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Elbin RJ, Durfee KJ, Womble MN, Jennings S, Fedor S, Dollar CM, Felt JM, Elbich DB, Hakun JG. Documenting Compliance and Symptom Reactivity for Ambulatory Assessment Methodology Following Concussion in Adolescents and Young Adults: Feasibility of the Mobile Neurocognitive Health (MNCH) Project. J Head Trauma Rehabil 2024:00001199-990000000-00174. [PMID: 38922030 DOI: 10.1097/htr.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVE Evaluate compliance, symptom reactivity, and acceptability/experience ratings for an ecological momentary assessment (EMA) protocol involving ultra-brief ambulatory cognitive assessments in adolescent and young adult patients with concussion. SETTING Outpatient concussion clinic. PARTICIPANTS 116 patients aged 13 to 25 years with concussion. DESIGN Prospective research design was used to examine compliance, symptom reactivity, and acceptability/experience for the Mobile Neurocognitive Health Project (MNCH); an EMA study of environmental exposures, symptoms, objective cognitive functioning, and symptom reactivity involving 4, daily EMA surveys (7:30 am, 10:30 am, 3:00 pm, 8:00 pm) for a period of 7 days following concussion. Overall compliance rates, symptom reactivity scores, and participant acceptability/experience ratings were described. A series of non-parametric Friedman Tests with post-hoc Wilcoxon signed-rank tests were used to examine differences in compliance and reactivity related to time of day and over the course of the protocol (first 3 days [Early Week] vs last 4 days [Late Week]). MAIN MEASURES Compliance rates, symptom reactivity scores, participant experience/acceptability. RESULTS Overall median compliance was 71%, and there were significantly fewer 7:30 am surveys completed compared to the 10:30 am (Z = -4.88,P ≤ .001), 3:00 pm (Z = -4.13,P ≤ .001), and 8:00 pm (Z = -4.68, P ≤ .001) surveys. Compliance for Early Week surveys were significantly higher than Late Week (Z = -2.16,P = .009). The median symptom reactivity score was 34.39 out of 100 and was significantly higher for Early Week compared to Late Week (Z = -4.59,P ≤ .001). Ninety-nine percent (89/90) of the sample agreed that the app was easy to use, and 18% (16/90) indicated that the app interfered with their daily life. CONCLUSION Adolescents and young adults with concussion were compliant with the MNCH EMA protocol. Symptom reactivity to the protocol was low and the majority of participants reported that the app and protocol were acceptable. These findings support further investigation into applications of EMA for use in concussion studies.
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Affiliation(s)
- R J Elbin
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, Arkansas (Dr Elbin and Ms Durfee); Inova Sports Medicine Concussion Program, Fairfax, Virginia (Drs Womble, Jennings, Fedor, and Dollar); Inova Physical Therapy Center, Fairfax, Virginia (Dr Fedor); Center for Healthy Aging, The Pennsylvania State University, University Park, Pennsylvania (Drs Felt and Hakun); Department of Neurology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania (Drs Elbich and Hakun); Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania (Dr Hakun); Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania (Dr Hakun) and Translational Brain Research Center, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania (Dr Hakun)
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Jo J, Berkner PD, Stephenson K, Maxwell BA, Iverson GL, Zuckerman SL, Terry DP. Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines. Clin J Sport Med 2024:00042752-990000000-00188. [PMID: 38780403 DOI: 10.1097/jsm.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 04/28/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC). DESIGN Retrospective cohort study. SETTING National Collegiate Athletic Association Division III collegiate programs. PARTICIPANTS Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023. INTERVENTION Preinjury migraines (yes/no) were self-reported by athletes. MAIN OUTCOME MEASURES Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores. RESULTS Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (β = 0.12, P <0 .001) and greater number of days to symptom evaluation (β = 0.08, P = 0.005) had higher PCSS scores. CONCLUSIONS Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.
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Affiliation(s)
- Jacob Jo
- Vanderbilt Sports Concussion Center, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul D Berkner
- College of Osteopathic Medicine, University of New England, Biddeford, Maine
| | - Katie Stephenson
- College of Osteopathic Medicine, University of New England, Biddeford, Maine
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Bruce A Maxwell
- Khoury College of Computer Science, Northeastern University, Seattle, Washington
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts; and
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, Massachusetts
| | - Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas P Terry
- Vanderbilt Sports Concussion Center, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Anderson M, Reynolds E, Gilliland T, Hammonds K, Driver S. The Association Among Clinical Profiles, Modifiers, and Prolonged Recovery in Adolescents With Sport-Related Concussion. Clin J Sport Med 2024; 34:266-272. [PMID: 37937954 DOI: 10.1097/jsm.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE The purposes were to (1) describe the prevalence of clinical profiles and modifiers, (2) examine the association between clinical profiles and prolonged recovery, and (3) examine the interaction between clinical profiles and modifiers and prolonged recovery in adolescents with sport-related concussion (SRC). DESIGN Retrospective, cross-sectional. SETTING Interdisciplinary specialty sports concussion clinic. PATIENTS Patients (n = 299) aged 12 to 19 years who were diagnosed with SRC within 30 days of injury. INDEPENDENT VARIABLES Clinical profiles and modifiers were decided by the clinical judgment of the clinical neuropsychologist and sports medicine physician, using data from the Clinical Profile Screen and information gathered from the clinical interview, neurocognitive, and vestibular and ocular motor testing. MAIN OUTCOME MEASURES Prolonged recovery was defined as ≥28 days from the date of injury to the date of clearance. RESULTS The most common clinical profiles were migraine (34.8%) and cognitive-fatigue (23.4%). There were no significant relationships between clinical profiles and prolonged recovery (Wald = 5.89, df = 4, P = 0.21). The presence of a modifier did not significantly affect the relationship between clinical profiles and prolonged recovery ( = 6.5, df = 5, P = 0.26). The presence of any modifier yielded a 10-day increase in median recovery time within the cognitive/fatigue clinical profile (Wilcoxon rank-sum = 268.5, P = 0.01). CONCLUSIONS Although patients with a clinical profile and modifier may not experience prolonged recovery, they may experience longer recovery time than patients with a clinical profile and no modifier.
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Affiliation(s)
- Morgan Anderson
- Baylor Scott & White Sports Therapy and Research, Frisco, Texas
- Baylor Scott & White Research Institute, Dallas, Texas
| | - Erin Reynolds
- Baylor Scott & White Sports Concussion Program, Frisco, Texas; and
| | - Taylor Gilliland
- Baylor Scott & White Sports Therapy and Research, Frisco, Texas
- Baylor Scott & White Research Institute, Dallas, Texas
| | | | - Simon Driver
- Baylor Scott & White Sports Therapy and Research, Frisco, Texas
- Baylor Scott & White Research Institute, Dallas, Texas
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Mathew AS, Caze T, Price AM, Vasquez D, Abt JP, Burkhart SO. Association between days for concussion recovery and initial specialty clinic evaluation within 48 hours. BMC Sports Sci Med Rehabil 2024; 16:75. [PMID: 38566116 PMCID: PMC10986090 DOI: 10.1186/s13102-024-00866-w] [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: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Researchers have highlighted the importance of early access to concussion care within one week of injury in reducing recovery times. However, a persisting question for concussion researchers is "just how early is important?" The purpose of this study was to examine differences in recovery time as predicted by the number of days elapsed since injury (DSI) to initial evaluation among patients who had access to a specialty concussion clinic within seven days. We hypothesized that DSI group membership, even within seven days, would significantly predict risk of protracted recovery (i.e., beyond 21 days). METHODS In this archival study, retrospective data were gathered from electronic medical records between September 2020 to March 2022. Records of participants between ages 12-18, those diagnosed with a sports-related concussion based on initial clinic visit diagnosis by a medical provider and those who established care within seven days of injury at a large pediatric specialty concussion clinic were examined. Participants were divided into three DSI groups (patients seen in < 48 h: "acute", patients seen between 49 h < and < 96 h: "sub-acute", and patients seen between 97 < and < 168 h: "post-acute"). A general linear model was constructed to examine relationships between relevant concussion factors (e.g., Post Concussion Scale Score, neurodevelopmental history, psychiatric history, concussion history, migraine history, overall VOMS change score, cognitive testing, sex, age, race, and ethnicity) that were either significant in the preliminary analysis or in clinical judgement and recovery time. Adjusted odds ratios (OR) were derived from a binary logistic regression model, in which recovery time was normal (≤ 21 recovery days) or protracted (> 21 recovery days). RESULTS A total of 856 participants were eligible. Adolescents in the acute group (M = 15.12, SD = 8.04) had shorter recovery times in days compared to those in the sub-acute (M = 17.98, SD = 10.18) and post-acute (M = 21.12, SD = 10.12; F = 26.00, p < .001) groups. Further, participants in the acute (OR = 4.16) and sub-acute (OR = 1.37) groups who accessed specialty concussion clinics within 48 h were 4 times more likely to have a normal recovery and recovered approximately 6 days faster than the post-acute care group. CONCLUSIONS Earlier concussion care access predicted recovery times and was associated with lower risk for protracted recovery.
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Affiliation(s)
- Abel S Mathew
- Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, TX, USA.
- Present Address: Children's Health Andrews Institute for Orthopaedics and Sports Medicine, 7211 Preston Rd., Plano, TX, 75024, USA.
| | - Todd Caze
- Caze Concussion Institute, Omaha, NE, USA
| | - August M Price
- Bellapianta Orthopaedics and Sports Medicine, Montclair, NJ, USA
| | - Desi Vasquez
- Texas A&M International University, Laredo, TX, USA
| | - John P Abt
- Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, TX, USA
| | - Scott O Burkhart
- Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, TX, USA
- University of Texas Southwestern-Psychiatry, Dallas, TX, USA
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McPherson JI, Nazir MSZ, Willer BS, Leddy JJ, Haider MN. Does Physiologic Post-Concussion Disorder Cause Persistent Post-Traumatic Headache? Curr Pain Headache Rep 2023; 27:793-799. [PMID: 37831366 DOI: 10.1007/s11916-023-01176-5] [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] [Accepted: 09/27/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE OF REVIEW One system classifies patients with symptoms after concussion into physiologic, vestibulo-ocular, cervicogenic, and mood/cognition post-concussion disorders (PCD) based upon the preponderance of specific symptoms and physical impairments. This review discusses physiologic PCD and its potential relationship to the development of persistent post-traumatic headaches (PPTH). RECENT FINDINGS Headache is the most reported symptom after a concussion. Headaches in physiologic PCD are suspected to be due to abnormal cellular metabolism, subclinical neuroinflammation, and dysfunction of the autonomic nervous system (ANS). These abnormalities have been linked to the development of migraine-like and neuralgia-related PPTH. Physiologic PCD is a potential cause of PPTH after a concussion. Future research should focus on how to prevent PPTH in patients with physiologic PCD.
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Affiliation(s)
- Jacob I McPherson
- Department of Rehabilitation Science, School of Public Health and Health Professions, State University of New York at Buffalo, 534 Kimball Tower, Buffalo, NY, 14214, USA.
| | - Muhammad S Z Nazir
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY, 14214, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
| | - John J Leddy
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
| | - Mohammad N Haider
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
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Aderman MJ, Brett BL, Ross JD, Malvasi SR, McGinty G, Jackson JC, Estevez CA, Brodeur RM, Svoboda SJ, McCrea MA, Broglio SP, McAllister TW, Pasquina PF, Cameron KL, Roach MH. Association Between Symptom Cluster Endorsement at Initiation of a Graduated Return-to-Activity Protocol and Time to Return to Unrestricted Activity After Concussion in United States Service Academy Cadets. Am J Sports Med 2023; 51:2996-3007. [PMID: 37551673 DOI: 10.1177/03635465231189211] [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: 08/09/2023]
Abstract
BACKGROUND The endorsement of symptoms upon initiation of a graduated return-to-activity (GRTA) protocol has been associated with prolonged protocols. It is unclear whether there are specific symptom clusters affecting protocol durations. PURPOSE To describe the endorsement of specific concussion symptom clusters at GRTA protocol initiation and examine the association between symptom cluster endorsement and GRTA protocol duration. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This study was conducted among cadets enrolled at 3 US service academies. Participants completed an evaluation upon GRTA protocol initiation. Participants endorsing symptoms were binarized based on 6 symptom clusters (cognitive, emotional, insomnia, physical, sensitivity, and ungrouped). The primary outcome of interest was GRTA protocol duration based on symptom cluster endorsement severity. Prevalence rates were calculated to describe symptom cluster endorsement. Kaplan-Meier survival estimates and univariate and multivariable Cox proportional hazards regression models were calculated for all 6 symptom clusters to estimate GRTA protocol duration while controlling for significant covariates. RESULTS Data from 961 concussed participants were analyzed. Of these, 636 participants were asymptomatic upon GRTA protocol initiation. Among the 325 symptomatic participants, the physical symptom cluster (80%) was most endorsed, followed by the cognitive (29%), insomnia (23%), ungrouped (19%), sensitivity (15%), and emotional (9%) clusters. Univariate results revealed a significant association between endorsing cognitive (hazard ratio [HR], 0.79; p = .001), physical (HR, 0.84; p < .001), insomnia (HR, 0.83; p = .013), sensitivity (HR, 0.70; p < .001), and ungrouped (HR, 0.75; p = .005) symptom clusters and GRTA protocol duration. Endorsing physical (HR, 0.84; p < .001) and sensitivity (HR, 0.81; p = .036) clusters maintained a significant association with GRTA protocol duration in the multivariable models. CONCLUSION Participants endorsing physical or sensitivity symptom clusters displayed GRTA protocols prolonged by 16% to 19% compared with participants not endorsing that respective cluster after controlling for significant covariates.
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Affiliation(s)
- Michael J Aderman
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Benjamin L Brett
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Jeremy D Ross
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven R Malvasi
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Gerald McGinty
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Jonathan C Jackson
- United States Air Force Academy, Colorado Springs, Colorado, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Carlos A Estevez
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Rachel M Brodeur
- United States Coast Guard Academy, New London, Connecticut, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven J Svoboda
- MedStar Health, Washington, DC, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Michael A McCrea
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven P Broglio
- University of Michigan Concussion Center, Ann Arbor, Michigan, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Thomas W McAllister
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Paul F Pasquina
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Kenneth L Cameron
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Megan H Roach
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA; Department of Clinical Investigations, Womack Army Medical Center, Fort Liberty, North Carolina, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
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7
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Martindale C, Presson AP, Schwedt TJ, Brennan KC, Cortez MM. Sensory hypersensitivities are associated with post-traumatic headache-related disability. Headache 2023; 63:1061-1069. [PMID: 37638410 PMCID: PMC10854013 DOI: 10.1111/head.14604] [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: 01/05/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE To examine whether sensory hypersensitivity contributes to headache-related disability in a secondary analysis of patients with post-traumatic headache. BACKGROUND Up to one-third of individuals with traumatic brain injuries report persistent headache 3 months post-injury. High rates of allodynia and photophobia have been observed in clinical studies and animal models of post-traumatic headache, but we do not fully understand how sensory amplifications impact post-traumatic headache-related disability. METHODS We identified a cross-sectional sample of patients from the American Registry for Migraine Research database with new or worsening headaches post-head injury from 2016 to 2020 and performed a secondary analysis of those data. We modeled the relationship between sensory sensitivity and Migraine Disability Assessment scores using questionnaires. Candidate variables included data collection features (study site and year), headache-related and general clinical features (headache frequency, migraine diagnosis, abuse history, sex, age, cognitive and affective symptom scores), and sensory symptoms (related to light, sound, and touch sensitivity). RESULTS The final sample included 193 patients (median age 46, IQR 22; 161/193, 83.4% female). Migraine Disability Assessment scores ranged from 0 to 260 (median 47, IQR 87). The final model included allodynia, hyperacusis, photosensitivity, headache days per month, abuse history, anxiety and depression, cognitive dysfunction, and age (R2 = 0.43). An increase of one point in allodynia score corresponded to a 3% increase in headache disability (95% CI: 0%-7%; p = 0.027), an increase of one-tenth of a point in the photosensitivity score corresponded to a 12% increase (95% CI: 3%-25%; p = 0.002), and an increase of one point in the hyperacusis score corresponded to a 2% increase (95% CI: 0%-4%; p = 0.016). CONCLUSIONS Increased photosensitivity, allodynia, and hyperacusis were associated with increased headache-related disability in this sample of patients with post-traumatic headache. Symptoms of sensory amplification likely contribute to post-traumatic headache-related disability and merit an ongoing investigation into their potential as disease markers and treatment targets.
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Affiliation(s)
| | - Angela P. Presson
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | | | - K. C. Brennan
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Melissa M. Cortez
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
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Engel J, van Ierssel JJ, Osmond MH, Tsampalieros A, Webster R, Zemek R. Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion. J Head Trauma Rehabil 2023; 38:319-328. [PMID: 36854112 DOI: 10.1097/htr.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit. SETTING, DESIGN, AND PARTICIPANTS We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study. MAIN MEASURES The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days. RESULTS Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small. CONCLUSION Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.
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Affiliation(s)
- Jake Engel
- University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (Mr Engel and Drs Osmond and Zemek); Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada (Drs van Ierssel, Osmond, Tsampalieros, Webster, and Zemek); and Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada (Drs Osmond and Zemek)
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Makdissi M, Critchley ML, Cantu RC, Caron JG, Davis GA, Echemendia RJ, Fremont P, Hayden KA, Herring SA, Hinds SR, Jordan B, Kemp S, McNamee M, Maddocks D, Nagahiro S, Patricios J, Putukian M, Turner M, Sick S, Schneider KJ. When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. Br J Sports Med 2023; 57:822-830. [PMID: 37316181 DOI: 10.1136/bjsports-2023-106815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC. DATA SOURCES Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically. STUDY ELIGIBILITY CRITERIA Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery. RESULTS Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC. CONCLUSION No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC. PROSPERO REGISTRATION NUMBER CRD42022155121.
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Affiliation(s)
- Michael Makdissi
- Australian Football League, Melbourne, Victoria, Australia
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
| | - Meghan L Critchley
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Robert C Cantu
- Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeffrey G Caron
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Québec, Canada
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Psychology, University of Missouri-Kansas City, Kansas City, MO, USA
- Orthopedics Center Concussion Care Clinic, State College, Pennsylvania, Pennsylvania, USA
| | - Pierre Fremont
- Rehabilitation, Laval University, Quebec, Quebec, Canada
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Barry Jordan
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Sciences, Swansea University, Swansea, UK
| | - David Maddocks
- Perry Maddocks Trollope Lawyers, Melbourne, Victoria, Australia
| | - Shinji Nagahiro
- Department of Neurosurgery, Yoshinogawa Hospital, Tokushima, Japan
| | - Jon Patricios
- Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Margot Putukian
- Major League Soccer, Princeton University, Princeton, New Jersey, USA
| | - Michael Turner
- International Concussion and Head Injury Research Foundation, London, UK
- University College London, London, UK
| | - Stacy Sick
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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10
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van Ierssel JJ, Tang K, Beauchamp M, Bresee N, Cortel-LeBlanc A, Craig W, Doan Q, Gravel J, Lyons T, Mannix R, Orr S, Zemek R, Yeates KO. Association of Posttraumatic Headache With Symptom Burden After Concussion in Children. JAMA Netw Open 2023; 6:e231993. [PMID: 36884251 PMCID: PMC9996395 DOI: 10.1001/jamanetworkopen.2023.1993] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/22/2023] [Indexed: 03/09/2023] Open
Abstract
Importance Headache is the most common symptom after pediatric concussion. Objectives To examine whether posttraumatic headache phenotype is associated with symptom burden and quality of life 3 months after concussion. Design, Setting, and Participants This was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) prospective cohort study, conducted September 2016 to July 2019 at 5 Pediatric Emergency Research Canada (PERC) network emergency departments. Children aged 8.0-16.99 years presenting with acute (<48 hours) concussion or orthopedic injury (OI) were included. Data were analyzed from April to December 2022. Exposure Posttraumatic headache was classified as migraine or nonmigraine headache, or no headache, using modified International Classification of Headache Disorders, 3rd edition, diagnostic criteria based on self-reported symptoms collected within 10 days of injury. Main Outcomes and Measures Self-reported postconcussion symptoms and quality-of-life were measured at 3 months after concussion using the validated Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0). An initial multiple imputation approach was used to minimize potential biases due to missing data. Multivariable linear regression evaluated the association between headache phenotype and outcomes compared with the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score and other covariates and confounders. Reliable change analyses examined clinical significance of findings. Results Of 967 enrolled children, 928 (median [IQR] age, 12.2 [10.5 to 14.3] years; 383 [41.3%] female) were included in analyses. HBI total score (adjusted) was significantly higher for children with migraine than children without headache (estimated mean difference [EMD], 3.36; 95% CI, 1.13 to 5.60) and children with OI (EMD, 3.10; 95% CI, 0.75 to 6.62), but not children with nonmigraine headache (EMD, 1.93; 95% CI, -0.33 to 4.19). Children with migraine were more likely to report reliable increases in total symptoms (odds ratio [OR], 2.13; 95% CI, 1.02 to 4.45) and somatic symptoms (OR, 2.70; 95% CI, 1.29 to 5.68) than those without headache. PedsQL-4.0 subscale scores were significantly lower for children with migraine than those without headache only for physical functioning (EMD, -4.67; 95% CI, -7.86 to -1.48). Conclusions and Relevance In this cohort study of children with concussion or OI, those with posttraumatic migraine symptoms after concussion had higher symptom burden and lower quality of life 3 months after injury than those with nonmigraine headache. Children without posttraumatic headache reported the lowest symptom burden and highest quality of life, comparable with children with OI. Further research is warranted to determine effective treatment strategies that consider headache phenotype.
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Affiliation(s)
| | - Ken Tang
- Independent statistical consultant
| | - Miriam Beauchamp
- Department of Psychology, Université de Montréal, Montréal, Québec, Canada
- CHU Sainte-Justine Hospital Research Centre, Montreal, Québec, Canada
| | - Natalie Bresee
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- University of Ottawa, Ottawa, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - William Craig
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Stollery Children’s Hospital, Edmonton, Canada
| | - Quynh Doan
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- BC Children’s Hospital Research Institute , Vancouver, Canada
| | - Jocelyn Gravel
- CHU Sainte-Justine Hospital Research Centre, Montreal, Québec, Canada
- Department of Pediatric Emergency Medicine, Université de Montréal, Montréal, Canada
| | - Todd Lyons
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Serena Orr
- Department of Pediatrics, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Keith Owen Yeates
- Alberta Children’s Hospital Research Institute, Calgary, Canada
- Department of Psychology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
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11
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Concussion in Ladies Gaelic Football: Self-reported History, Clinical Profiles, and Management Behavior. Clin J Sport Med 2023; 33:157-164. [PMID: 36473235 DOI: 10.1097/jsm.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 09/14/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the prevalence, characteristics, and management behavior of self-reported sport-related concussion (SRC) in Ladies Gaelic Football (LGF) players. DESIGN Cross-sectional study. SETTING Online survey distributed to LGF clubs throughout Ireland. PARTICIPANTS Elite and nonelite adult LGF players (n = 657). INTERVENTIONS Participants were recruited by convenience sampling and answered an online survey. Questions on demographic characteristics, SRC history, symptoms, injury characteristics, and management behavior after SRCs that occurred while playing LGF during the previous season were included. MAIN OUTCOME MEASURES Overall concussion history, occurrence of an SRC during the previous LGF season, clinical profile scores, characteristics (eg mechanism and setting), and management behavior (eg following a graded RTP program) after SRCs that occurred during the previous season. RESULTS Approximately one-fifth (17.5%) of participants sustained a suspected or diagnosed SRC during the previous season, which was higher among elite (26.1%) than nonelite (15.3%) players ( P < 0.01). The highest scoring clinical profiles were the ocular and migraine profiles. Only 3.5% of respondents adhered to all SRC management recommendations. Although players who reported a medically diagnosed versus a suspected SRC more often followed these guidelines, SRC management beyond the initial phase of injury remained inadequate. CONCLUSION SRC is common in LGF; however, adherence to recommended management guidelines is poor, even among players who receive medical assistance. In particular, few LGF athletes receive clinical concussion care beyond the initial diagnosis and acute management phase. Further research is needed to examine the underlying reasons for poor SRC management in LGF, which will guide the development of future sport-specific interventions.
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Langdon S, Goedhart E, Inklaar M, Oosterlaan J, Königs M. Heterogeneity of persisting symptoms after sport-related concussion (SRC): exploring symptom subtypes and patient subgroups. J Neurol 2023; 270:1512-1523. [PMID: 36411387 PMCID: PMC9970953 DOI: 10.1007/s00415-022-11448-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/23/2022]
Abstract
This study aimed to explore the heterogeneity of persisting symptoms after sport-related concussion (SRC). We examined the structure of symptom subtypes within 163 patients with SRC (M = 16.7 weeks post-injury). Subsequently, we investigated the existence of subgroups of patients based on comparable configuration of co-occurring symptom subtypes. To explore factors that may contribute to the emergence of SRC patient subgroups, subgroups were compared on pre-injury (i.e., demographics and medical history), personality (Severity Indices of Personality Problems Short Form) and SRC characteristics (i.e., history of prior concussions, loss of consciousness and post-traumatic amnesia). To investigate the relevance of SRC subgrouping for clinical outcome, subgroups were compared on symptom severity (Sport Concussion Assessment Tool 5). The results provide empirical evidence for the existence of symptom subtypes, characterized as a: neurocognitive, fatigue, emotional, migraine and vestibular-ocular symptom subtype in patients with persisting SRC. Study results also showed evidence for the existence of SRC subgroups of patients with a comparable configuration of co-occurring prevailing symptom subtypes, including a neurocognitive-migraine, fatigue, migraine-emotional and neurocognitive-emotional subgroup. The subgroups differed on pre-injury, personality and SRC characteristics, suggesting that these factors may contribute to the emergence of specific SRC patient subgroups. The subgroups also differed in the severity of persisting symptoms, highlighting the clinical relevance of SRC subgrouping. These results support the idea that patient subgroups with persisting SRC with a comparable pattern of co-occurring symptom subtypes exists, which may require targeted prognosis, clinical management and treatment to optimize recovery.
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Affiliation(s)
- S Langdon
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
| | - E Goedhart
- Football Medical Centre, Royal Netherlans Football Association (KNVB), Zeist, The Netherlands
| | - M Inklaar
- Football Medical Centre, Royal Netherlans Football Association (KNVB), Zeist, The Netherlands
| | - J Oosterlaan
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Follow-Me Program and Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M Königs
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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13
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Comparison of Clinical Outcomes Between Athletes With Immediate and Delayed Onset of Symptoms Following Sport-Related Concussion. Clin J Sport Med 2023; 33:26-32. [PMID: 35981461 DOI: 10.1097/jsm.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/27/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare characteristics and clinical outcomes of adolescent athletes with immediate and delayed onset of symptoms following sport-related concussion (SRC). A secondary objective was to describe the symptoms that are delayed and the timing of symptom onset. DESIGN Prospective, repeated measures study. SETTING Concussion Specialty Clinic. PARTICIPANTS One hundred fifty-two participants (63.3% men) aged 11 to 24 (15.78 ± 3.47) evaluated within 7 days (3.47 ± 1.66) of sustaining an SRC. INDEPENDENT VARIABLE Group classification of immediate (IMMEDIATE) or delayed onset of symptoms (DELAYED; >60 seconds following mechanism of injury) through structured clinical interview. MAIN OUTCOME MEASURES Group comparisons on demographic and medical history factors, concussion and clinical profile symptom scores, computerized neurocognitive test scores, vestibular/oculomotor screening scores, and days to medical clearance. RESULTS 24.3% of athletes in the sample were DELAYED. The groups did not differ on demographics and medical history. The DELAYED group had increased likelihood of posttraumatic migraine (PTM) as a primary/secondary clinical profile ( P = 0.03). Groups did not differ on any other clinical profiles ( P > 0.05). Groups did not differ on recovery time ( P = 0.47), the IMMEDIATE group higher dizziness on vestibular/ocular motor screening ( P = 0.016) and increased likelihood of dizziness being the initial symptom experienced ( P < 0 .001). CONCLUSIONS The results indicated that delayed onset of symptoms in athletes were relatively common following SRC, supporting continued evaluation of athletes for several days following suspected injuries. Delayed onset of symptoms was associated with PTM, whereas immediate onset was associated with more pronounced vestibular dysfunction, suggesting that clinicians should consider the timing of symptom onset when assessing and treating athletes following SRC.
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14
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Relationship Between Self-Reported Concomitant Depressive and Anxiety Symptoms and the Post-Concussion Symptoms Scale (PCSS). J Int Neuropsychol Soc 2022; 28:1064-1074. [PMID: 34895377 DOI: 10.1017/s135561772100134x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The current study explored how affective disturbances, particularly concomitant anxiety and depressive symptoms, impact baseline symptom self-reporting on the Post-Concussion Symptoms Scale (PCSS) in college athletes. METHODS Athletes were separated into four groups (Healthy Control (HC) (n = 581), Depression Only (n = 136), Anxiety Only (n = 54), Concomitant Depression/Anxiety (n = 62)) based on their anxiety and depression scores. Groups were compared on Total PCSS Score as well as 5 PCSS Symptom Cluster scores (Cognitive, Physical, Affective, Sleep, and Headache). RESULTS The three affective groups reported significantly greater symptomatology than HCs, with the Concomitant group showing the highest symptomatology scores across all clusters. The depressive symptoms only group also reported significantly elevated symptomatology, compared to HCs, on every symptom cluster except headache. The anxiety symptoms only group differed from HCs on only the cognitive symptoms cluster. Additionally, the Concomitant group reported significantly increased PCSS symptomatology, in terms of total scores and all 5 symptom clusters, compared to the depressive symptoms only and anxiety symptoms only groups. CONCLUSIONS Our findings suggest that athletes experiencing concomitant depressive/anxiety symptoms report significantly greater levels of symptomatology across all 5 PCSS symptom clusters compared to HCs. Further, results suggest that athletes experiencing concomitant affective disturbance tend to report greater symptomatology than those with only one affective disturbance. These findings are important because, despite the absence of concussion, the concomitant group demonstrated significantly elevated symptomatology at baseline. Thus, future comparisons with post-concussion data should account for this increased symptomatology, as test results may be skewed by affective disturbances at baseline.
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15
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Ernst N, Eagle S, Trbovich A, Kissinger-Knox A, Bitzer H, Kontos AP. Lower post-injury psychological resilience is associated with increased recovery time and symptom burden following sport-related concussion. APPLIED NEUROPSYCHOLOGY. CHILD 2022; 11:781-788. [PMID: 34410842 DOI: 10.1080/21622965.2021.1964966] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The purpose of this study was to compare athletes with high and low resilience scores on concussion outcomes, and identify significant predictors associated with protracted recovery (>30 days). Forty-five adolescent and young adult athletes (28 males; aged 15.13 ± 2.74; range of 11-22) were diagnosed with an SRC within 14 days of injury (M = 4.9 days) and grouped as high or low resilience based on score on the Connor-Davidson Resilience Scale-10 (CD-RISC-10). Primary dependent measures included days to full clearance, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Depression Anxiety and Stress Scale-21 (DASS-21), and Vestibular/Ocular Motor Screening (VOMS). The low resilience group (n = 22) had a longer recovery (36.0 ± 27.6 vs 17.8 ± 11.2 days), endorsed more mood symptoms (PCSS Affective cluster; 3.8 ± 0.8 vs 0.9 ± 0.7), and were more likely to have VOMS scores above cut off (p = 0.01-0.02), compared to those with high psychological resilience (n = 23). Logistic regression found low resilience scores was the only significant predictor for protracted recovery among injury characteristics and risk factors. Psychological resilience is a critical factor associated with recovery time following sport-related concussions. Low resilience was also associated with other poor clinical outcomes, greater subjective symptom report, more severe vestibular dysfunction, and elevated levels of mood symptoms following injury.
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Affiliation(s)
- Nathan Ernst
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Shawn Eagle
- Department of Orthopedics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alicia Trbovich
- Department of Orthopedics, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Hannah Bitzer
- Department of Orthopedics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony P Kontos
- Department of Orthopedics, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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16
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Burns KN, Langford TD, Tierney R, McDevitt J. Premorbid Primary Headache and Vestibular and Oculomotor Baseline Assessments in Collegiate Athletes. Clin J Sport Med 2022; 32:e457-e460. [PMID: 36083331 DOI: 10.1097/jsm.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 10/06/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the effects of premorbid headache status on vestibular and oculomotor baseline tests in collegiate club athletes. DESIGN Retrospective case-control study. SETTING Sport Concussion Laboratory. PATIENTS OR PARTICIPANTS Collegiate club athletes with a self-reported premorbid headache history (n = 32, 19.50 ± 1.98 years, and 31% women) and age-sex-sport-matched controls (n = 32, 19.56 ± 1.47 years, and 31% women) without a self-reported headache history were included. INTERVENTIONS Participants were grouped based on a self-reported headache history at baseline. Controls were randomly matched to self-reported headache participants by age, sex, and sport. MAIN OUTCOME MEASURES Vestibular/ocular motor screen (VOMS) baseline symptoms, symptom provocation, near point of convergence (NPC) distance, and King-Devick (K-D) test time were compared between groups. RESULTS Athletes with a self-reported headache history at baseline are 3.82 times more likely to have abnormal NPC scores (P = 0.032) and 4.76 times more likely to have abnormal K-D test times (P = 0.014) than those without a headache history. There was no difference in VOMS baseline symptoms or symptom provocation between groups (P > 0.05). CONCLUSIONS Club collegiate athletes with a headache history were more likely to screen as abnormal during a vestibular/ocular motor function assessment than athletes without a history of headaches. Healthcare professionals should screen for pre-existing headache during baseline concussion assessments before test interpretation. CLINICAL RELEVANCE A premorbid headache history at preseason baseline assessment may influence vestibular and oculomotor function, and care should be taken when interpreting these individuals' tests.
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Affiliation(s)
- Karlee N Burns
- Department of Kinesiology, Temple University, Philadelphia, Pennsylvania
| | - Theresa Dianne Langford
- Department of Neuroscience, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania; and
| | - Ryan Tierney
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, Pennsylvania
| | - Jane McDevitt
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, Pennsylvania
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17
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Abstract
Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.
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18
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Elbin RJ, Womble MN, Elbich DB, Dollar C, Fedor S, Hakun JG. Ambulatory Assessment in Concussion Clinical Care and Rehabilitation. Front Digit Health 2022; 4:924965. [PMID: 35814821 PMCID: PMC9260167 DOI: 10.3389/fdgth.2022.924965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Concussion is a mild traumatic brain injury that is characterized by a wide range of physical, emotional, and cognitive symptoms as well as neurocognitive, vestibular, and ocular impairments that can negatively affect daily functioning and quality of life. Clinical consensus statements recommend a targeted, clinical profile-based approach for management and treatment. This approach requires that clinicians utilize information obtained via a clinical interview and a multi-domain assessment battery to identify clinical profile(s) (e.g., vestibular, mood/anxiety, ocular, migraine, cognitive fatigue) and prescribe a corresponding treatment/rehabilitation program. Despite this comprehensive approach, the clinical picture can be limited by the accuracy and specificity of patient reports (which often conflate timing and severity of symptomology), as well as frequency and duration of exposure to symptom exacerbating environments (e.g., busy hallways, sitting in the back seat of a car). Given that modern rehabilitation programs leverage the natural environment as a tool to promote recovery (e.g., expose-recover approach), accurate characterization of the patient clinical profile is essential to improving recovery outcomes. Ambulatory assessment methodology could greatly benefit concussion clinical care by providing a window into the symptoms and impairments experienced by patients over the course of their daily lives. Moreover, by evaluating the timing, onset, and severity of symptoms and impairments in response to changes in a patient's natural environment, ambulatory assessments can provide clinicians with a tool to confirm clinical profiles and gauge effectiveness of the rehabilitation program. In this perspective report, we review the motivations for utilizing ambulatory assessment methodology in concussion clinical care and report on data from a pilot project utilizing smart phone-based, ambulatory assessments to capture patient reports of symptom severity, environmental exposures, and performance-based assessments of cognition for 7 days following their initial evaluation.
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Affiliation(s)
- R. J. Elbin
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR, United States
| | - Melissa N. Womble
- Inova Sports Medicine Concussion Program, Fairfax, VA, United States
| | - Daniel B. Elbich
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
| | - Christina Dollar
- Inova Sports Medicine Concussion Program, Fairfax, VA, United States
| | - Sheri Fedor
- Inova Sports Medicine Concussion Program, Fairfax, VA, United States
| | - Jonathan G. Hakun
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
- Department of Psychology, The Pennsylvania State University, State College, PA, United States
- Center for Healthy Aging, The Pennsylvania State University, State College, PA, United States
- Translational Brain Research Center, College of Medicine, The Pennsylvania State University, Hershey, PA, United States
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19
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Klein SK, Brown CB, Ostrowski-Delahanty S, Bruckman D, Victorio MC. Identifying Migraine Phenotype Post Traumatic Headache (MPTH) to Guide Overall Recovery From Traumatic Brain Injury. J Child Neurol 2022; 37:8830738221100327. [PMID: 35656769 DOI: 10.1177/08830738221100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The primary aim of this study is to develop an easy way to identify migraine phenotype posttraumatic headache (MPTH) in children with traumatic brain injury, to treat headache in traumatic brain injury effectively, and to promote faster recovery from traumatic brain injury symptoms overall. Methods: We evaluated youth aged 7-20 years in a pediatric neurology traumatic brain injury (TBI) clinic, assigning a migraine phenotype for post-traumatic headache (MPTH) at the initial visit with the 3-item ID Migraine Screener. We stratified the sample by early (≤6 weeks) and late (>6 weeks) presenters, using days to recovery from concussion symptoms as the primary outcome variable. Results: 397 youth were assessed; 54% were female. Median age was 15.1 years (range 7.0-20.4 years), and 34% of the sample had sports-related injuries. Migraine phenotype for posttraumatic headache (MPTH) was assigned to 56.1% of those seen within 6 weeks of traumatic brain injury and 50.7% of those seen after the 6-week mark. Irrespective of whether they were early or late presenters to our clinic, patients with migraine phenotype (MPTH) took longer to recover from traumatic brain injury than those with posttraumatic headache (PTH) alone. Log rank test indicated that the survival (ie, recovery) distributions between those with migraine phenotype posttraumatic headache (MPTH) and those with posttraumatic headache (PTH) were statistically different, χ2(3) = 50.186 (P < .001). Conclusions: Early identification of migraine phenotype posttraumatic headache (MPTH) following concussion can help guide more effective treatment of headache in traumatic brain injury and provide a road map for the trajectory of recovery from traumatic brain injury symptoms. It will also help us understand better the mechanisms that underlie conversion to persistent posttraumatic headache and chronic migraine after traumatic brain injury.
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Affiliation(s)
- Susan K Klein
- Neurology, NDSC, 1079Akron Children's Hospital, Akron, OH, USA
| | - Cynthia B Brown
- Neurology, NDSC, 1079Akron Children's Hospital, Akron, OH, USA
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20
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Leibovit‐Reiben Z, Ishii R, Dodick DW, Dumkrieger G, Cortez MM, Brennan KC, Digre K, Schwedt TJ. The impact of pre‐morbid headaches on headache features and long‐term health outcomes following traumatic brain injury: Insights from the American Registry for Migraine Research. Headache 2022; 62:566-576. [DOI: 10.1111/head.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/01/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Zachary Leibovit‐Reiben
- Mayo Clinic Phoenix Arizona USA
- University of Arizona College of Medicine – Tucson Tucson Arizona USA
| | - Ryotaro Ishii
- Department of Neurology Kyoto Prefectural University of Medicine Kyoto Japan
| | | | | | | | - Kevin C. Brennan
- Department of Neurology University of Utah Salt Lake City Utah USA
| | - Kathleen Digre
- Department of Neurology University of Utah Salt Lake City Utah USA
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21
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Eagle SR, Asken B, Trbovich A, Houck ZM, Bauer RM, Clugston JR, Broglio SP, McAllister TW, McCrea MA, Pasquina P, Collins MW, Kontos AP, Putukian M, Hoy A, Ortega J, Port N, Buckley T, Kaminski T, Houston M, Duma S, Miles C, Lintner L. Estimated Duration of Continued Sport Participation Following Concussions and Its Association with Recovery Outcomes in Collegiate Athletes: Findings from the NCAA/DoD CARE Consortium. Sports Med 2022; 52:1991-2001. [DOI: 10.1007/s40279-022-01668-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
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22
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Mollica A, Greben R, Oriuwa C, Siddiqi SH, Burke MJ. Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms. Curr Neurol Neurosci Rep 2022; 22:171-181. [PMID: 35175543 DOI: 10.1007/s11910-022-01183-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI. RECENT FINDINGS Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.
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Affiliation(s)
- Adriano Mollica
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, FG26, Toronto, ON, M4N 3M5, Canada
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Rachel Greben
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, FG26, Toronto, ON, M4N 3M5, Canada
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Chika Oriuwa
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, FG26, Toronto, ON, M4N 3M5, Canada
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, FG26, Toronto, ON, M4N 3M5, Canada.
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Womble MN, Reynolds E, Kissinger-Knox A, Collins MW, Kontos AP, West RV, Eagle S, Elbin RJ. The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic. J Head Trauma Rehabil 2022; 37:E49-E54. [PMID: 34320559 DOI: 10.1097/htr.0000000000000713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.
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Affiliation(s)
- Melissa N Womble
- Inova Sports Medicine Concussion Program, Fairfax, Virginia (Dr Womble); Baylor Scott & White Sports Concussion Program, Frisco, Texas (Dr Reynolds); Sports Medicine Concussion Program, Department of Orthopaedics, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Drs Kissinger-Knox, Collins, Kontos, and Eagle); Inova Sports Medicine, Fairfax, Virginia (Dr West); and Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville (Dr Elbin)
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Post-traumatic headache after mild traumatic brain injury in a one-year follow up study - risk factors and return to work. J Headache Pain 2022; 23:27. [PMID: 35183101 PMCID: PMC8903563 DOI: 10.1186/s10194-022-01398-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/29/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Post-traumatic headache (PTH) is a common symptom following mild traumatic brain injury (mTBI). Patients at risk to develop acute PTH (aPTH) and further persistent PTH (pPTH) need to be recognized. METHODS This is a one-year follow-up of 127 patients with mTBI, aged 18 to 68, referred to outpatient clinic in the Helsinki University Hospital. Symptoms were assessed at the emergency department (ED), with structured interview at outpatient clinic visit and with Rivermead post-concussion symptom questionnaire at one, three, and 12 months after injury. Psychiatric disorders were assessed with Structured Clinical Interview for DSM-IV Axis I disorders at 3-4 months and return to work (RTW) from patient records. RESULTS At one month, 77/127 patients (61%) had aPTH. According to multiple logistic regression analysis, risk factors for aPTH were headache at the emergency department (ED) (OR 5.43), other pain (OR 3.19), insomnia (OR 3.23), and vertigo (OR 5.98). At three months, 17 patients (22% of aPTH patients) had developed pPTH, and at one year, 4 patients (24% of pPTH patients) still presented with pPTH. Risk factors for pPTH at three months were older age (OR 1.06) and current insomnia (OR 12.3). The frequency of psychiatric disorders did not differ between the groups. pPTH patients performed worse on their RTW. CONCLUSIONS Risk factors for aPTH were insomnia, headache at ED, other pain, and vertigo and for pPTH, insomnia and older age. RTW rate was lower among pPTH patients.
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Pate J, Mooney J, Katz E, Cignetti C, McLeod C, Gould S. Efficacy of outpatient infusion therapy in pediatric patients with postconcussive headaches. Childs Nerv Syst 2022; 38:103-108. [PMID: 34671849 DOI: 10.1007/s00381-021-05383-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/28/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine the relative efficacy of intravenous therapy for postconcussive headaches in a pediatric population, as compared to oral therapy. METHODS Pediatric patients treated for postconcussive headaches at an outpatient infusion clinic from 2016 to 2018 were selected for inclusion in the study. Of the 95 patients who were treated in clinic, 53 patients were selected for a retrospective chart review. Clinic visits before and after infusions were reviewed to determine changes in headache score (HA), symptom severity score (SSS), and self-reported symptom relief. An age-matched and SSS-matched group served as a control. The control group received only oral therapy for their headaches. The infusion consisted of parenteral ketorolac, compazine, diphenhydramine, and a normal saline bolus (20 mg/kg). RESULTS Following infusion therapy, overall mean HA and SSS scores were both reduced (p < 0.0001). Oral therapy demonstrated a similar mean overall reduction in HA and SS scores (p < 0.0001). While both groups achieved a reduction in HA and SS scores, there was not a statistically significant difference in reduction of symptoms scores between the oral and infusion groups. CONCLUSION Infusion therapy is as effective at reducing HA and SSS as established oral therapies. Infusion therapy may have a shorter time to headache abortion than oral therapy based on pharmacokinetics. Further, some physicians are unwilling to allow an athlete to return to play while taking suppressive medication. Future studies may show that an infusion could allow a more rapid return to play and resolution of symptoms.
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Affiliation(s)
- James Pate
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, 1802 6th Avenue South, FOT 1001, Birmingham, AL, 35233, USA.
| | - Erin Katz
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Carly Cignetti
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sara Gould
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Anderson MN, Lempke LB, Johnson RS, Lynall RC, Schmidt JD. Concussion Characteristics and Early Postinjury Outcomes Between College Students and Intercollegiate Athletes. Arch Phys Med Rehabil 2021; 103:323-330. [PMID: 34673035 DOI: 10.1016/j.apmr.2021.09.013] [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] [Received: 06/15/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe concussion characteristics among general college students and compare postinjury outcomes to intercollegiate student athletes. DESIGN Retrospective cohort. SETTING Large university in the Southeast region of the United States. PARTICIPANTS A total of 179 (N=179) college students' (female=120; 67.0%; 23.9±3.9 years) and 49 athletes' (female=28, 57.1%;19.3±1.3 years) medical records were examined. Participants self-reported injury mechanism, health history information, and completed clinical assessments acutely (<7 days postinjury). MAIN OUTCOME MEASURES Descriptive statistics were calculated for each group. Concussion outcomes between students with and without certain health history diagnoses were assessed using separate t tests. We conducted univariate regression analyses to determine if sex, age, and time from concussion to first clinical assessment were significant predictors of clinical outcomes. Statistically significant variables were included as covariates in a series of 1-way analyses of covariance to identify differences in balance, symptom severity, total symptom presence, and neurocognitive domain performance between students and athletes. Fisher exact tests were used to compare health history information between groups (α<0.05). RESULTS Among students, 24% reported sustaining a concussion while participating in recreational sports, and 27% of impacts occurred to the back of the head. Students had higher proportions of headache, migraine, anxiety, and depression (P<.05). Students reported greater total symptom presence (P=.006) and performed worse on the computerized neurocognitive test domain score for complex attention (P=.015) relative to athletes. CONCLUSIONS These findings highlight the need for better access to medical care for non- National Collegiate Athletic Association sanctioned athletes because of a large proportion of concussions in the student sample being sustained during sports participation. Identifying common injury mechanisms can provide clinicians with powerful information to improve evaluation and treatment models.
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Affiliation(s)
- Melissa N Anderson
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia.
| | - Landon B Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia; Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts; Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
| | - Rachel S Johnson
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
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Charek DB, Elbin RJ, Sufrinko A, Schatz P, D'Amico NR, Collins MW, Kontos AP. Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion. J Head Trauma Rehabil 2021; 35:85-91. [PMID: 31033740 DOI: 10.1097/htr.0000000000000476] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate a dose-response relationship between continuing to play following concussion and outcomes. PARTICIPANTS A total of 130 athletes (age 11-19 years). DESIGN Repeated-measures design comparing symptoms, neurocognitive performance, and recovery time between 52 athletes immediately removed from play (Removed), 24 who continued to play for 15 minutes or less (Short-Play), and 32 who continued to play for more than 15 minutes (Long-Play). MAIN MEASURES Recovery was the number of days from injury to clearance. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) measured neurocognitive outcomes and the Post-Concussion Symptom Scale (PCSS) measured symptom severity. RESULTS Long-Play (44.09 ± 27.01 days) took longer to recover than Short-Play (28.42±12.74 days) and Removed (18.98 ± 13.76 days). Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed. Both Play groups had worse neurocognitive performance and higher symptom scores than Removed at days 1 to 7, with Long-Play demonstrating worse reaction time than Short-Play. At days 8 to 30, both Play groups performed worse than Removed on visual memory and visual motor speed, while only Long-Play performed worse on verbal memory and reaction time. CONCLUSIONS Results provide initial evidence of a dose-response effect for continuing to play on recovery from concussion, highlighting the importance of removal from play.
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Affiliation(s)
- Daniel B Charek
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pennsylvania (Drs Charek, Sufrinko, Collins, and Kontos); Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville (Dr Elbin and Mr D'Amico); and Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania (Dr Schatz)
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Acute Effects of Concussion in Youth With Pre-existing Migraines. Clin J Sport Med 2021; 31:430-437. [PMID: 31842054 DOI: 10.1097/jsm.0000000000000791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/13/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine associations between pre-existing migraines and postconcussion symptoms and cognitive performance acutely (within 72 hours) after a suspected concussion. DESIGN Nested case-control study. SETTING High schools in Maine, USA. PARTICIPANTS From a sample of 39 161 adolescent athletes who underwent baseline preseason testing, 633 were assessed within 3 days of a suspected concussion. Of these, 59 reported a history of treatment for migraines at baseline (9.3%). These athletes were individually matched to 2 athletes who had a suspected concussion but denied preinjury migraines (total N = 177; age: M = 15.8, SD = 1.3). ASSESSMENT OF RISK FACTORS Self-reported history of treatment for migraines by a physician. MAIN OUTCOME MEASURES Post-Concussion Symptom Scale total score, ImPACT composite scores, and individual symptom endorsement. RESULTS Individuals with a pre-existing migraine disorder endorsed greater symptom severity (M = 8.4, SD = 9.9) compared with controls (M = 4.5, SD = 6.5; Cohen's d = 0.47) at preinjury baseline and acutely after suspected injury (migraine: M = 26.0, SD = 25.5; controls: M = 16.7, SD = 15.4; d = 0.44). Acutely after a suspected concussion, greater proportions of athletes with migraine disorders reported mental fogginess (49.2% vs 33.9%) and memory problems (39.0% vs 24.6%; P < 0.05). Baseline ImPACT composite scores were similar between migraine and control groups (d = 0.04-0.13). Adolescents with pre-existing migraine disorders performed worse after a suspected concussion compared with the control participants on verbal memory (F = 4.32, P = 0.041) and visual memory (F = 3.95, P = 0.049). CONCLUSIONS Individuals with pre-existing migraine disorders may be at higher risk for worse outcomes, including greater overall burden of symptoms and worse cognitive functioning in the memory domain, in the first 72 hours after concussion.
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Guty E, Riegler K, Meyer J, Walter AE, Slobounov SM, Arnett P. Symptom Factors and Neuropsychological Performance in Collegiate Athletes with Chronic Concussion Symptoms. Arch Clin Neuropsychol 2021; 36:746-756. [PMID: 33140096 DOI: 10.1093/arclin/acaa092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/07/2020] [Accepted: 09/25/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The present study explored the relationship between specific types of postconcussion symptoms and cognitive outcomes in student-athletes with chronic concussion symptoms. METHOD Forty student-athletes with chronic concussion symptoms were given a battery of neuropsychological tests and rated themselves on a variety of postconcussion symptoms, which included the following factors derived from prior work: Physical, Sleep, Cognitive, Affective, and Headache. Cognitive outcomes included performance on composites for the memory and attention/executive functioning speed tests, respectively. The following covariates were also explored: Sex, depression symptoms, number of previous concussions, and time since injury. RESULTS Headache was the only individual symptom factor that significantly (p < .05) predicted worse attention/executive functioning performance. None of the symptom factors were significantly related to memory performance over and above the variable of time since injury, such that longer time since injury was related to worse memory performance. CONCLUSION Comparable to work examining symptom predictors of cognitive outcomes in acutely concussed samples, headache predicted worse attention/executive functioning performance. Additionally, we found that the longer athletes had been symptomatic since injury, the "worse" their memory functioning. Understanding how headache and the length of time an individual is symptomatic are related to cognitive outcomes can help inform treatment and recommendations for athletes with prolonged symptom recovery.
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Affiliation(s)
- Erin Guty
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Kaitlin Riegler
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Jessica Meyer
- Department of Behavioral Health, Summa Health System, Akron, OH, USA
| | - Alexa E Walter
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
| | - Semyon M Slobounov
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
| | - Peter Arnett
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
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Womble MN, McAllister-Deitrick J, Marchetti GF, PsyD ER, Collins MW, Elbin RJ, Kontos AP. Risk Factors for Vestibular and Oculomotor Outcomes After Sport-Related Concussion. Clin J Sport Med 2021; 31:e193-e199. [PMID: 31219931 PMCID: PMC6904531 DOI: 10.1097/jsm.0000000000000761] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the association between risk factors and vestibular-oculomotor outcomes after sport-related concussion (SRC). STUDY DESIGN Cross-sectional study of patients seen 5.7 ± 5.4 days (range 0-30 days) after injury. SETTING Specialty clinic. PARTICIPANTS Eighty-five athletes (50 male athletes and 35 female athletes) aged 14.1 ± 2.8 years (range 9-24 years) seeking clinical care for SRC. INTERVENTIONS Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocularmotor screening (VOMS). Chi-square tests with odds ratios and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes. MAIN OUTCOME MEASURES The VOMS. RESULTS Female sex (χ2 = 4.9, P = 0.03), on-field dizziness (χ2 = 7.1, P = 0.008), fogginess (χ2 = 10.3, P = 0.001), and post-traumatic migraine (PTM) symptoms including headache (χ2 = 16.7, P = 0.001), nausea (χ2 = 10.9, P = 0.001), light sensitivity (χ2 = 14.9, P = 0.001), and noise sensitivity (χ2 = 8.7, P = 0.003) were associated with presence of one or more postconcussion VOMS score above clinical cutoff. On-field dizziness (χ2 = 3.8, P = 0.05), fogginess (χ2 = 7.9, P = 0.005), and PTM-like symptoms including nausea (χ2 = 9.0, P = 0.003) and noise sensitivity (χ2 = 7.2, P = 0.007) were associated with obtaining a postconcussion near-point convergence (NPC) distance cutoff >5 cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively. CONCLUSIONS Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment after SRC.
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Affiliation(s)
- Melissa N. Womble
- Inova Medical Group, Department of Sports Medicine, Inova Sports Medicine Concussion Program, Fairfax, VA
| | | | - Gregory F. Marchetti
- Duquesne University, Department of Physical Therapy, Rangos School of Health Sciences, Pittsburgh, PA
| | - Erin Reynolds PsyD
- Baylor Scott & White Sports Therapy & Research, Sports Concussion Center, Frisco, TX
| | - Michael W. Collins
- University of Pittsburgh, Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA
| | - RJ Elbin
- University of Arkansas, Department of Health, Human Performance and Recreation, Office for Sport Concussion Research, Fayetteville, AR
| | - Anthony P. Kontos
- University of Pittsburgh, Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA
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Li G, Han X, Gao L, Tong W, Xue Q, Gong S, Song Y, Chen S, Dong Y. Association of Anxiety and Depressive Symptoms with Memory Function following Traumatic Brain Injury. Eur Neurol 2021; 84:340-347. [PMID: 34182550 DOI: 10.1159/000513195] [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] [Received: 05/18/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Memory impairment and mood disorders are among the most troubling sequelae following traumatic brain injury (TBI). The relationships between comorbid psychiatric disorders and memory function have not been well illustrated. The aim of the study was to explore the relationships of comorbid anxiety and depressive symptoms with memory function following TBI. METHODS A total of 46 TBI participants across all levels of injury and 23 healthy controls were enrolled in this case-control study. Wechsler Memory Scale-Chinese Revision (WMS-CR) picture, recognition, associative learning, comprehension memory, and digit span were administered to evaluate several categories of memory capacity. The Hospital Anxiety and Depression Scale (HADS) was employed to evaluate the anxiety and depressive symptoms. Stepwise multiple linear regressions were conducted. RESULTS Compared to healthy controls, the participants with TBI reported more anxiety and depressive symptoms. In the meanwhile, they performed more poorly on memory tests, showing 1.84 SDs, 1.07 SDs, and 0.68 SDs below healthy participants on visuospatial memory, working memory, and verbal memory, respectively. A variety of variables, including HADS depression, HADS anxiety, age, GCS, and education were associated with posttraumatic memory function in the bivariate models. The stepwise multiple linear regressions demonstrated a negative association between HADS depression and posttraumatic memory function, especially performance on visuospatial and verbal memory and a positive association between education and posttraumatic memory function. CONCLUSION More depressive symptoms rather than anxiety symptoms and less years of education are significant predictors for posttraumatic memory dysfunction.
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Affiliation(s)
- Gaoyi Li
- Department of Neurosurgery, Shanghai Pudong New Area People's Hospital, Shanghai, China
| | - Xi Han
- Department of Neurosurgery, Shanghai Hushan Hospital, Fudan University, Shanghai, China
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wusong Tong
- Department of Neurosurgery, Shanghai Pudong New Area People's Hospital, Shanghai, China
| | - Qiang Xue
- Department of Neurosurgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Shun Gong
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Song
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Songyu Chen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yan Dong
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Tenth People's Hospital Clinical Medicine Scientific and Technical Innovation Park, Shanghai, China
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Abstract
PURPOSE OF REVIEW To discuss the treatment of post-traumatic headache (PTH) and how to choose pharmacotherapy based upon known pathophysiology. RECENT FINDINGS Preclinical models of traumatic brain injury are finally revealing some of the mechanisms of PTH, including the significant role that inflammatory neuropeptides like calcitonin gene-related peptide (CGRP) play in the initiation and persistence of symptoms. To effectively treat post-traumatic headache (PTH), one needs to understand the pathophysiology behind the initiation and persistence of symptoms. Recent animal models are starting to elucidate these mechanisms, but effective treatment will also likely rely on the identification of patients who are most at risk for persistent PTH. Trials of early, targeted therapy for at-risk patients will be needed to validate these hypotheses. Additionally, high powered clinical trials are lacking in the field of persistent PTH for medications that are known to be effective in primary headache disorders. Effective treatment for persistent PTH also requires understanding how headache interacts with the complex nature of persistent post-concussion symptoms, as this disease often necessitates a multi-disciplinary approach. Regardless, with the knowledge gained by new PTH models cited in this paper, and an increasing availability of novel headache medications, more effective treatment models are on the horizon.
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Affiliation(s)
- Joshua Kamins
- Goldberg Migraine Program, Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
- Steve Tisch BrainSPORT Program, Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
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Singman E. From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement. J Clin Med 2021; 10:jcm10122598. [PMID: 34204619 PMCID: PMC8231255 DOI: 10.3390/jcm10122598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 12/18/2022] Open
Abstract
Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.
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Affiliation(s)
- Eric Singman
- Wilmer Eye Institute, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
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Wang AR, Calandra MJ, Friedman BW. Clinical predictors of poor 30-day headache outcomes after an emergency department visit for acute post-traumatic headache. Am J Emerg Med 2021; 49:158-162. [PMID: 34118783 DOI: 10.1016/j.ajem.2021.05.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We investigated clinical risk factors that predict poor 30-day headache outcomes among patients evaluated in the emergency department (ED) for post-traumatic headache (PTH). METHODS This was an analysis of data from a randomized, placebo-controlled study of IV metoclopramide + diphenhydramine for acute PTH. Patients were enrolled during an ED visit and received telephone follow-up with a structured questionnaire 30 days later. The primary outcome was frequency of headaches 30 days after ED discharge. We used multivariable logistic regression models to determine which clinical variables were associated with frequent headaches at 30 days. RESULTS In total, 160 patients were enrolled in the study. 134 (84%) patients completed the 30-day questionnaire and were included in the analysis, including 90 females and 44 males. 30 patients (22%, 95% CI = 0.16 to 0.30) reported frequent headaches at 30-day follow-up. In the multivariable analysis, female sex (OR = 4.03, 95% CI = 1.23±13.13), patients who blamed themselves for their injury (OR = 0.13, 95% CI = 0.04±0.45), and patients who were unsure if they sustained loss of consciousness during the traumatic incident (OR = 5.63, 95% CI = 1.89±16.78) were found to be associated with poor 30-day outcomes. Medication received in the ED and age were not associated. CONCLUSIONS More than 1 out of five patients treated in the ED for acute PTH experienced frequent headaches 30 days later. Women and patients who were uncertain as to whether they had experienced loss of consciousness were at increased risk of frequent PTH. Blaming oneself for the head trauma was associated with less frequent PTH.
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Affiliation(s)
- Andrew R Wang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| | - Mark J Calandra
- A.T. Still University School of Osteopathic Medicine in Arizona, 5850 E. Still Circle, Mesa, AZ 85206, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, 111 East 210th Street, Bronx, NY 10467, USA.
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Cortez MM, Millsap L, Rea NA, Sciarretta C, Brennan KC. Photophobia and allodynia in persistent post-traumatic headache are associated with higher disease burden. Cephalalgia 2021; 41:1089-1099. [PMID: 33910382 DOI: 10.1177/03331024211010304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess photophobia and allodynia in subjects with post-traumatic headache and examine how these sensory hypersensitivities associate with clinical measures of disease burden. BACKGROUND Post-traumatic headache is the most frequent and disabling long-term consequence of mild traumatic brain injury. There is evidence of sensory dysfunction in acute post-traumatic headache, and it is known from other headache conditions that sensory amplifications correlate with more severe disease. However, systematic studies in post-traumatic headache are surprisingly scarce. METHODS We tested light and tactile sensitivity, along with measures of disease burden, in 30 persistent post-traumatic headache subjects and 35 controls. RESULTS In all, 79% of post-traumatic headache subjects exhibited sensory hypersensitivity based on psychophysical assessment. Of those exhibiting hypersensitivity, 54% exhibited both light and tactile sensitivity. Finally, sensory thresholds were correlated across modalities, as well as with headache attack frequency. CONCLUSIONS In this study, post-traumatic headache subjects with both light and tactile sensitivity had significantly higher headache frequencies and lower sensitivity thresholds to both modalities, compared to those with single or no sensory hypersensitivity. This pattern suggests that hypersensitivity across multiple modalities may be functionally synergistic, reflect a higher disease burden, and may serve as candidate markers of disease.
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Affiliation(s)
- Melissa M Cortez
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Leah Millsap
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Natalie A Rea
- University of Utah, School of Medicine, Salt Lake City, UT, USA.,Mayo Clinic, Rochester, MN, USA
| | | | - K C Brennan
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
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Walker GA, Wilson JC, Seehusen CN, Provance AJ, Howell DR. Is near point of convergence associated with symptom profiles or recovery in adolescents after concussion? Vision Res 2021; 184:52-57. [PMID: 33866266 DOI: 10.1016/j.visres.2021.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/22/2021] [Accepted: 03/08/2021] [Indexed: 11/16/2022]
Abstract
Our purpose was to compare the clinical and injury characteristics of concussion patients with a receded near point of convergence (NPC) vs those without a receded NPC. Concussion patients were seen within 14 days of injury. We compared those with receded a NPC (>6 cm) break point distance and those with a normal NPC distance on symptom, behavioral, and clinical assessments. We also compared NPC break points between those who did/did not recover within 28 days of injury. 123 patients completed the assessment. 77/123 (63%) of participants demonstrated a receded NPC when tested within 14 days of injury. Those with receded a NPC break point (n = 77; mean = 14.9, SD = 1.5 years; 47% female) were significantly younger than those with a normal NPC break point (n = 46; mean = 15.7, SD = 1.7 years; 46% female). The receded NPC break point group had a significantly greater proportion of patients reporting headaches (86% vs. 61%), as well as significantly greater cognitive (mean = 13.4, SD = 8.7 vs. mean = 8.8, SD = 8.6), somatic (mean = 10.0, SD = 5.9 vs. mean = 6.9, SD = 6.6), and overall (mean = 23.7, SD = 13.6 vs. mean = 15.8, SD = 14.4) symptom severity. Our multivariable model indicated among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC break point (β = 0.26; 95% CI = 0.01, 0.52). The group who went onto experience persistent symptoms had a significantly greater NPC break point at initial evaluation than those without persistent symptoms (mean = 9.7, SD = 7.5 cm vs. mean = 7.0, SD = 4.0 cm). Those with a receded NPC break point at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without a receded NPC break point.
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Affiliation(s)
- Gregory A Walker
- Sports Medicine Center, Children's Hospital Colorado, CO, USA; Department of Orthopedics, University of Colorado School of Medicine, CO, USA
| | - Julie C Wilson
- Sports Medicine Center, Children's Hospital Colorado, CO, USA; Department of Orthopedics, University of Colorado School of Medicine, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, CO, USA
| | | | - Aaron J Provance
- Sports Medicine Center, Children's Hospital Colorado, CO, USA; Department of Orthopedics, University of Colorado School of Medicine, CO, USA
| | - David R Howell
- Sports Medicine Center, Children's Hospital Colorado, CO, USA; Department of Orthopedics, University of Colorado School of Medicine, CO, USA.
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Beebe KE, Reynolds E, Driver S. One size fits none: neurobiologic-specific modifications for the assessment, diagnosis, and treatment of sport-related concussion (SRC). Brain Inj 2021; 35:505-510. [PMID: 33822673 DOI: 10.1080/02699052.2020.1837957] [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: 10/21/2022]
Abstract
PRIMARY OBJECTIVE - To discuss how the underlying neuroanatomy and neurobiology of five sport-related concussion (SRC) clinical profiles impacts assessment and treatment. RESEARCH DESIGN - Narrative review. METHODS AND PROCEDURES - Based on the current literature and clinical experience, arguments against the traditional SRC protocol and for a clinical profiles-based SRC protocol are made. MAIN OUTCOMES AND RESULTS - While the clinical profiles-based SRC protocol is widely used and accepted, there has been little published regarding the link to the underlying neuropathology. Our narrative review describes the five SRC clinical profiles: vestibular, ocular, mood, post-traumatic migraine, and cognitive/fatigue. For these profiles, the underlying neuroanatomy and neurobiology is outlined, as well as how that anatomy and biology impact the profiles' etiology, assessment, and treatment. The cervical and sleep modifiers are also briefly covered. CONCLUSIONS - Utilizing this model, clinicians are able to provide an individualized assessment, conceptualization, and treatment plan for SRC, leading to improved outcomes and clinical experiences for athletes.
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Affiliation(s)
- Kelzie E Beebe
- Department of Psychology, University of North Texas, Denton, Texas, USA
| | - Erin Reynolds
- Director, Baylor Scott & White Sports Concussion Program, Frisco, Texas, USA
| | - Simon Driver
- Research Center Director, Baylor Scott & White Research Institute, Frisco, Texas, USA
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Abstract
Objective Current clinical guidelines provide a unitary approach to manage sport-related concussion (SRC), while heterogeneity in the presentation of symptoms suggests that subtypes of SRC may exist. We systematically reviewed the available evidence on SRC subtypes and associated clinical outcomes. Data Sources Ovid Medline, Embase, PsycINFO, and SPORTDiscus Eligibility Criteria for Selecting Studies Electronic databases were searched for studies: (i) identifying SRC symptom clusters using classification methodology; or (ii) associating symptom clusters to clinical outcome variables. A total of 6,146 unique studies were identified, of which 75 full texts were independently assessed by two authors for eligibility. A total of 22 articles were included for systematic review. Data Extraction Two independent authors performed data extraction and risk of bias analysis using the Cochrane Collaboration tool. Data Synthesis Six studies found evidence for existence of SRC symptom clusters. Combining the available literature through Multiple Correspondence Analysis (MCA) provided evidence for the existence of a migraine cluster, a cognitive–emotional cluster, a sleep–emotional cluster, a neurological cluster, and an undefined feelings cluster. Nineteen studies found meaningful associations between SRC symptom clusters and clinical outcomes. Clusters mapping to the migraine cluster were most frequently reported in the literature and were most strongly related to aspects of clinical outcome. Conclusions The available literature provides evidence for the existence of at least five subtypes in SRC symptomatology, with clear relevance to clinical outcome. Systematically embedding the differentiation of SRC subtypes into prognosis, clinical management, and intervention strategies may optimize the recovery from SRC. Electronic supplementary material The online version of this article (10.1007/s40279-020-01321-9) contains supplementary material, which is available to authorized users.
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Kamins J, Richards R, Barney BJ, Locandro C, Pacchia CF, Charles AC, Cook LJ, Gioia G, Giza CC, Blume HK. Evaluation of Posttraumatic Headache Phenotype and Recovery Time After Youth Concussion. JAMA Netw Open 2021; 4:e211312. [PMID: 33683335 PMCID: PMC7941198 DOI: 10.1001/jamanetworkopen.2021.1312] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The Four Corners Youth Consortium was created to fill the gap in our understanding of youth concussion. This study is the first analysis of posttraumatic headache (PTH) phenotype and prognosis in this cohort of concussed youth. OBJECTIVE To describe the characteristics of youth with PTH and determine whether the PTH phenotype is associated with outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined outcomes from patients in a multi-institutional registry of traumatic brain injury (TBI) clinics from December 2017 to June 2019. Inclusion criteria included being between ages 5 and 18 years at enrollment and presentation within 8 weeks of a mild TBI. Data were analyzed between February 2019 and January 2021. EXPOSURE Mild TBI with standard care. MAIN OUTCOMES AND MEASURES Time to recovery and headache 3 months after injury; measurement device is the Postconcussion Symptom Inventory (PCSI). PTH with migraine phenotype was defined as moderate-severe headache that is new or significantly worse compared with baseline and associated with nausea and/or photophobia and phonophobia. RESULTS A total of 612 patients with 625 concussions were enrolled, of whom 387 patients with 395 concussions consented to participate in this study. One hundred nine concussions were excluded (concussions, rather than patients, were the unit of analysis), leaving 281 participants with 286 concussions (168 [58.7%] girls; 195 [75.6%] White; 238 [83.2%] aged 13-18 years). At the initial visit, 133 concussions (46.5%) were from patients experiencing PTH with a migraine phenotype, 57 (20%) were from patients experiencing PTH with a nonmigraine phenotype, and 96 (34%) were from patients with no PTH. Patients with any PTH after concussion were more likely to have prolonged recovery than those without PTH (median [interquartile range], 89 [48-165] days vs 44 [26-96] days; log-rank P < .001). Patients with PTH and a migraine phenotype took significantly longer to recover than those with nonmigraine phenotype (median [interquartile range], 95 [54-195] days vs 70 [46-119] days; log-rank P = .01). Within each phenotype, there was no significant difference between sexes in recovery or PTH at 3 months. CONCLUSIONS AND RELEVANCE PTH with a migraine phenotype is associated with persistent symptoms following concussion compared with nonmigraine PTH or no PTH. Given that female sex is associated with higher rates of migraine and migraine PTH, our finding may be one explanation for findings in prior studies that girls are at higher risk for persistent postconcussion symptoms than boys.
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Affiliation(s)
- Joshua Kamins
- Goldberg Migraine Program, Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles
- UCLA Steve Tisch BrainSPORT Program, Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles
| | - Rachel Richards
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | | | | | - Andrew C. Charles
- Goldberg Migraine Program, Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles
| | | | - Gerard Gioia
- Division of Pediatric Neuropsychology, Children's National Hospital, SCORE Program, Rockville, Maryland
| | - Christopher C. Giza
- UCLA Steve Tisch BrainSPORT Program, Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles
- Department of Pediatrics, Pediatric Neurology Division, UCLA Mattel Children’s Hospital, University of California, Los Angeles
| | - Heidi K. Blume
- Division of Pediatric Neurology, Seattle Children’s Hospital, University of Washington, Seattle
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Lempke LB, Howell DR, Eckner JT, Lynall RC. Examination of Reaction Time Deficits Following Concussion: A Systematic Review and Meta-analysis. Sports Med 2021; 50:1341-1359. [PMID: 32162242 DOI: 10.1007/s40279-020-01281-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Reaction time (RT) deficits are reported following concussion, but it is unknown when these deficits normalize to pre-injury status. It is also unclear how factors such as RT measurement technique and participant characteristics influence post-concussion RT. OBJECTIVE The purpose of this systematic review and meta-analysis was to (1) characterize acute post-concussion (0-3 days) RT impairments, (2) examine RT recovery over time, and (3) explore moderating factors related to acute RT impairment following concussion. METHODS Database searches (PubMed, CINAHL, EBSCOhost) were conducted according to PRISMA guidelines for articles published in English from January 2002 to March 2019. Studies compared baseline-to-post-injury RT within individuals (within-subject) and/or RT in concussed individuals to non-concussed controls (between-subject). Sixty studies met inclusion criteria, reporting on a total of 9688 participants with 214 discrete RT effects (Hedges' d; between-subject: N = 29, k = 129; within-subject: N = 42, k = 85). Of the 214 effects, 93 occurred in the acute (0-3 days) post-injury timeframe (k = 47 between-subject). Numerous demographic [sex, age, concussion history, population type (athlete, military, and general population), athlete level (high school, college), and sport], and method-based (RT test and measure type, computerized neurocognitive testing platform, concussion definition, and time post-injury) moderators were examined for mean effect influence. Mixed-effects multi-level modeling with restricted-maximum-likelihood estimation was used to account for nested effects and high heterogeneity for the pooled effect size (D+). RESULTS Significant medium-magnitude RT deficits were observed acutely for between- (D+ = - 0.7279, 95% CI - 0.9919, - 0.4639, I2 = 88.66, p < 0.0001) and within-subject (D+ = - 0.7472, 95% CI - 0.9089, - 0.5855, I2 = 89.21, p < 0.0001) effect models. RT deficits were present at the sub-acute and intermediate-term timeframes for between-subject effects (sub-acute: D+ = - 0.5655, 95% CI - 0.6958, - 0.4352, p < 0.0001; intermediate-term: D+ = - 0.3219, 95% CI - 0.5988, - 0.0450, p = 0.0245). No significant RT mean effect was observed for the between-subject model at the long-term timeframe, indicating RT recovery among concussed participants relative to controls (D+ = 0.3505, 95% CI - 0.4787, 1.1797, p = 0.3639). Sex was a significant moderator for between-subject effects, with every 1% male sample size increase demonstrating - 0.0171 (95% CI - 0.0312, - 0.0029, p = 0.0193) larger RT deficits. Within-subject effect models resulted in RT measure type (simple: [D+ = - 0.9826] vs. mixed: [D+ = - 0.6557], p = 0.0438) and computerized neurocognitive testing platforms (ANAM: [D+ = - 0.3735] vs. HeadMinder CRI: [D+ = - 1.4799] vs. ImPACT: [D+ = - 0.6749], p = 0.0004) having significantly different RT-deficit magnitudes. No other moderators produced significantly different RT-deficit magnitudes (between-subject: [p ≥ 0.0763], within-subject: [p ≥ 0.1723]). CONCLUSIONS Robust RT deficits were observed acutely following concussion. Minimal magnitude differences were noted when comparing between- and within-subject effects, suggesting that pre-injury baselines may not add clinical value in determining post-injury RT impairment. RT deficits persisted up till the intermediate-term (21-59 days post-injury) timeframe and indicate lingering deficits exist. Mean effect size differences were observed between RT measure types and computerized neurocognitive testing platforms; however, all categories displayed negative effects consistent with impaired RT following concussion. Clinical interpretation suggests that measuring RT post-concussion is more important than considering the RT method employed so long as reliable and valid tools are used. PROSPERO Registration #CRD42019119323.
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Affiliation(s)
- Landon B Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Ramsey Student Center, 330 River Rd., Athens, GA, 30602, USA. .,UGA Biomechanics Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA.
| | - David R Howell
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA.,Department of Orthopaedics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Ramsey Student Center, 330 River Rd., Athens, GA, 30602, USA.,UGA Biomechanics Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
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Abstract
OBJECTIVES To evaluate the relationship between preinjury risk factors (RFs) and subsequent occurrence of concussion and examine whether preinjury RFs or postinjury assessments predict clinical recovery in collegiate athletes. METHODS Risk factors (sex, sport, and self-report history of concussion, migraine, attention-deficit disorder, learning disability, depression, and anxiety) and Sport Concussion Assessment Tool (SCAT), depression/anxiety screenings, and neuropsychological testing were obtained before the season. For athletes who sustained concussion, RFs, postinjury SCAT, neuropsychological assessment, and clinical recovery were assessed. RESULTS We assessed 1152 athletes (69% male) at baseline and 145 (75% male) after subsequent concussion diagnosis. Only sport type (Wald = 40.29, P = 0.007) and concussion history (Wald = 9.91, P = 0.007) accounted for unique variance in subsequent concussion. Of athletes followed until full recovery, mean days until symptom-free (DUSF) was 9.84 ± 11.11 days (n = 138, median = 5 days, range = 1-86) and mean days until full return to play (DUFRTP) was 20.21 ± 19.17 (n = 98, median = 20.21, range = 4-150). None of the RFs or baseline testing measures were associated with DUSF or DUFRTP (P's > 0.05). After injury, athletes who reported more total symptoms (rs = 0.31, P < 0.001) and higher symptom severity (rs = 0.33, P < 0.001) exhibited longer DUSF. Days until symptom-free correlated with DUFRTP (rs = 0.75, P < 0.001). Among athletes assessed within 2 days after injury, DUSF was associated with Immediate Postconcussion Assessment and Cognitive Test visual motor (rs = -0.31, P = 0.004), reaction time (rs = 0.40, P < 0.001), and symptom score (rs = 0.54, P < 0.001). CONCLUSIONS Only sport type and concussion history predicted subsequent occurrence of concussion, and none of the RFs or baseline measures predicted clinical recovery. Immediate postinjury assessments, including symptom number and severity, and select clinical measures predicted longer clinical recovery.
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Covassin T, McGowan AL, Bretzin AC, Anderson M, Petit KM, Savage JL, Katie SL, Elbin RJ, Pontifex MB. Preliminary investigation of a multimodal enhanced brain function index among high school and collegiate concussed male and female athletes. PHYSICIAN SPORTSMED 2020; 48:442-449. [PMID: 32228157 DOI: 10.1080/00913847.2020.1745717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: The primary purpose of this study was to examine the longitudinal effects of sports-related concussion (SRC) on a multi-faceted assessment battery which included neuropsychological testing, symptom reporting, and enhanced brain function index (eBFI) among athletes with and without SRC. A secondary purpose was to explore longitudinal sex differences among these measures in athletes with and without SRC. Methods: A case-control, repeated-measures design was used for this study. A total of 186 athletes (concussed group:n= 87 controls:n= 99) participated in the study. A repeated-measures design was used in which each athlete was tested at four time points following an SRC: within 72 h of injury (Day 0; 2.0 ± 0.9 days following injury), 5 days following injury (Day 5; 5.0 ± 0.0), at return to play (RTP; 18.3 ± 13.8 days following injury), and within 45 days following RTP (RTP45; 66.2 ± 19.0 days following injury). All analyses were conducted separately using a 2 (Group: concussed, control) × 2 (Sex: male, female) × 4 (Time:Day 0, Day 5, RTP, RTP45) univariate multi-level model including the random intercept for each participant. A higher eBFI score indicates a better performance. Alpha level was set aprior at .05. This study was registered on clinicaltrials.gov (Objective Brain Function Assessment of mTBI/Concussion in College/high school Athletes NCT02477943, NCT02661633, CAS 13-25 NCT03963804). Results: Concussed athletes exhibited impaired eBFI within 72 h of SRC and at Day 5 compared to controls (p<.001). Analysis of eBFI scores between male and female athletes revealed a main effect of sex (p=.05), with female athletes exhibiting lower eBFI (33.9 ± 30.7) relative to male athletes (40.4 ± 33.0), however, it did not indicate interactions between sex, group, and time (p's ≥ 0.786). Conclusion: The eBFI appears to be a useful tool in determining concussed athletes during the acute stages of an SRC. However, this index may lack the sensitivity to detect sex-related differences between groups at various time points during recovery.
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Affiliation(s)
- Tracey Covassin
- Department of Kinesiology, Michigan State University , East Lansing, MI, USA
| | - Amanda L McGowan
- Department of Kinesiology, Michigan State University , East Lansing, MI, USA
| | - Abigail C Bretzin
- Penn Injury Science Center, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania , Philadelphia, PA, USA
| | - Morgan Anderson
- Department of Kinesiology, Michigan State University , East Lansing, MI, USA
| | - Kyle Michael Petit
- Department of Kinesiology, Michigan State University , East Lansing, MI, USA
| | - Jennifer L Savage
- Rudy School of Nursing and Health Professions, Cumberland University , Lebanon, TN, USA
| | - Stephenson L Katie
- Department of Health, Human Performance and Recreation, University of Arkansas , Fayetteville, AR, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas , Fayetteville, AR, USA
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43
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Abstract
After traumatic brain injury (TBI), a host of symptoms of varying severity and associated functional impairment may occur. One of the most commonly encountered and challenging to treat are the post-traumatic cephalalgias. Post-traumatic cephalalgia (PTC) or headache is often conceptualized as a single entity as currently classified using the ICHD-3. Yet, the terminology applicable to the major primary, non-traumatic, headache disorders such as migraine, tension headache, and cervicogenic headache are often used to specify the specific type of headache the patients experiences seemingly disparate from the unitary definition of post-traumatic headache adopted by ICHD-3. More complex post-traumatic presentations attributable to brain injury as well as other headache conditions are important to consider as well as other causes such as medication overuse headache and medication induced headache. Treatment of any post-traumatic cephalalgia must be optimized by understanding that there may be more than one headache pain generator, that comorbid traumatic problems may contribute to the pain presentation and that pre-existing conditions could impact both symptom complaint, clinical presentation and recovery. Any treatment for PTC must harmonize with ongoing medical and psychosocial aspects of recovery.
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Affiliation(s)
- Brigid Dwyer
- Department of Neurology, Boston University, Boston, Massachusetts, USA
| | - Nathan Zasler
- Concussion Care Centre of Virginia Ltd. and Tree of Life Services, Inc., Richmond, Virginia, USA.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
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Brett BL, Kramer MD, McCrea MA, Broglio SP, McAllister T, Nelson LD, Hazzard JB, Kelly LA, Ortega J, Port N, Pasquina PF, Jackson J, Cameron KL, Houston MN, Goldman JT, Giza C, Buckley T, Clugston JR, Schmidt JD, Feigenbaum LA, Eckner JT, Master CL, Collins MW, Kontos AP, Chrisman SPD, Duma SM, Miles CM, Susmarski A. Bifactor Model of the Sport Concussion Assessment Tool Symptom Checklist: Replication and Invariance Across Time in the CARE Consortium Sample. Am J Sports Med 2020; 48:2783-2795. [PMID: 32809856 PMCID: PMC7484253 DOI: 10.1177/0363546520946056] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying separate dimensions of concussion symptoms may inform a precision medicine approach to treatment. It was previously reported that a bifactor model identified distinct acute postconcussion symptom dimensions. PURPOSE To replicate previous findings of a bifactor structure of concussion symptoms in the Concussion Assessment Research and Education (CARE) Consortium sample, examine measurement invariance from pre- to postinjury, and evaluate whether factors are associated with other clinical and biomarker measures. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS Collegiate athletes were prospectively evaluated using the Sport Concussion Assessment Tool-3 (SCAT-3) during preseason (N = 31,557); 2789 were followed at <6 hours and 24 to 48 hours after concussion. Item-level SCAT-3 ratings were analyzed using exploratory and confirmatory factor analyses. Bifactor and higher-order models were compared for their fit and interpretability. Measurement invariance tested the stability of the identified factor structure across time. The association between factors and criterion measures (clinical and blood-based markers of concussion severity, symptom duration) was evaluated. RESULTS The optimal structure for each time point was a 7-factor bifactor model: a General factor, on which all items loaded, and 6 specific factors-Vestibulo-ocular, Headache, Sensory, Fatigue, Cognitive, and Emotional. The model manifested strict invariance across the 2 postinjury time points but only configural invariance from baseline to postinjury. From <6 to 24-48 hours, some dimensions increased in severity (Sensory, Fatigue, Emotional), while others decreased (General, Headache, Vestibulo-ocular). The factors correlated with differing clinical and biomarker criterion measures and showed differing patterns of association with symptom duration at different time points. CONCLUSION Bifactor modeling supported the predominant unidimensionality of concussion symptoms while revealing multidimensional properties, including a large dominant General factor and 6 independent factors: Headache, Vestibulo-ocular, Sensory, Cognitive, Fatigue, and Emotional. Unlike the widely used SCAT-3 symptom severity score, which declines gradually after injury, the bifactor model revealed separable symptom dimensions that have distinct trajectories in the acute postinjury period and different patterns of association with other markers of injury severity and outcome. CLINICAL RELEVANCE The SCAT-3 total score remains a valuable, robust index of overall concussion symptom severity, and the specific factors identified may inform management strategies. Because some symptom dimensions continue to worsen in the first 24 to 48 hours after injury (ie, Sensory, Fatigue, Emotional), routine follow-up in this time frame may be valuable to ensure that symptoms are managed effectively.
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Affiliation(s)
- Benjamin L. Brett
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | | | - Michael A. McCrea
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Steven P. Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI USA
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN USA
| | - Lindsay D. Nelson
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | | | - Joseph B Hazzard
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Louise A Kelly
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Justus Ortega
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicholas Port
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul F Pasquina
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jonathan Jackson
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth L Cameron
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Megan N Houston
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joshua T Goldman
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christopher Giza
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas Buckley
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James R Clugston
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julianne D Schmidt
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Luis A Feigenbaum
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James T Eckner
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christina L Master
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael W Collins
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anthony P Kontos
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sara P D Chrisman
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stefan M Duma
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christopher M Miles
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adam Susmarski
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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45
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Irwin SL, Kacperski J, Rastogi RG. Pediatric Post‐Traumatic Headache and Implications for Return to Sport: A Narrative Review. Headache 2020; 60:1076-1092. [DOI: 10.1111/head.13824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/06/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Samantha L. Irwin
- Department of Neurology University of California San Francisco San Francisco CA USA
| | - Joanne Kacperski
- Division of Neurology Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Department of Pediatrics College of Medicine University of Cincinnati Cincinnati OH USA
| | - Reena G. Rastogi
- Department of Neurology Barrow Neurological Institute at Phoenix Children's Hospital Phoenix AZ USA
- Department of Neurology University of Arizona College of Medicine Phoenix AZ USA
- Department of Child Health University of Arizona College of Medicine Phoenix AZ USA
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46
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Ptito A, Papa L, Gregory K, Folmer RL, Walker WC, Prabhakaran V, Wardini R, Skinner K, Yochelson M. A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to
Mild‐to‐Moderate
Traumatic Brain Injury. Neuromodulation 2020; 24:1412-1421. [PMID: 32347591 PMCID: PMC9291157 DOI: 10.1111/ner.13159] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 12/22/2022]
Abstract
Objectives Materials and Methods Results Conclusions
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Affiliation(s)
- Alain Ptito
- Psychology Department McGill University Health Centre; Montreal Neurological Institute and Hospital Montreal QC Canada
| | - Linda Papa
- Department of Emergency Medicine Orlando Health Orlando FL USA
| | - Kenton Gregory
- Center for Regenerative Medicine Oregon Health and Science University Portland OR USA
| | - Robert L. Folmer
- Department of Otolaryngology Oregon Health and Science University Portland OR USA
- National Center for Rehabilitative Auditory Research VA Portland Health Care System Portland OR USA
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation Virginia Commonwealth University Richmond VA USA
| | - Vivek Prabhakaran
- Department of Radiology, University of Wisconsin Hospitals and Clinics University of Wisconsin Madison WI USA
| | | | | | - Michael Yochelson
- Shepherd Center Atlanta GA USA
- MedStar National Rehabilitation Network Washington DC USA
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47
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Andersen AM, Ashina H, Iljazi A, Al-Khazali HM, Chaudhry B, Ashina M, Ashina S, Schytz HW. Risk Factors for the Development of Post-Traumatic Headache Attributed to Traumatic Brain Injury: A Systematic Review. Headache 2020; 60:1066-1075. [PMID: 32320055 DOI: 10.1111/head.13812] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/25/2020] [Accepted: 03/27/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To systematically identify risk factors for the development of post-traumatic headache (PTH) attributed to traumatic brain injury (TBI) as defined in the International Classification of Headache Disorders (ICHD). BACKGROUND PTH is a common sequela of TBI and a leading cause of injury-related disability worldwide. However, little is known about risk factors for the development of PTH attributed to TBI. METHODS We searched PubMed and Embase for literature on risk factors for the development of acute and/or persistent PTH attributed to TBI in accordance with any version of the ICHD. Original studies published in English and of prospective, cross-sectional or retrospective design were considered for the review. Data extraction was performed independently by 2 investigators. RESULTS Of 1993 potentially relevant articles identified, 3 articles met the inclusion criteria. The following risk factors were assessed for the development of acute PTH: age, sex, type of injury, loss of consciousness, previous TBIs, history of primary headache disorders, history of chronic pain condition other than headache, current treatment for depression/anxiety, attention or learning disorders, body mass index, and other diseases (not further specified). None of the included studies assessed risk factors for the development of persistent PTH. CONCLUSIONS We found that there is little evidence for any risk factors involved in the development of acute PTH, whereas no study had assessed risk factors for the development of persistent PTH. Further studies are warranted and should be powered to examine possible risk factors for the development of PTH. Rigorous methodology and standardized monitoring should be prioritized to support high-quality research and validate potential findings.
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Affiliation(s)
- Amalie M Andersen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Afrim Iljazi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Haidar M Al-Khazali
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Basit Chaudhry
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sait Ashina
- Department of Neurology and Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Henrik W Schytz
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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48
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Whitney SL, Eagle SR, Marchetti G, Mucha A, Collins MW, Kontos AP. Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion. Brain Inj 2020; 34:840-845. [DOI: 10.1080/02699052.2020.1755055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Susan L. Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn R. Eagle
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Anne Mucha
- Centers for Rehabilitation Service, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael W. Collins
- Centers for Rehabilitation Service, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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49
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Ofoghi Z, Dewey D, Barlow KM. A Systematic Review of Structural and Functional Imaging Correlates of Headache or Pain after Mild Traumatic Brain Injury. J Neurotrauma 2020; 37:907-923. [DOI: 10.1089/neu.2019.6750] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Zahra Ofoghi
- Department of Neuroscience, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah Dewey
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen M. Barlow
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Paediatric Neurology Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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50
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Kwan V, Plourde V, Yeates KO, Noel M, Brooks BL. Headache long after pediatric concussion: presence, intensity, interference, and association with cognition. Brain Inj 2020; 34:575-582. [PMID: 32050786 DOI: 10.1080/02699052.2020.1725842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Document headache presence, intensity, and interference after concussion(s), as well as examine its association with cognition.Participants: Participants 8-19 years of age were assessed on average 34 months (SD = 21.5) after an orthopedic injury (OI, n = 29), single concussion (n = 21), or multiple concussions (n = 15).Measures: Headache intensity was rated using the Headache Rating Scale and headache interference was rated using the Post-Concussion Symptom Inventory (PCSI). Cognition was rated using the PCSI and measured using CNS Vital Signs.Results: Type of injury did not differ significantly in headache presence or intensity. However, there was a dose-response relationship found for children's ratings of headache interference, which was rated highest among children with multiple concussions, intermediate among those with single concussion, and lowest among children with OI. Both headache intensity and interference ratings correlated significantly with self and parent ratings of cognition on the PCSI, but not with cognitive test performance.Conclusions: Youth with single or multiple concussions report greater headache interference - but not higher headache intensity - compared to youth without concussion. Although higher headache intensity and interference were associated with more self-reported cognitive symptoms, headaches did not correlate with cognitive test performance.
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Affiliation(s)
- Vivian Kwan
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Vickie Plourde
- School of Psychology, Université de Moncton, Moncton, Canada
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Melanie Noel
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Brian L Brooks
- Neurosciences Program, Alberta Children's Hospital, Calgary, Alberta, Canada.,Departments of Pediatrics, Clinical Neurosciences, and Psychology, University of Calgary, Calgary, Canada
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