Ms Miley and Drs Morrison, Wade, and Kurowski) and Emergency Medicine (Dr Rhine), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and Department of Psychology, University of Cincinnati, Cincinnati, Ohio (Dr Wade)
| | | | | | | | | | | | | |
Collapse
|
15
|
Mollica A, Dey A, Cairncross M, Silverberg N, Burke MJ. Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches. Semin Neurol 2022; 42:168-181. [PMID: 35114694 DOI: 10.1055/s-0041-1742143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.
Collapse
Affiliation(s)
- Adriano Mollica
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ayan Dey
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Molly Cairncross
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Noah Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
16
|
Carter KM, Pauhl AN, Christie AD. The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis. Med Sci Sports Exerc 2021; 53:1835-1845. [PMID: 33787531 DOI: 10.1249/mss.0000000000002663] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to conduct a systematic review and meta-analysis of active rehabilitation on concussion management. We also examined moderator variables that may contribute to differences across studies: symptom scale, physical activity type, time of injury to recruitment, and mechanism of injury. METHODS The standardized effect size of physical activity on concussion management was computed for 23 studies (29 effect sizes). Effect sizes were coded as positive when studies reported an improvement in symptom scores, which was represented by a decrease in postconcussive symptom scores. RESULTS The overall effect size of physical activity on concussion recovery was large and positive (g = 1.03). Subthreshold aerobic activity provided the largest effect size (g = 1.71), whereas multimodal interventions had a moderate effect size (g = 0.70). All other moderator variables produced positive effect sizes ranging from g = 0.59 to g = 1.46. CONCLUSIONS This systematic review and meta-analysis demonstrates that current evidence supports the notion that physical activity is beneficial in decreasing postconcussive symptoms in both the acute and chronic phases after concussion. The results indicate that unimodal subthreshold aerobic activity may be the best course of action compared with multimodal interventions. Despite this growing body of evidence, additional research is needed to determine the optimal intensity, duration, and time to initiation of aerobic exercise after concussion.
Collapse
Affiliation(s)
- Kathryn M Carter
- Faculty of Health Sciences, School of Kinesiology, Western University, Ontario, CANADA
| | | | | |
Collapse
|
17
|
Sicard V, Caron G, Moore RD, Ellemberg D. Post-exercise cognitive testing to assess persisting alterations in athletes with a history of concussion. Brain Inj 2021; 35:978-985. [PMID: 34223775 DOI: 10.1080/02699052.2021.1944668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary Objective: To determine whether a physical exercise protocol could reveal persistent cognitive alterations in university athletes with a history of concussion (HOC). Thirty-four HOC and 34 controls participated in this study.Research Design: Cross-sectional.Methods and Procedures: The exercise protocol consisted of a 20-min bout on a stationary bike at 80% of the theoretical maximal heart rate. Before and after the exercise, participants performed a computerized switch task designed specifically to recruit executive functions. Group × Condition (pre- and post-exercise) repeated measures of ANCOVAs for accuracy, reaction time, and inverse efficiency score on the switch task were conducted. Chi-square tests were run to determine if the proportion of HOC and controls who underperformed (at least 2SD lower than the control group's average score) at rest and post-exercise were similar. Whilst no interaction or main effects were found with ANCOVAs, significantly more HOC athletes (21%) underperformed following exercise than at rest (3%) on the switch task, p = .02. The current results indicate that an acute bout of exercise can reveal persistent alterations that are not present at rest in the protracted phase of concussion. They also highlight the importance of considering inter-individual differences in recovery trajectories.
Collapse
Affiliation(s)
- Veronik Sicard
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
| | - Gabriel Caron
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
| | - Robert Davis Moore
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Dave Ellemberg
- School of Kinesiology and Exercise Science, Université De Montréal, Montreal, QC, Canada.,Centre De Recherche En Neuropsychologie Et Cognition, 90 Rue Vincent d'Indy, Université De Montréal, Montreal, QC, Canada
| |
Collapse
|
18
|
Mercier LJ, Fung TS, Harris AD, Dukelow SP, Debert CT. Improving symptom burden in adults with persistent post-concussive symptoms: a randomized aerobic exercise trial protocol. BMC Neurol 2020; 20:46. [PMID: 32024486 PMCID: PMC7003424 DOI: 10.1186/s12883-020-1622-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/21/2020] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Persistent post-concussive symptoms (PPCS) affect up to 30% of individuals following mild traumatic brain injury. PPCS frequently includes exercise intolerance. Sub-symptom threshold aerobic exercise has been proposed as a treatment option for symptom burden and exercise intolerance in this population. The primary aim of this study is to evaluate whether a progressive, sub-symptom threshold aerobic exercise program can alleviate symptom burden in adults with PPCS. METHODS Fifty-six adults (18-65) with PPCS (>3mos-5 yrs) will be randomized into two groups: an immediate start 12-week aerobic exercise protocol (AEP) or delayed start 6-week placebo-like stretching protocol (SP), followed by AEP. Aerobic or stretching activities will be completed 5x/week for 30 mins during the intervention. Online daily activity logs will be submitted. Exercise prescriptions for the AEP will be 70-80% of heart rate at the point of symptom exacerbation achieved on a treadmill test with heart rate monitoring. Exercise prescription will be updated every 3-weeks with a repeat treadmill test. The Rivermead Post-concussion Symptom Questionnaire will be the primary outcome measure at 6 and 12-weeks of intervention. Secondary outcomes include assessments of specific symptoms (headache, quality of life, mood, anxiety, fatigue, dizziness, sleep parameters, daytime sleepiness) in addition to blood biomarkers and magnetic resonance imaging and spectroscopy data for quantification of brain metabolites including γ-aminobutyric acid (GABA), glutathione, glutamate and N-acetyl aspartate (NAA) all measured at 6 and 12-weeks of intervention. DISCUSSION This trial will evaluate the use of aerobic exercise as an intervention for adults with PPCS, thus expanding our knowledge of this treatment option previously studied predominantly for adolescent sport-related concussion. TRIAL REGISTRATION ClinicalTrials.gov - NCT03895450 (registered 2019-Feb-11).
Collapse
Affiliation(s)
- Leah J Mercier
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, AB, Canada.
| | - Tak S Fung
- Information Technologies, University of Calgary, Calgary, AB, Canada
| | - Ashley D Harris
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Sean P Dukelow
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, AB, Canada
| | - Chantel T Debert
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, AB, Canada
| |
Collapse
|