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Hammerle MH, Lu LH, Thomas LC, Swan AA, Treleaven JM. Validation of a modified-composite autonomic symptom score (COMPASS-31) as an outcome measure for persistent autonomic symptoms post-concussion: an observational pilot study. Brain Inj 2024; 38:896-901. [PMID: 38766859 DOI: 10.1080/02699052.2024.2355588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 05/05/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE Persistent symptoms post-mild traumatic brain injury (mTBI) includes autonomic dysregulation (AD). The composite autonomic symptoms score, (COMPASS-31), was developed to quantify AD symptom severity in the last year, which limits clinical utility. The primary aim was to determine validity of a modified-COMPASS-31 measuring symptoms in the last month compared to the original, secondarily to compare both original and modified versions to the Neurobehavioral Symptom Inventory (NSI), and tertiarily to detect change post-treatment of the modified-COMPASS-31 compared to NSI and headache intensity (HI). PARTICIPANTS Thirty-three military personnel with persistent headache post-mTBI. MAIN OUTCOME MEASURES Total and domain scores for COMPASS-31 (original vs. modified) NSI and HI at baseline. Change in modified-COMPASS-31. NSI, and HI. RESULTS Baseline COMPASS-31 versions were comparable and highly correlated (r = 0.72, p < 0.001), they were moderately correlated at best to the NSI (r < 0.6), which may suggest differences in measurement metrics. The mean change in modified-COMPASS-31 scores (15.4/100, effect size 0.8) was mild to moderately correlated to the change in HI (r = 0.39) score, but not to NSI (r = 0.28). CONCLUSION The modified-COMPASS-31 appears to be valid, can measure change of AD symptom severity, and is recommended as an outcome measure.
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Affiliation(s)
- Matt H Hammerle
- Brooke Army Medical Center Brain Injury Rehabilitation Service, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Lisa H Lu
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- Brooke Army Medical Center, JBSA, Texas, USA
- General Dynamics Information Technology, Falls Church, Virginia, USA
| | - Lucy C Thomas
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
| | - Alicia A Swan
- Department of Psychology, South Texas Veterans Health Care System & The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Julia M Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
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Papini MG, Avila AN, Fitzgerald M, Hellewell SC. Evidence for Altered White Matter Organization After Mild Traumatic Brain Injury: A Scoping Review on the Use of Diffusion Magnetic Resonance Imaging and Blood-Based Biomarkers to Investigate Acute Pathology and Relationship to Persistent Post-Concussion Symptoms. J Neurotrauma 2024. [PMID: 39096132 DOI: 10.1089/neu.2024.0039] [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: 08/04/2024] Open
Abstract
Mild traumatic brain injury (mTBI) is the most common form of traumatic brain injury. Post-concussive symptoms typically resolve after a few weeks although up to 20% of people experience these symptoms for >3 months, termed persistent post-concussive symptoms (PPCS). Subtle white matter (WM) microstructural damage is thought to underlie neurological and cognitive deficits experienced post-mTBI. Evidence suggests that diffusion magnetic resonance imaging (dMRI) and blood-based biomarkers could be used as surrogate markers of WM organization. We conducted a scoping review according to PRISMA-ScR guidelines, aiming to collate evidence for the use of dMRI and/or blood-based biomarkers of WM organization, in mTBI and PPCS, and document relationships between WM biomarkers and symptoms. We focused specifically on biomarkers of axonal or myelin integrity post-mTBI. Biomarkers excluded from this review therefore included the following: astroglial, perivascular, endothelial, and inflammatory markers. A literature search performed across four databases, EMBASE, Scopus, Google Scholar, and ProQuest, identified 100 records: 68 analyzed dMRI, 28 assessed blood-based biomarkers, and 4 used both. Blood biomarker studies commonly assessed axonal cytoskeleton proteins (i.e., tau); dMRI studies assessed measures of WM organization (i.e., fractional anisotropy). Significant biomarker alterations were frequently associated with heightened symptom burden and prolonged recovery time post-injury. These data suggest that dMRI and blood-based biomarkers may be useful proxies of WM organization, although few studies assessed these complementary measures in parallel, and the relationship between modalities remains unclear. Further studies are warranted to assess the benefit of a combined biomarker approach in evaluating alterations to WM organization after mTBI.
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Affiliation(s)
- Melissa G Papini
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - André N Avila
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - Sarah C Hellewell
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
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Treleaven J. The Role of the Cervical Spine in Dizziness. J Neurol Phys Ther 2024:01253086-990000000-00074. [PMID: 39146225 DOI: 10.1097/npt.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
The neck can be implicated in dizziness via several, separate, discreet mechanisms. Proprioceptive cervicogenic dizziness (CGD) is the most common and reflects the cervical spine's important role, along with visual and vestibular input, for sensorimotor control. Impaired cervical proprioception can lead to symptoms such as dizziness, unsteadiness, visual disturbances, and altered sensorimotor control, and treatment directed toward cervical musculoskeletal and sensorimotor control is efficacious to improve this in individuals with cervical musculoskeletal disorders. Despite this, CGD is difficult to diagnose. Many people present with both neck pain and dizziness, and often the onset of both follows head and neck trauma, but neither necessarily implicate the neck as the cause of dizziness. Further, people often present with mixed forms of dizziness. Thus, rather than diagnosing CGD, it might be more important to consider the potential for the neck to have no (nil, co-morbid cervical condition) or some (minor, major, or compensatory) role in dizziness. Determining the precise role of the cervical spine role in dizziness requires a skilled interview and examination for cervical musculoskeletal and related sensorimotor impairments and relevant testing of other potential causes. A combination and cluster of test outcomes in addition to comparing responses to specific tests when the cervical afferents are stimulated and not stimulated will be important. Considering the role of the neck in dizziness will allow a balanced approach in assessment and management to allow timely, effective intervention to be provided to the large number of individuals presenting with neck pain and dizziness (Supplemental Digital Content, available at: http://links.lww.com/JNPT/A484).
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Affiliation(s)
- Julia Treleaven
- Neck and Head Research Unit, SHRS, The University of Queensland,Brisbane, Queensland, Australia
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DeGroot A, Huber DL, Leddy JJ, Raff H, McCrea MA, Johnson BD, Nelson LD. Use of the Buffalo Concussion Treadmill Test in community adult patients with mild traumatic brain injury. PM R 2024; 16:826-835. [PMID: 38411367 PMCID: PMC11323219 DOI: 10.1002/pmrj.13132] [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: 03/10/2023] [Revised: 11/27/2023] [Accepted: 12/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown. OBJECTIVE Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI-related symptoms, and BCTT duration. DESIGN Prospective, observational, longitudinal. SETTING Academic medical center. PARTICIPANTS Thirty-seven adults treated in a level 1 trauma center emergency department with mTBI; 24 uninjured controls (UC). INTERVENTIONS N/A. MAIN MEASURES Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15-minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration. RESULTS Persons with mTBI discontinued earlier than UC at 1-week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI-related intolerance was 55.6% at 1 week (36.1% for mTBI-related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age-predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI-related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39-61%) and physical exertion (9-26%). Shorter duration was associated with higher body mass index (r = -0.42 - -0.45), shorter height (r = 0.22-0.29), female gender (r = -0.26 - -0.27), and greater RPQ symptoms (r = -0.28 - -0.47). CONCLUSION The BCTT exacerbates mTBI-related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes.
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Affiliation(s)
- Andrew DeGroot
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine; SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Hershel Raff
- Department of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee WI and the Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Blair D Johnson
- Department of Kinesiology, Indiana University, Bloomington, Indiana, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Neill MG, Burma JS, Miutz LN, Kennedy CM, Penner LC, Newel KT, Smirl JD. Transcranial Doppler Ultrasound and Concussion-Supplemental Symptoms with Physiology: A Systematic Review. J Neurotrauma 2024; 41:1509-1523. [PMID: 38468559 DOI: 10.1089/neu.2023.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Sport-related concussion (SRC) can impair the cerebrovasculature both acutely and chronically. Transcranial Doppler (TCD) ultrasound assessment has the potential to illuminate the mechanisms of impairment and provide an objective evaluation of SRC. The current systematic review investigated studies employing TCD ultrasound assessment of intracranial arteries across three broad categories of cerebrovascular regulation: neurovascular coupling (NVC), cerebrovascular reactivity (CVR), and dynamic cerebral autoregulation (dCA). The current review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021275627). The search strategy was applied to PubMed, as this database indexes all biomedical journals. Original articles on TCD for athletes with medically diagnosed SRC were included. Title/abstract and full-text screening were completed by three authors. Two authors completed data extraction and risk of bias using the Methodological Index for Non-Randomized Studies and Scottish Intercollegiate Guideline Network checklists. Of the 141 articles identified, 14 met the eligibility criteria. One article used an NVC challenge, eight assessed CVR, and six investigated dCA. Methodologies varied widely among studies, and results were heterogeneous. There was evidence of cerebrovascular impairment in all three domains roughly 2 days post-SRC, but the magnitude and recovery of these impairments were not clear. There was evidence that clinical symptom resolution occurred before cerebrovascular function, indicating that physiological deficits may persist despite clinical recovery and return to play. Collectively, this emphasizes an opportunity for the use of TCD to illuminate the cerebrovascular deficits caused by SRC. It also highlights that there is need for consistent methodological rigor when employing TCD in a SRC population.
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Affiliation(s)
- Matthew G Neill
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Joel S Burma
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Lauren N Miutz
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
- Department of Health and Sport Science, University of Dayton, Dayton, Ohio, USA
| | - Courtney M Kennedy
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Linden C Penner
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kailey T Newel
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia, Kelowna, British Columbia, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan D Smirl
- Cerebrovascular Concussion Lab, University of Calgary, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
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Glendon K, Blenkinsop G, Belli A, Pain MTG. Does early exercise intolerance effect time to return to play, symptom burden, neurocognition, Vestibular-Ocular-Motor (VOM) function and academic ability in acutely concussed student-athletes? Brain Inj 2024:1-11. [PMID: 38910338 DOI: 10.1080/02699052.2024.2367477] [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: 10/30/2023] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Early Exercise Intolerance (EEI) is associated with delayed recovery and longer time to Return To Play (RTP), but this has not been established.Participants; (n = 52, male n = 30) UK university-aged rugby-union student-athletes. METHODS Student-athletes completed baseline screening (July-October 2021 and 2022). The test battery was repeated within 48 h, 4, 8 and 14 days after a Sports-Related Concussion (SRC) with the Buffalo Concussion Bike or Treadmill Test to set sub-symptom heart rate threshold. Student-athletes then completed a controlled early exercise protocol in-between reassessment (days 3, 5-7 and 9-13). Those with EEI were compared to those with early-exercise tolerance. OUTCOME MEASURES Post-Concussion Symptom Scale, Immediate Post-Concussion and Cognitive Test, Vestibular-Ocular Motor Screening Tool and the Revised Perceived Academic Impact Tool. RESULTS EEI was seen throughout the initial 14-days post-SRC (23.8%, 22.4%, 25.5%. 25.0%). EEI was associated with a slower reaction time within 48 h (-0.01 (-0.030-0.043) Vs 0.06 (0.033-0.24), p = 0.004) and greater VOMS scores within 48 h; (0.00 (0.00-4.00) Vs 5.50 (2.75-9.00), p = 0.016) and 4 days (0.00 (0.00-2.00) Vs 5.00 (0.00-6.00), p = 0.044). RTP was 12.5 days longer in those with EEI at 14-days post-SRC. CONCLUSION EEI is prevalent following an SRC in university-aged student-athletes and was associated with delayed recovery and RTP.
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Affiliation(s)
- K Glendon
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - G Blenkinsop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - A Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - M T G Pain
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Farrell G, Chapple C, Kennedy E, Reily-Bell M, Sampath K, Gisselman AS, Cook C, Katare R, Tumilty S. Autonomic nervous system and endocrine system response to upper or lower cervical spine mobilization in males with persistent post-concussion symptoms: a proof-of-concept trial. J Man Manip Ther 2024:1-17. [PMID: 38904298 DOI: 10.1080/10669817.2024.2363018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/29/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION The peripheral stress response, consisting of the autonomic nervous system (ANS) and hypothalamic pituitary adrenal-axis (HPA-axis), functions to maintain homeostasis in response to stressors. Cervical spine manual therapy has been shown to differentially modulate the stress response in healthy populations. No study has investigated whether cervical spine mobilizations can differentially modulate the stress response in individuals with persistent post-concussion symptoms (PPCS), a population characterized by a dysfunctional stress response. METHODS A randomized, controlled, parallel design trial was performed to investigate whether upper or lower cervical spine mobilization can differentially modulate components of the stress response in individuals with PPCS. The outcomes were salivary cortisol (sCOR) concentration (primary) and the HRV metric, rMSSD, measured with a smartphone application (secondary). Nineteen males diagnosed with PPCS, aged 19-35, were included. Participants were randomly assigned into either intervention group, upper (n = 10) or lower (n = 9) cervical spine mobilization. Each outcome was collected at different time points, pre- and post-intervention. Statistical analyses were performed using the Friedman's Two-Way ANOVA, Mann-Whitney U test, and Wilcoxon Signed Rank Test. RESULTS There was a statistically significant within-group reduction in sCOR concentration 30 minutes following lower cervical spine mobilizations and statistically significant within-group increase in rMSSD 30 minutes following upper cervical spine mobilizations. CONCLUSION The results of this trial provide preliminary evidence for cervical spine mobilizations to differentially modulate components of the stress response at specific time points. Understanding the mechanisms of the effect of cervical spine mobilizations on the stress response provides a novel rationale for selecting cervical spine mobilizations to rehabilitate individuals with PPCS.
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Affiliation(s)
- Gerard Farrell
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, Dunedin, New Zealand
| | - Cathy Chapple
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, Dunedin, New Zealand
| | - Ewan Kennedy
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, Dunedin, New Zealand
| | - Matthew Reily-Bell
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Kesava Sampath
- Centre for Health and Social Practice, Waikato Institute of Technology-Rotokauri Campus, Hamilton, Waikato, New Zealand
| | | | - Chad Cook
- Doctor of Physical Therapy Program, Duke University, Durham, NC, USA
| | - Rajesh Katare
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Steve Tumilty
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, Dunedin, New Zealand
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Gallow S, Beard J, McGinley J, Olver J, Williams G. Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review. Brain Inj 2024:1-12. [PMID: 38828871 DOI: 10.1080/02699052.2024.2361638] [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: 07/16/2023] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI). METHODS A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies. RESULTS Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported. CONCLUSION There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.
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Affiliation(s)
- Sara Gallow
- Department of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Jack Beard
- Department of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - Jennifer McGinley
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
- Department of Rehabilitation, Epworth Monash Rehabilitation Medicine Unit, Melbourne, Australia
| | - Gavin Williams
- Department of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
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Rosenblum D, Donahue C, Higgins H, Brna M, Resch J. False-Positive Rates, Risk Factors, and Interpretations of the Vestibular/Ocular Motor Screening in Collegiate Athletes. J Athl Train 2024; 59:600-607. [PMID: 38014805 PMCID: PMC11220773 DOI: 10.4085/1062-6050-0317.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
CONTEXT Biological sex and history of motion sickness are known modifiers associated with a false-positive baseline Vestibular/Ocular Motor Screening (VOMS). However, other factors may be associated with a false-positive VOMS in collegiate athletes. OBJECTIVE To identify contributing factors to false-positive VOMS assessments using population-specific criteria. We also critically appraised previously reported interpretation criteria. DESIGN Descriptive laboratory study. SETTING Single-site collegiate athletic training clinic. PATIENTS OR OTHER PARTICIPANTS National Collegiate Athletic Association Division I athletes (n = 462 [41% female]) aged 18.8 ± 1.4 years. MAIN OUTCOME MEASURE(S) Participants completed the Athlete Sleep Behavior Questionnaire, the 7-Item Generalized Anxiety Index, the Immediate Postconcussion Assessment and Cognitive Testing battery, the Patient Health Questionnaire-9, the Revised Head Injury Scale, the Sensory Organization Test, and the VOMS as part of a multidimensional baseline concussion assessment. Participants were classified into 2 groups based on whether they had a total symptom score of greater than or equal to 8 after VOMS administration, excluding the baseline checklist. We used χ2 and independent t tests to compare group demographics. A binary logistic regression with adjusted odds ratios (ORs) was used to evaluate the influence of sex, corrected vision, attention-deficit/hyperactivity disorder, Immediate Postconcussion Assessment and Cognitive Testing composite scores, concussion history, history of treatment for headache and/or migraine, Generalized Anxiety Index scores, Patient Health Questionnaire-9 scores, Athlete Sleep Behavior Questionnaire scores, and Sensory Organization Test equilibrium scores and somatosensory, visual, and vestibular sensory ratios on false-positive rates. RESULTS Approximately 9.1% (42 of 462 [30 females]) met criteria for a false-positive VOMS. A significantly greater proportion of females had false positives (χ21 = 18.37, P < .001). Female sex (OR = 2.79; 95% CI = 1.17, 6.65; P = .02) and history of treatment for headache (OR = 4.99; 95% CI = 1.21, 20.59; P = .026) were the only significant predictors of false-positive VOMS. Depending on cutoff interpretation, false-positive rates using our data ranged from 9.1% to 22.5%. CONCLUSIONS Our results support the most recent interpretation guidelines for the VOMS in collegiate athletes due to a low false-positive rate and ease of interpretation. Biological sex and history of headaches should be considered when administering the VOMS in the absence of a baseline.
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Affiliation(s)
- Daniel Rosenblum
- Exercise and Sport Injury Laboratory (EaSIL), University of Virginia, Charlottesville. Dr Donahue is now at Sports Medicine Center, Children's Hospital of Colorado, Aurora
| | - Catherine Donahue
- Exercise and Sport Injury Laboratory (EaSIL), University of Virginia, Charlottesville. Dr Donahue is now at Sports Medicine Center, Children's Hospital of Colorado, Aurora
| | - Haven Higgins
- Exercise and Sport Injury Laboratory (EaSIL), University of Virginia, Charlottesville. Dr Donahue is now at Sports Medicine Center, Children's Hospital of Colorado, Aurora
| | - Madison Brna
- Exercise and Sport Injury Laboratory (EaSIL), University of Virginia, Charlottesville. Dr Donahue is now at Sports Medicine Center, Children's Hospital of Colorado, Aurora
| | - Jacob Resch
- Exercise and Sport Injury Laboratory (EaSIL), University of Virginia, Charlottesville. Dr Donahue is now at Sports Medicine Center, Children's Hospital of Colorado, Aurora
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Langevin P, Frémont P, Fait P, Dubé MO, Roy JS. Moving from the clinic to telehealth during the COVID-19 pandemic - a pilot clinical trial comparing in-clinic rehabilitation versus telerehabilitation for persisting symptoms following a mild Traumatic brain injury. Disabil Rehabil 2024; 46:2880-2889. [PMID: 37466379 DOI: 10.1080/09638288.2023.2236016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE The objective of this study was to compare the effects of an in-clinic cervicovestibular rehabilitation program (education, home exercises, manual techniques, sub-symptom threshold aerobic exercise [STAE] program) to a similar program (education, home-exercises, STAE program), but without manual techniques, provided in a telerehabilitation format in adults with persisting post-concussion symptoms (PCS). MATERIALS AND METHODS DESIGN In this parallel-group non-randomized clinical trial, 41 adults with persisting PCS were allocated to the in-clinic (n = 30) or telerehabilitation (n = 11) program. The outcome measures, which included the Post-Concussion Symptom Scale (PCSS; primary outcome), Numerical Pain Rating Scale (NPRS) for neck pain and headache and three disability questionnaires, were collected at baseline, weeks 6, 12, and 26. Non-parametric analysis for longitudinal data (NparLD) was used. RESULTS For the PCSS, there was a group-by-time interaction (p = 0.05) with significant between-group differences at week 6, 12, and 26 (p < 0.05) for the in-clinic group. There were also group-by-time interactions for NPRS neck pain and headache (p < 0.05) for the in-clinic group. CONCLUSION The study suggests that a telehealth format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement. These results must be interpreted with caution given the limited number of participants. ClinicalTrials.gov Identifier: NCT03677661.IMPLICATION FOR REHABILITATIONThe telerehabilitation format for adults with persisting post-concussion symptoms was widely implemented in the COVID-19 pandemic without any evidence of efficacy over the more traditional in-clinic rehabilitation format.The study suggests that a telerehabilitation format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement.Clinicians should try to incorporate some in-clinic appointments when a telerehabilitation format is required such as for patients in underserved area.
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Affiliation(s)
- Pierre Langevin
- Clinique Cortex and Physio Interactive, Québec, Canada
- Department of Rehabilitation, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), Quebec City, Canada
| | - Pierre Frémont
- Department of Rehabilitation, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
| | - Philippe Fait
- Clinique Cortex and Physio Interactive, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), Quebec City, Canada
- Department of Human Kinetics, University of Quebec at Trois-Rivières, Trois-Rivières, Canada
- Research Center in Neuropsychology and Cognition (CERNEC), Montréal, Canada'
| | - Marc-Olivier Dubé
- Clinique Cortex and Physio Interactive, Québec, Canada
- Department of Rehabilitation, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), Quebec City, Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute (CIRRIS), Quebec City, Canada
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11
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Suzuki S, Mattson CL, Obermeier MC, Casanova AD, Doda AK, Sayles LA, Custer AM, Chmielewski TL. Athletic Fear Avoidance in Athletes Receiving Rehabilitation for Sport-Related Concussion: A Preliminary Study. Sports Health 2024; 16:457-464. [PMID: 37208905 PMCID: PMC11025521 DOI: 10.1177/19417381231172513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Fear avoidance after musculoskeletal injury is avoiding activity due to fear of pain and contributes to persistent symptoms, depression, and disability. Little is known about fear avoidance for sport (athletic fear avoidance) in athletes with sport-related concussion (SRC). HYPOTHESIS Athletic fear avoidance after SRC would be elevated at the start of rehabilitation, improve over time, and be associated with postconcussion recovery outcomes. STUDY DESIGN Observational study. LEVEL OF EVIDENCE Level 4. METHODS Athletes in rehabilitation after SRC participated. Testing at initial and discharge visits and 6-month follow-up included Athletic Fear Avoidance Questionnaire (AFAQ), Postconcussion Symptom Scale (PCSS), Profile of Mood States (POMS), and Dizziness Handicap Inventory (DHI). Differences were explored in AFAQ score at initial testing based on sex or age (<18 or ≥18 years). Change in questionnaire scores over time was examined. Association of AFAQ score with other questionnaire scores was determined at each timepoint. RESULTS A total of 48 athletes participated: 28 completed initial testing only (INITIAL ONLY), and 20 completed all testing (LONGITUDINAL). Across cohorts, the mean (SD) AFAQ score at initial testing was 24.3 (7.6) points, with no significant difference by sex or age. AFAQ, PCSS, POMS, and DHI scores improved in LONGITUDINAL; the effect size was large from initial to discharge testing (1.0, 1.0, 1.0, and 1.2, respectively) and variable from discharge to follow-up testing (0.52, -0.34, -0.08, and 0.02, respectively). AFAQ scores increased from discharge to follow-up in 3 athletes and were consistently above the mean value in 2 athletes. AFAQ score was significantly correlated to the other questionnaire scores at each timepoint (range, r = 0.36-0.75). CONCLUSION Athletic fear avoidance was elevated at the start of SRC rehabilitation, improved over time in most patients, and was associated with postconcussion symptoms, mood, and disability. CLINICAL RELEVANCE Athletic fear avoidance may impact recovery after SRC.
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Affiliation(s)
- Shuhei Suzuki
- TRIA Orthopedics, Bloomington, Minnesota, ATP Tour Inc, Ponte Vedra Beach, Florida
| | | | | | | | | | | | | | - Terese L. Chmielewski
- TRIA Orthopedics, Bloomington, Minnesota, University of Minnesota, Minneapolis, Minnesota
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12
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Kumar A, Kara S, van der Werf B, Fulcher M. Can the Buffalo Concussion Treadmill Test Be Used as a Prognostic Indicator for Patients With Sport-Related Mild Traumatic Brain Injury? Clin J Sport Med 2024; 34:91-96. [PMID: 37389465 DOI: 10.1097/jsm.0000000000001170] [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: 05/31/2022] [Accepted: 05/22/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To establish whether time to exercise cessation using the Buffalo Concussion Treadmill Test (BCTT) protocol can be used as a prognostic indicator of recovery after sport-related mild traumatic brain injury (SR-mTBI). DESIGN Retrospective analysis of prospectively collected data. SETTING Specialist Concussion Clinic. PARTICIPANTS Three hundred and twenty one patients presenting between 2017 and 2019 who underwent BCTT for SR-mTBI. INTERVENTIONS Participants who remained symptomatic at a 2-week follow-up appointment after SR-mTBI underwent BCTT to develop a progressive subsymptom threshold exercise program with fortnightly follow-up until clinical recovery. MAIN OUTCOME MEASURES Clinical recovery was the primary outcome measure. RESULTS A total of 321 participants were eligible to participate in this study (mean age 22.94% and 46% female). The BCTT test duration was divided into 4-minute intervals and those who completed full 20 minutes. There was higher probability of clinical recovery in those who finished the entire 20-minute BCTT protocol compared with those who managed 17-<20 minutes (Hazard Ratio, HR 0.57), 13 to 16 minutes (HR 0.53), 9 to 12 minutes (HR 0.6), 5 to 8 minutes (HR 0.4), and 1 to 4 minutes (HR 0.7), respectively. Those seen earlier after injury ( P = 0.009), male patients ( P = 0.116), younger patients ( P = 0.0003), and those with physiological or cervical dominant ( P = 0.416) symptom clusters were more likely to achieve clinical recovery. Fifty percent of those who completed the full BCTT protocol achieved clinical recovery at day 19 post-injury. CONCLUSIONS The group completing full 20 minutes of BCTT achieved clinical recovery more quickly than those who did not complete full BCTT.
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Affiliation(s)
- Amitesh Kumar
- Axis Sports Medicine Specialists, Auckland, New Zealand
| | - Stephen Kara
- Axis Sports Medicine Specialists, Auckland, New Zealand
| | - Bert van der Werf
- Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; and
| | - Mark Fulcher
- Axis Sports Medicine Specialists, Auckland, New Zealand
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13
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Thorne J, Hellewell SC, Cowen G, Ring A, Jefferson A, Chih H, Gozt AK, Buhagiar F, Thomas E, Papini M, Bynevelt M, Celenza A, Xu D, Honeybul S, Pestell CF, Fatovich D, Fitzgerald M. Symptoms Associated With Exercise Intolerance and Resting Heart Rate Following Mild Traumatic Brain Injury. J Head Trauma Rehabil 2024:00001199-990000000-00129. [PMID: 38453632 DOI: 10.1097/htr.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVES People may experience a myriad of symptoms after mild traumatic brain injury (mTBI), but the relationship between symptoms and objective assessments is poorly characterized. This study sought to investigate the association between symptoms, resting heart rate (HR), and exercise tolerance in individuals following mTBI, with a secondary aim to examine the relationship between symptom-based clinical profiles and recovery. METHODS Prospective observational study of adults aged 18 to 65 years who had sustained mTBI within the previous 7 days. Symptoms were assessed using the Post-Concussion Symptom Scale, HR was measured at rest, and exercise tolerance was assessed using the Buffalo Concussion Bike Test. Symptom burden and symptom-based clinical profiles were examined with respect to exercise tolerance and resting HR. RESULTS Data from 32 participants were assessed (mean age 36.5 ± 12.6 years, 41% female, 5.7 ± 1.1 days since injury). Symptom burden (number of symptoms and symptom severity) was significantly associated with exercise intolerance (P = .002 and P = .025, respectively). Physiological and vestibular-ocular clinical profile composite groups were associated with exercise tolerance (P = .001 and P = .014, respectively), with individuals who were exercise intolerant having a higher mean number of symptoms in each profile than those who were exercise tolerant. Mood-related and autonomic clinical profiles were associated with a higher resting HR (>80 bpm) (P = .048 and P = .028, respectively), suggesting altered autonomic response for participants with symptoms relating to this profile. After adjusting for age and mechanism of injury (sports- or non-sports-related), having a higher mood-related clinical profile was associated with persisting symptoms at 3 months postinjury (adjusted odds ratio = 2.08; 95% CI, 1.11-3.90; P = .013). CONCLUSION Symptom-based clinical profiles, in conjunction with objective measures such as resting HR and exercise tolerance, are important components of clinical care for those having sustained mTBI. These results provide preliminary support for the concept that specific symptoms are indicative of autonomic dysfunction following mTBI.
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Affiliation(s)
- Jacinta Thorne
- Author Affiliations: School of Allied Health (Ms Thorne and Mr Ring) and Curtin Medical School (Drs Cowen, Jefferson, and Xu), Faculty of Health Sciences, Curtin Health Innovation Research Institute (Mss Thorne and Papini and Drs Hellewell, Cowen, Gozt, Pestell, and Fitzgerald), and School of Population Health (Drs Chih, Thomas, and Xu), Curtin University, Bentley, Western Australia; Perron Institute for Neurological and Translational Science, Nedlands, Western Australia (Mss Thorne and Papini and Drs Hellewell, Gozt, and Fitzgerald); Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia (Mr Ring); School of Psychological Science (Drs Buhagiar and Pestell) and Divisions of Surgery (Dr Thomas) and Emergency Medicine (Dr Celenza), School of Medicine, The University of Western Australia, Nedlands, Western Australia; Neurological Intervention & Imaging Service of Western Australia (Dr Bynevelt) and Emergency Department (Dr Celenza), Sir Charles Gairdner Hospital, Nedlands, Western Australia; The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China (Dr Xu); Sir Charles Gairdner, Royal Perth and Fiona Stanley Hospitals, Perth, Western Australia (Dr Honeybul); Emergency Medicine, Royal Perth Hospital, University of Western Australia (Dr Fatovich); and Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, Western Australia (Dr Fatovich)
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14
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Ingram EO, Karr JE. The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms. Clin Neuropsychol 2024:1-24. [PMID: 38369485 PMCID: PMC11330539 DOI: 10.1080/13854046.2024.2315735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/20/2023] [Indexed: 02/20/2024]
Abstract
Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥ 84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η 2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η 2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.
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Affiliation(s)
- Eric O Ingram
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
| | - Justin E Karr
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
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15
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McPherson JI, Marsh AC, Cunningham A, Leddy JJ, Corrado C, Cheema ZD, Nazir MSZ, Nowak AS, Farooq O, Willer BS, Haider MN. An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion. Clin J Sport Med 2024:00042752-990000000-00173. [PMID: 38329287 DOI: 10.1097/jsm.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment. DESIGN Secondary analysis of a published cohort study and clinician consensus. SETTING Three university-affiliated sports medicine centers. PARTICIPANTS Two hundred seventy children (14.9 ± 1.9 years). INDEPENDENT VARIABLES Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm. MAIN OUTCOME MEASURES Correlations between independent variables were calculated, and network graphs were made. k-means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes. RESULTS Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait). CONCLUSIONS Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.
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Affiliation(s)
- Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York
| | | | - Adam Cunningham
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - John J Leddy
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Cathlyn Corrado
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - Zaheerud D Cheema
- Department of Neurology, Division of Pediatric Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Muhammad S Z Nazir
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
| | - Andrew S Nowak
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan; and
| | - Osman Farooq
- Department of Neurology, Division of Pediatric Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Mohammad N Haider
- University Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, Buffalo, New York
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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Caberwal T, Cecchini AS, Wentz LM, Berry-Cabán CS. Prevalence of Neck Pain in Soldiers as a Result of Mild Traumatic Brain Injury-Associated Trauma. Mil Med 2024; 189:e182-e187. [PMID: 37384536 DOI: 10.1093/milmed/usad228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023] Open
Abstract
INTRODUCTION Many of the injury mechanisms that cause mild traumatic brain injury (mTBI) also create forces commonly associated with whiplash, resulting in cervical pain injury. The prevalence of associated neck pain with mTBI is not well established. There is a strong indication that injury to the cervical spine may aggravate, cause, and/or impact recovery of symptoms and impairments associated with the concussive event and its primary effect on the brain. The purpose of this study is to help identify the prevalence of ensuing cervical pain within 90 days of a previously documented mTBI and to examine the role of neck pain during concurrent concussive symptoms, in a military population stationed at a large military installation. MATERIALS AND METHODS This retrospective design utilized a de-identified dataset using predetermined search and filter criteria, which included male active duty service members (SMs), 20 to 45 years of age, who received medical care at any clinic on Fort Liberty (Fort Bragg, NC) during fiscal year (FY) 2012 to FY 2019, with documented cervicalgia and mTBI (via the International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes), verified using electronic medical records. The final dataset served as the basis for subject sampling and was analyzed to determine the total number of documented cervicalgia and mTBI diagnoses. Results are presented as descriptive statistics. Approval for this study was received from the Andrews University Office of Research (18-097) and the Womack Army Medical Center Human Protections Office. RESULTS Between FY 2012 and FY 2019, 14,352 unique SMs accessed a Fort Bragg, NC health care facility, at least once (Table I). Overall, 52% of SMs diagnosed with cervicalgia were found to have a previously diagnosed mTBI during the 90 days before the cervicalgia diagnosis. In contrast, the prevalence of same-day cervicalgia and mTBI diagnosis was <1% (Table IV). The prevalence of isolated cervicalgia diagnosis at any time during the reporting period was 3%, whereas isolated mTBI diagnosis was 1% (Table III). CONCLUSIONS Over 50% of SMs diagnosed with cervicalgia had sustained a documented mTBI within 90 days prior, whereas less than 1% were diagnosed with cervicalgia at the time of initial primary care or emergency room encounter following the mTBI event. This finding suggests that the close anatomical and neurophysiological connections between the head and the cervical spine are both likely to be impacted through the same mechanism of injury. Delayed evaluation (and treatment) of the cervical spine may contribute to lingering post-concussive symptoms. Limitations of this retrospective review include the inability to assess the causality of the relationship between neck pain and mTBI, as only the existence and strength of the prevalence relationship can be identified. The outcome data are exploratory and intended to identify relationships and trends that may suggest further study across installations and across mTBI populations.
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Affiliation(s)
- Tara Caberwal
- Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | | | - Laurel M Wentz
- Department of Nutrition and Health Care Management, Appalachian State University, Boone, NC 28607, USA
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17
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Fan F, Anderson V, Morawakage T, Khan N, Shapiro JS, Ignjatovic V, Takagi M. Post-traumatic headache pathophysiology in paediatric concussion: A systematic review. Neurosci Biobehav Rev 2024; 156:105498. [PMID: 38043751 DOI: 10.1016/j.neubiorev.2023.105498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
Post-traumatic headache (PTH) represents the most common acute and persistent symptom following concussion in children, yet the underlying pathophysiology remains unclear. This systematic review sought to: (i) rigorously examine the current evidence of PTH pathophysiology in paediatric concussion (0-18 years), (ii) assess the quality of evidence, and (iii) provide directions for future research in accordance with PRISMA guidelines. Eligible studies (n = 19) totalling 1214 concussion participants investigated cerebrovascular function (n = 6), white matter integrity (n = 3), functional connectivity (n = 3), electrophysiology (n = 1), neurometabolics (n = 2), biological fluid markers (n = 4), vestibular and oculomotor function (n = 4); two studies used a multi-modal approach. Majority of studies were rated as fair quality (90%) and Level 3 evidence (84%). The true underlying mechanisms of PTH following paediatric concussion remain unclear. Overall quality of the available evidence is generally weak with a fair risk of bias and characterised by relative scarcity and lack of specificity of PTH pathophysiology. Future research is required to rigorously isolate pathophysiology specific to PTH with strict adherence to clinical definitions and standardised measurement tools of PTH.
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Affiliation(s)
- Feiven Fan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia.
| | - Vicki Anderson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Psychology Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | - Noor Khan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia
| | - Jesse S Shapiro
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Victoria, Australia; Institute for Clinical & Translational Research, Johns Hopkins All Children's, St Petersburg, FL, USA; Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Takagi
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
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18
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McPherson JI, Kaur G, Darling SR, Surace A, Willer BS, Leddy JJ, Haider MN. Early Identification and Management of Cervical Impairments in Pediatric Patients With Concussion May Reduce Risk of Delayed Recovery. Clin J Sport Med 2024; 34:25-29. [PMID: 37462603 DOI: 10.1097/jsm.0000000000001179] [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: 02/09/2023] [Accepted: 05/22/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury. DESIGN Prospective cohort study. SETTING Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019. PATIENTS One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion). INDEPENDENT VARIABLES Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness). MAIN OUTCOME MEASURES Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS. RESULTS Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340). CONCLUSIONS We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery.
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Affiliation(s)
- Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York
| | - Gurleen Kaur
- Department of Biological Sciences, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Scott R Darling
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Anthony Surace
- Niagara Falls Memorial Medical Center, Niagara Falls, New York
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York; and
| | - John J Leddy
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Mohammad N Haider
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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Hammerle MH, Treleaven JM. Application of biomechanical principles to upper cervical spine anatomy to alleviate symptoms of intermittent cranial nerve IX irritation. Directions for successful self-management of headache post-concussion? A case series. J Man Manip Ther 2023; 31:457-465. [PMID: 37427896 PMCID: PMC10642312 DOI: 10.1080/10669817.2023.2233723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND The neck has been implicated as a potential generator of symptoms such as dizziness and headache in individuals with persistent symptoms post concussion. Anatomically, the neck could also be a potential trigger for autonomic or cranial nerve symptoms. The glossopharyngeal nerve which innervates the upper pharynx is one possible autonomic trigger that might be affected by the upper cervical spine. CASE DESCRIPTION This is a case series of three individuals with persistent post-traumatic headache (PPTH) and symptoms of autonomic dysregulation who also had signs of intermittent glossopharyngeal nerve irritation associated with certain neck positions or movements. Biomechanical principles were applied to anatomical research on the path of the glossopharyngeal nerve, in relation to the upper cervical spine and the dura mater, to alleviate these intermittent symptoms. The patients were provided techniques to be used as tools to immediately alleviate the intermittent dysphagia, which also alleviated the constant headache at the same time. As part of the overall long-term management program, patients were also taught daily exercises to improve upper cervical and dural stability and mobility. OUTCOME The result was a decrease in intermittent dysphagia, headache, and autonomic symptoms in the long term in persons with PPTH following concussion. DISCUSSION Autonomic and dysphagia symptoms may provide clues as to the origin of symptoms in a subgroup of individuals with PPTH.
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Affiliation(s)
- Matt H Hammerle
- JBSA Fort Sam Houston, Brooke Army Medical Center Brain Injury Rehabilitation Service, TX, USA
| | - Julia M. Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Queensland, Australia
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Vuu S, Barr CJ, Killington M, Howie J, Hutchins S, van den Berg MEL. The Buffalo Concussion Treadmill and Bike Tests in People With Mild-to-Moderate Traumatic Brain Injury: An Exploratory Clinical Audit. J Head Trauma Rehabil 2023; 38:E414-E423. [PMID: 37115938 DOI: 10.1097/htr.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
OBJECTIVE To assess the performance on the Buffalo Concussion Treadmill and Bike Tests in nonathletic people following a mild-to-moderate traumatic brain injury. SETTING An outpatient rehabilitation clinic. PARTICIPANTS Forty-nine patients with mild-to-moderate traumatic brain injury who underwent the Buffalo Concussion Treadmill or Bike Test as usual clinical care. DESIGN A retrospective clinical audit. MAIN MEASURES Demographics and brain injury-specific clinical data, Depression Anxiety Stress Scale; Rivermead Post-Concussion Symptom Questionnaire, and performance outcomes on the Buffalo Concussion Treadmill or Bike Test. RESULTS Forty-nine patients (mean age: 33.7 ± 13.0 years), on average 56.2 ± 36.4 days post-injury, completed the Buffalo Concussion Treadmill or Bike Test. Fourteen patients stopped the test due to symptom exacerbation with a mean test duration of 8.1 ± 4.5 minutes, reaching an age-predicted maximum heart rate of 72.9% ± 12.4% and reporting a rating of perceived exertion of 13.4 ± 2.2. Those who terminated the test for other reasons had a significantly longer test duration (14.0 ± 4.7 minutes, P = .01), with a higher age-predicted maximum heart rate (83.3% ± 12.8%, P = .01) and rating of perceived exertion (17.0 ± 2.5, P = .01). Within the group who stopped for other reasons, 10 were due to symptoms deemed unrelated to the injury at the time of the test and 2 were stopped by the therapist for safety reasons. A significant but weak correlation between heart rate and rating of perceived exertion existed only for those who terminated the test for other reasons ( r = 0.38, P = .02). Overall, a shorter test duration was associated with higher scores of both self-reported depression ( r = -0.41, P < .01) and late postconcussion symptoms ( r = -0.40, P < .01). CONCLUSION The Buffalo Concussion Treadmill or Bike Test can be used in the nonathletic mild-to-moderate traumatic brain injury population to differentiate between those who experience symptom exacerbation during exercise and those who do not based on symptom exacerbation, test duration, and poor perception of exertion. Further research is required to determine whether other reasons for test termination are related to the injury.
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Affiliation(s)
- Sally Vuu
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia (Ms Vuu and Drs Barr and van den Berg); Brain Injury Rehabilitation Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia (Dr Killington and Ms Hutchins); and Physiotherapy, Brain Injury Rehabilitation Services, Adelaide, Australia (Ms Howie)
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21
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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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Thorne J, Hellewell S, Cowen G, Fitzgerald M. Neuroimaging to enhance understanding of cardiovascular autonomic changes associated with mild traumatic brain injury: a scoping review. Brain Inj 2023; 37:1187-1204. [PMID: 37203154 DOI: 10.1080/02699052.2023.2211352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Cardiovascular changes, such as altered heart rate and blood pressure, have been identified in some individuals following mild traumatic brain injury (mTBI) and may be related to disturbances of the autonomic nervous system and cerebral blood flow. METHODS We conducted a scoping review according to PRISMA-ScR guidelines across six databases (Medline, CINAHL, Web of Science, PsychInfo, SportDiscus and Google Scholar) to explore literature examining both cardiovascular parameters and neuroimaging modalities following mTBI, with the aim of better understanding the pathophysiological basis of cardiovascular autonomic changes associated with mTBI. RESULTS Twenty-nine studies were included and two main research approaches emerged from data synthesis. Firstly, more than half the studies used transcranial Doppler ultrasound and found evidence of cerebral blood flow impairments that persisted beyond symptom resolution. Secondly, studies utilizing advanced MRI identified microstructural injury within brain regions responsible for cardiac autonomic function, providing preliminary evidence that cardiovascular autonomic changes are a consequence of injury to these areas. CONCLUSION Neuroimaging modalities hold considerable potential to aid understanding of the complex relationship between cardiovascular changes and brain pathophysiology associated with mTBI. However, it is difficult to draw definitive conclusions from the available data due to variability in study methodology and terminology.
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Affiliation(s)
- Jacinta Thorne
- School of Allied Health, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
| | - Sarah Hellewell
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
| | - Gill Cowen
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Melinda Fitzgerald
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
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Coenen J, Reinsberger C. Neurophysiological Markers to Guide Return to Sport After Sport-Related Concussion. J Clin Neurophysiol 2023; 40:391-397. [PMID: 36930211 DOI: 10.1097/wnp.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
SUMMARY Sport-related concussion (SRC) has been defined as a subset of mild traumatic brain injury (mTBI), without structural abnormalities, reflecting a functional disturbance. Over the past decade, SRC has gained increasing awareness and attention, which coincides with an increase in incidence rates. Because this injury has been considered one of the most challenging encounters for clinicians, there is a need for objective biomarkers to aid in diagnosis (i.e., presence/severity) and management (i.e., return to sport) of SRC/mTBI.The primary aim of this article was to present state-of-the-art neurophysiologic methods (e.g., electroencephalography, magnetoencephalography, transcranial magnetic stimulation, and autonomic nervous system) that are appropriate to investigate the complex pathophysiological process of a concussion. A secondary aim was to explore the potential for evidence-based markers to be used in clinical practice for SRC management. The article concludes with a discussion of future directions for SRC research with specific focus on clinical neurophysiology.
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Affiliation(s)
- Jessica Coenen
- Department of Exercise and Health, Institute of Sports Medicine, Paderborn University, Paderborn, Germany; and
| | - Claus Reinsberger
- Department of Exercise and Health, Institute of Sports Medicine, Paderborn University, Paderborn, Germany; and
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Brigham and Women's Hospital, Boston, Massachusetts
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Memmini AK, Popovich MJ, Schuyten KH, Herring SA, Scott KL, Clugston JR, Choe MC, Bailey CM, Brooks MA, Anderson SA, McCrea MA, Kontos AP, Wallace JS, Mihalik JKR, Kasamatsu TM, McLeod TV, Rawlins MLW, Snedden TR, Kaplan M, Akani B, Orr LCL, Hasson RE, Rifat SF, Broglio SP. Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion. J Head Trauma Rehabil 2023; 38:E299-E311. [PMID: 36731046 DOI: 10.1097/htr.0000000000000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure. SETTING Remote semistructured interviews and online surveys. PARTICIPANTS The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff. DESIGN An exploratory-sequential mixed-methods approach. MAIN MEASURES Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus. RESULTS The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements). CONCLUSIONS These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.
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Affiliation(s)
- Allyssa K Memmini
- Concussion Center, University of Michigan, Ann Arbor, Michigan (Drs Memmini and Broglio); Department of Health, Exercise & Sports Sciences, University of New Mexico, Albuquerque, New Mexico (Dr Memmini); Department of Neurology, University of Michigan, Ann Arbor, Michigan (Dr Popovich); MedSport Physical Therapy, Michigan Medicine, Ann Arbor, Michigan (Dr Schuyten); Rehabilitation Medicine, University of Washington, Seattle, Washington (Dr Herring); Behavioral Medicine, Brooks Rehabilitation, Jacksonville, Florida (Dr Scott); Department of Community Health & Family Medicine and Department of Neurology, University of Florida, Gainesville, Florida (Dr Clugston); Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California (Dr Choe); Department of Neurology, Case Western Reserve School of Medicine/University Hospitals, Cleveland, Ohio (Dr Bailey); Department of Orthopedics & Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin (Dr Brooks); Department of Athletics, University of Oklahoma, Norman, Oklahoma (Mr Anderson); Center for Neurotrauma Research, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin (Dr McCrea); Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Kontos); Department of Health Science, The University of Alabama, Tuscaloosa, Alabama (Dr Wallace); Matthew Gfeller Center and STAR Heel Performance Laboratory, Department of Exercise and Sport Science, The University of North Carolina Chapel Hill, Durham, North Carolina (Dr Mihalik); Department of Kinesiology, California State University, Fullerton, California (Dr Kasamatsu); Athletic Training Programs, A. T. Still University, Mesa, Arizona (Dr McLeod); School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California (Dr Rawlins); School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin (Dr Snedden); Center for Research on Learning & Teaching, University of Michigan, Ann Arbor, Michigan (Dr Kaplan); College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Michigan (Ms Akani); School of Kinesiology, University of Michigan, Ann Arbor, Michigan (Ms Orr and Dr Hasson); and University of Michigan Athletics, Michigan Medicine, Ann Arbor, Michigan and Department of Orthopaedics, Cleveland Clinic, Cleveland, Ohio (Dr Rifat)
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Churchill NW, Graham SJ, Schweizer TA. Perfusion Imaging of Traumatic Brain Injury. Neuroimaging Clin N Am 2023; 33:315-324. [PMID: 36965948 DOI: 10.1016/j.nic.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
The mechanisms for regulating cerebral blood flow (CBF) are highly sensitive to traumatic brain injury (TBI). The perfusion imaging technique may be used to assess CBF and identify perfusion abnormalities following a TBI. Studies have identified CBF disturbances across the injury severity spectrum and correlations with both acute and long-term indices of clinical outcome. Although not yet widely used in the clinical context, this is an important area of ongoing research.
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Affiliation(s)
- Nathan W Churchill
- Neuroscience Research Program, Saint Michael's Hospital, 209 Victoria Street, Toronto, ON M5B 1M8, Canada; Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 209 Victoria Street, Toronto, ON M5B 1M8, Canada; Physics Department, Toronto Metropolitan University, 60 St George St, Toronto, ON M5S 1A7, Canada.
| | - Simon J Graham
- Department of Medical Biophysics, University of Toronto, 101 College Street, Suite 15-701, Toronto, ON M5G 1L7, Canada; Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Wellness Way, Toronto, ON M4N 3M5, Canada; Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Tom A Schweizer
- Neuroscience Research Program, Saint Michael's Hospital, 209 Victoria Street, Toronto, ON M5B 1M8, Canada; Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 209 Victoria Street, Toronto, ON M5B 1M8, Canada; Faculty of Medicine (Neurosurgery), University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada
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Hutchison MG, Di Battista AP, Pyndiura K, Blanc S, Quaid PT, Richards D. Incidence of Remote Near-Point of Convergence in University Athletes After Sport-Related Concussion. Clin J Sport Med 2023; 33:258-263. [PMID: 36584046 PMCID: PMC10128903 DOI: 10.1097/jsm.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 09/14/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Near-point of convergence (NPC) testing is an attractive screening tool in the sport setting because it is rapid, requires few resources, and is easy to administer. Remote NPC has been reported after sport-related concussion (SRC), although the incidence among a university-aged population is not well defined. The purpose of the study was to examine the incidence of remote NPC after SRC in a cohort of Canadian interuniversity athletes. DESIGN Cross-sequential. SETTING University. PARTICIPANTS One hundred thirty-two university athletes [SRC, n = 68; musculoskeletal (MSK) injury, n = 64] were tested before the beginning of their competitive season and again after their injury. INDEPENDENT VARIABLES Healthy athletes measured preseason were compared with athletes after SRC or MSK injury using both longitudinal and cross-sectional designs. MAIN OUTCOME MEASURES Remote NPC (pass/fail), measured at 6 cm or greater, repeated 3 times. RESULTS After SRC, 22% of athletes failed their test postinjury (95% CI, 14%-33%). Comparatively, in the MSK group, 3% of athletes failed their test postinjury (95% CI, 1%-7%). A direct comparison of both injury groups yielded a mean 19% higher prevalence of failed NPC tests after SRC versus MSK injury (95% CI, 10%-30%). There seems to be no relationship between reported symptom burden and NPC performance after SRC. CONCLUSION Remote NPC occurs in approximately 1 of 5 athletes after SRC and is rarely observed after MSK injury.
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Affiliation(s)
- Michael G. Hutchison
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto ON, Canada
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto ON, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - Alex P. Di Battista
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto ON, Canada
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Kyla Pyndiura
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto ON, Canada
| | - Shirley Blanc
- Complete Eye Care Services, Toronto, ON, Canada; and
| | | | - Doug Richards
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto ON, Canada
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Hammerle MH, Thomas LC, Swan AA, Lu LH, Treleaven JM. Sub-occipital muscle pressure pain thresholds correlate to direction of symptomatic active comfortable sustained neck rotation testing in post-concussive headache: a retrospective observational cross-sectional study. J Man Manip Ther 2023; 31:124-129. [PMID: 36102346 PMCID: PMC10013433 DOI: 10.1080/10669817.2022.2122370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVES To compare sub-occipital muscle pressure sub pain thresholds (PPTs) in individuals with persistent-post-traumatic-headache (PPTH) in relation to the presence or not of cranial nerve and/or autonomic symptoms reported during sustained neck rotation (SNR). BACKGROUND Previously 81% of military service members with PPTH demonstrated symptoms with SNR up to 60 seconds. Of these, 54% reported symptoms in one (Uni-Symp) and 46% in both directions of rotation (Bi-Symp). Sub-occipital PPTs, in relation to SNR direction, were of interest. METHODS Retrospective review of records of 77 individuals, with PPTH with both SNR and PPTs. Average suboccipital and scalene PPTs were compared between Asymptomatic (n = 13), upon SNR testing, or Symptomatic (Uni-Symp, n = 32, Bi-Symp, n = 32), groups. RESULTS The Bi-Symp group had significantly reduced sub-occipital PPTs relative to the Asymptomatic group on both sides [p < 0.009] with no side-to-side differences in either group. The Uni-Symp group had significantly lower sub-occipital PPTs on the symptomatic SNR test direction compared to the asymptomatic side [t(31) = 3.37, p = 0.002]. There were no differences within or between groups in the scalene PPTs(p's > 0.08). CONCLUSIONS An upper cervical mechanical trigger of symptoms during SNR tests in some individuals with PPTH is possible. The direction of symptomatic SNR tests may indicate direction of guarded hypermobile dysfunction and direct treatment.
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Affiliation(s)
- Matt H. Hammerle
- Brooke Army Medical Center, Brain Injury Rehabilitation Service, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Lucy C. Thomas
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
| | - Alicia A. Swan
- Department of Psychology & South Texas Veterans Health Care System, The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Lisa H. Lu
- Defense and Veterans Brain Injury Center, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Julia M. Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane, Queensland, Australia
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Hammerle MH, Lu LH, Thomas LC, Swan AA, Hoppes CW, Nelson JT, Treleaven JM. Possible autonomic or cranial nerve symptoms triggered during sustained neck rotation in persistent headache post-concussion: a retrospective observational cross-sectional study. J Man Manip Ther 2023; 31:113-123. [PMID: 35695356 PMCID: PMC10013563 DOI: 10.1080/10669817.2022.2085850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To examine and categorize symptoms occurring within 60 s of vertebrobasilar-insufficiency (VBI) testing (left- and right-neck rotation) in individuals with persistent post-traumatic headache. BACKGROUND As part of routine clinical cervical screening in our patients, we found extended VBI testing often triggered additional symptoms. Therefore, we aimed to document the prevalence and precise symptoms occurring during each movement direction of this test and determine any demographic or baseline signs or symptoms associated with a positive test. METHODS A retrospective medical record review on military personnel receiving treatment for persistent post-traumatic headache was performed. Participants were grouped according to presence of non-headache related symptoms triggered during the tests. Frequency, onset, and symptom characteristics reported were categorized as potentially vascular and/or possible autonomic or cranial nerve in nature. RESULTS At least one symptom was reported by 81.3% of 123 patients. Of these, 54% reported symptoms in one and 46% in both directions of rotation, yielding 146 abnormal tests. Most reported symptoms were tear disruption (41%), altered ocular-motor-control (25%), and blepharospasm (16%). Enlisted individuals and those with altered baseline facial sensation were more likely to have a positive test. CONCLUSIONS The majority reported symptoms not typical of VBI within 60 seconds of sustained neck rotation. Further study is needed to better understand the mechanisms and clinical relevance.
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Affiliation(s)
- Matt H Hammerle
- Brain Injury Rehabilitation Service, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Lisa H Lu
- Defense and Veterans Brain Injury Center, JBSA Ft Sam Houston, San Antonio, Texas, USA
| | - Lucy C Thomas
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane Queensland, Australia
| | - Alicia A Swan
- Department of Psychology & South Texas Veterans Health Care System, the University of Texas at San Antonio, San Antonio, Texas, USA
| | - Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, San Antonio, Texas, USA
| | - Jeremy T Nelson
- Department of Radiology and Imaging Sciences, Military Health Institute, the University of Texas Health Science Center at San Antonio & Indiana University, San Antonio, Texas, USA
| | - Julia M Treleaven
- Neck Pain and Whiplash Research Unit, School of Health and Rehabilitation Services, University of Queensland, Brisbane Queensland, Australia
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LeMarshall SJ, Stevens LM, Ragg NP, Barnes L, Foster J, Canetti EFD. Virtual reality-based interventions for the rehabilitation of vestibular and balance impairments post-concussion: a scoping review. J Neuroeng Rehabil 2023; 20:31. [PMID: 36869367 PMCID: PMC9985280 DOI: 10.1186/s12984-023-01145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/27/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Concussions and mild traumatic brain injuries are the most common causes of physical and cognitive disability worldwide. Concussion can result in post-injury vestibular and balance impairments that can present up to five years post initial concussion event, ultimately affecting many daily and functional activities. While current clinical treatment aims to reduce symptoms, the developing use of technology in everyday life has seen the emergence of virtual reality. Current literature has failed to identify substantial evidence regarding the use of virtual reality in rehabilitation. The primary aim of this scoping review is to identify, synthesise, and assess the quality of studies reporting on the effectiveness of virtual reality for the rehabilitation of vestibular and balance impairments post-concussion. Additionally, this review aims to summarise the volume of scientific literature and identify the knowledge gaps in current research pertaining to this topic. METHODS A scoping review of six databases (PubMed, Embase, CINAHL, ProQuest, SportDiscus, Scopus) and a grey literature (Google Scholar) was conducted using three key concepts (virtual reality, vestibular symptoms, and post-concussion). Data was charted from studies and outcomes were categorised into one of three categories: (1) balance; (2) gait; or (3) functional outcome measures. Critical appraisal of each study was conducted using the Joanna Briggs Institute checklists. A critical appraisal of each outcome measure was also completed utilising a modified GRADE appraisal tool to summarise the quality of evidence. Effectiveness was assessed using calculations of change in performance and change per exposure time. RESULTS Three randomised controlled trials, three quasi-experimental studies, three case studies, and one retrospective cohort study were ultimately included, using a thorough eligibility criteria. All studies were inclusive of different virtual reality interventions. The ten studies had a 10-year range and identified 19 different outcome measures. CONCLUSION The findings from this review suggests that virtual reality is an effective tool for the rehabilitation of vestibular and balance impairments post-concussion. Current literature shows sufficient but low level of evidence, and more research is necessary to develop a quantitative standard and to better understand appropriate dosage of virtual reality intervention.
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Affiliation(s)
- Soraya J LeMarshall
- Doctor of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Lachlan M Stevens
- Doctor of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Nicholas P Ragg
- Doctor of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Leia Barnes
- Integrated Specialist ENT Service, Logan Hospital, Meadowbrook, Australia
| | - Jacinta Foster
- Integrated Specialist ENT Service, Logan Hospital, Meadowbrook, Australia
| | - Elisa F D Canetti
- Doctor of Physiotherapy, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia. .,Tactical Research Unit, Bond University, Gold Coast, Australia.
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Sheeba S, Cavaleri R, Summers S, Browne C. Effectiveness of non-pharmacological treatments for vestibular and oculomotor dysfunction in patients with persistent post-concussive symptoms: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e066634. [PMID: 36609322 PMCID: PMC9827270 DOI: 10.1136/bmjopen-2022-066634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Concussion is a form of mild traumatic brain injury that disrupts brain function. Although symptoms are mostly transient, recovery can be delayed and result in persistent postconcussive symptoms (PPCS). Vestibular and oculomotor dysfunction are among the most debilitating impairments associated with PPCS. However, pharmacological interventions for these impairments are associated with deleterious side effects. Accordingly, increasing research has examined the utility of non-pharmacological interventions for PPCS. The aim of this review is to synthesise and evaluate the effectiveness of non-pharmacological interventions for the treatment of vestibular and oculomotor dysfunction for patients with PPCS. METHODS AND ANALYSIS Systematic searches of MEDLINE, PubMed, Web of Science and Scopus will identify randomised controlled trials employing non-pharmacological treatments for vestibular and/or oculomotor dysfunction for PPCS. Such interventions may include, but are not limited to, vestibular rehabilitation, optokinetic stimulation and vestibulo-ocular reflex exercises. Assessments of oculomotor function will include versional eye movements, vergence eye movements, visual-fixation movements and accommodation response. Assessments of vestibular function will include the Fukuda Step test, functional balance tests, force displacement tests, and subjective reports of balance disruption or vertigo. Where appropriate, meta-analyses of standardised mean differences will be conducted using a random effects model for continuous outcomes. For dichotomous outcomes (improved vs not improved following treatment), effects will be expressed as relative risk. The impact of heterogeneity will be calculated using the I2 statistic. The Physiotherapy Evidence Database scale will be used to determine the methodological quality of individual studies and Grading of Recommendations, Assessment, Development and Evaluations used to assess the certainty and quality of evidence for each outcome. ETHICS AND DISSEMINATION Ethical approval is not required for this review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42021254720.
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Affiliation(s)
- Stella Sheeba
- School of Science, Western Sydney University, Sydney, New South Wales, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Rocco Cavaleri
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Simon Summers
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cherylea Browne
- School of Science, Western Sydney University, Sydney, New South Wales, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- Translational Neuroscience Facility, UNSW Sydney, Sydney, New South Wales, Australia
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Moran RN, Bretzin AC. Long-term test-retest reliability of the vestibular/ocular motor screening for concussion in child athletes: A preliminary study. APPLIED NEUROPSYCHOLOGY. CHILD 2023:1-6. [PMID: 36592365 DOI: 10.1080/21622965.2022.2163172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The Vestibular/Ocular Motor Screening (VOMS) is a sport-related concussion screening tool that assesses vestibular ocular reflex (VOR) and oculomotor symptom provocation. Long-term test-retest reliability of the VOMS over multiple athletic seasons has not yet been established in a pediatric population. Fifty-one child athletes (females = 28, 54.9%) 8-13 years of age, completed a baseline VOMS assessment at two timepoints, 18 months apart. Cronbach's alpha was used to examine the internal consistency at both time points. Two-way mixed intra-class correlation coefficients and Cohen's Kappa statistics were used to evaluate test-retest reliability. High internal consistency existed at both initial (α = 0.91) and follow-up (α = 0.95) for VOMS symptom provocation items. Strong inter-item correlations were noted between vertical VOR (r = ≥0.70) and visual motion sensitivity (VMS) (r = ≥0.70). Fair agreement was produced for convergence (κ = 0.23, vertical VOR (κ = 0.25) and VMS (κ = 0.25), as well as reliability on NPC distance (ICC2,k = 0.31). All other VOMS scores yielded poor agreement between time points. Symptom provocation was the same for 49% of athletes between timepoints, while 31.4% had a decrease in scoring at follow-up. Symptom provocation from VOMS tasks lessened with increasing age and time; therefore, clinicians should consider annual baseline testing to improve accuracy for concussion evaluation and management in pediatrics.
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Affiliation(s)
- Ryan N Moran
- Department of Health Science, Athletic Training Research Laboratory, The University of Alabama, Tuscaloosa, AL, USA
| | - Abigail C Bretzin
- Department of Emergency Medicine, University of Michigan Injury Prevention Center, The University of Michigan, Ann Arbor, MI, USA
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Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes. Clin J Sport Med 2022; 32:e556-e561. [PMID: 36315823 DOI: 10.1097/jsm.0000000000001047] [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: 11/09/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the prevalence of acute neck pain in high school athletes following sports-related concussion (SRC) and to examine the role of acute neck pain in modifying or amplifying concurrent concussive symptoms. DESIGN Retrospective observational. SETTING High school sporting events. PARTICIPANTS High school athletes who suffered a sports-related concussion between the 2011 and 2019 academic years academic years from the National Athletic Treatment, Injury and Outcomes Network (NATION) Study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence of neck pain (yes/no) along with 33 other commonly reported concussion symptoms, number of symptoms reported, mechanism of injury (contact with person/surface or object), sport type (contact/noncontact), and injury history (first time/repeated injury). RESULTS One hundred thirty-eight of 401 athletes (33.9%) indicated acute neck pain following SRC. Those with neck pain reported significantly more symptoms overall (M = 13.53, SD = 6.89) relative to their non-neck pain counterparts (M = 8.46, SD = 5.68; t [191.35] = 7.11, P < 0.001). Athletes with SRC due to contact with a surface were significantly less likely to report neck pain than those reported contact with a person. Neck pain, repeated injury, and female sex were significantly associated with a greater number of concussion symptoms in the acute phase. CONCLUSIONS Our data suggest that acute neck pain is a frequent acute symptom following SRC and signals the necessity for additional screening to seek and identify comorbid cervical pathology. Prospective studies should seek to access the benefit of cervical therapy in the early stages in SRC patients with neck pain to reduce the risk of persistent postconcussion symptoms.
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Migotto BDJ, Gill S, Sem M, Macpherson AK, Hynes LM. Sex-related differences in sternocleidomastoid muscle morphology in healthy young adults: A cross-sectional magnetic resonance imaging measurement study. Musculoskelet Sci Pract 2022; 61:102590. [PMID: 35667320 DOI: 10.1016/j.msksp.2022.102590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 05/19/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Changes in sternocleidomastoid (SCM) muscle cross-sectional area (CSA) and volume may contribute to neck-related concussion symptoms and whiplash-associated disorders. Magnetic resonance imaging (MRI) data on healthy SCM morphology can provide information that may lead to targeted treatment protocols. OBJECTIVES To examine sex-related differences in MRI-based SCM CSA, SCM volume and neck area in healthy young adults, to analyze associations between measurements and participant variables and to assess inter-rater reliability for measurement quantification. DESIGN Cross-sectional study. METHODS 13 males and 14 females underwent MRI scans. Slices obtained from C3-C7 were analyzed by three raters. SCM CSA at C4, total SCM volume from C3-C7 and neck area at C4 were quantified. Measurements were calculated as absolute and normalized values by body mass. Multivariable regression was used to analyze associations between normalized measurement values and participant variables. Inter-rater reliability was determined using intraclass correlation coefficients (ICC). RESULTS Females had significantly lower normalized overall average SCM CSA (mean difference 1.3 mm2/kg (95% CI 0.4-2.2, p = 0.006) and total SCM volume (mean difference 140.8 mm3/kg (95% CI 66.1-215.5, p < 0.001) than males. Regression models indicated female sex was associated with lower normalized overall average SCM CSA (p = 0.004) and total SCM volume (p < 0.001). Inter-rater reliability was excellent for SCM CSA (ICC3,3 = 0.909), SCM volume (ICC3,3 = 0.910) and neck area (ICC3,3 = 0.995). CONCLUSIONS These results enhance our understanding of sex-related differences in SCM morphology and will inform future research and clinical practice related to cervical muscle injury.
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Affiliation(s)
- Ben D J Migotto
- Whiplash and Head Injury Prevention/Rehabilitation (WHIPR) Lab, York University, 4700, Keele Street, Toronto, ON, M3J 1P3, Canada; School of Kinesiology & Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Sandeep Gill
- Whiplash and Head Injury Prevention/Rehabilitation (WHIPR) Lab, York University, 4700, Keele Street, Toronto, ON, M3J 1P3, Canada; School of Kinesiology & Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Matthew Sem
- Whiplash and Head Injury Prevention/Rehabilitation (WHIPR) Lab, York University, 4700, Keele Street, Toronto, ON, M3J 1P3, Canada; School of Kinesiology & Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Alison K Macpherson
- School of Kinesiology & Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada; York University Sport Medicine Team, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Loriann M Hynes
- Whiplash and Head Injury Prevention/Rehabilitation (WHIPR) Lab, York University, 4700, Keele Street, Toronto, ON, M3J 1P3, Canada; School of Kinesiology & Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada; York University Sport Medicine Team, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada.
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Vuu S, Barr CJ, Killington M, Jill G, van den Berg ME. Physical exercise for people with mild traumatic brain injury: A systematic review of randomized controlled trials. NeuroRehabilitation 2022; 51:185-200. [DOI: 10.3233/nre-220044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Recent research recommends physical exercise rather than rest following a mild traumatic brain injury (mTBI). OBJECTIVE: To determine the effect of physical exercise on persistent symptoms in people with mTBI. METHODS: A search of randomized controlled trials was conducted in CINAHL, Cochrane Library, EMBASE, MEDLINE, SportDiscus and Web of Science, from 2010 to January 2021. Studies were included if they described the effects of a physical exercise intervention in people with mTBI on persistent symptoms. Study quality, intervention reporting, and confidence in review findings were assessed with the CASP, TIDieR and GRADE respectively. RESULTS: 11 eligible studies were identified for inclusion. Study interventions broadly comprised of two categories of physical exercise, i.e., aerobic (n = 8) and vestibular (n = 3). A meta-analysis (n = 3) revealed the aerobic exercise group improvement was significantly larger compared to the usual care group –0.39 (95% CI: –0.73 to –0.05, p = 0.03). Only three studies using vestibular exercise reported on persistent symptoms and yielded mixed results. CONCLUSIONS: This study demonstrated that the use of aerobic exercise is supported by mixed quality evidence and moderate certainty of evidence, yet there is limited evidence for the use of vestibular exercise for improving persistent symptoms in people with mTBI.
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Affiliation(s)
- Sally Vuu
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Christopher J. Barr
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Maggie Killington
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Garner Jill
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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Browne CJ, Fahey P, Sheeba SR, Sharpe MH, Rosner M, Feinberg D, Mucci V. Visual disorders and mal de debarquement syndrome: a potential comorbidity questionnaire-based study. Future Sci OA 2022; 8:FSO813. [PMID: 36248065 PMCID: PMC9540399 DOI: 10.2144/fsoa-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022] Open
Abstract
Aim: Mal de debarquement syndrome (MdDS) is a neurological condition characterized by a constant sensation of self-motion; onset may be motion-triggered (MT) or non-motion-triggered/spontaneous (NMT/SO). People with MdDS experience similar symptoms to those with vertical heterophoria, a subset of binocular visual dysfunction. Hence, we aimed to explore potential visual symptom overlaps. Methods: MdDS patients (n = 196) and controls (n = 197) completed a visual health questionnaire. Results: Compared with controls, the MdDS group demonstrated higher visual disorder scores and visual complaints. NMT/SO participants reported unique visual symptoms and a higher prevalence of mild traumatic brain injury. Conclusion: Our findings suggest visual disorders may coexist with MdDS, particularly the NMT/SO subtype. The difference in visual dysfunction frequency and medical histories between subtypes, warrants further investigation into differing pathophysiological mechanisms.
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Affiliation(s)
- Cherylea J Browne
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
- Translational Neuroscience Facility (TNF), School of Medical Sciences, UNSW Sydney, NSW, 2033, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Paul Fahey
- School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Stella R Sheeba
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Margie H Sharpe
- Dizziness & Balance Disorders Center, Adelaide, SA, 5000, Australia
| | - Mark Rosner
- NeuroVisual Medicine Institute, Bloomfield Hills, MI 48302, USA
| | - Debby Feinberg
- NeuroVisual Medicine Institute, Bloomfield Hills, MI 48302, USA
| | - Viviana Mucci
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
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Comparison of Prescribed Physical Therapy to a Home Exercise Program for Pediatric Sports-Related Concussion Patients. CHILDREN 2022; 9:children9091371. [PMID: 36138680 PMCID: PMC9497931 DOI: 10.3390/children9091371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/24/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022]
Abstract
The purpose of this retrospective chart review was to compare sports-related concussion (SRC) recovery time in protracted recovery (≥28 days) patients who were prescribed physical therapy (PPT) with those who were only provided a home exercise program (HEP). We hypothesized PPT would be associated with shorter recovery times relative to HEP. Associations were evaluated with multivariable zero-truncated negative binomial regressions. Among the 48 (30.2%) PPT and 111 (69.8%) HEP patients, the majority were female (57.9%), the mean age was 15.3 ± 1.4 (PPT) and 14.2 ± 2.8 (HEP), and time to clinic was a median 6.0 (IQR = 3.0–27.0; PPT) and 7.0 (IQR = 3.0–23.0; HEP) days. After adjusting for demographic (age, sex) and clinical measures (concussion history, convergence, VOMS, PCSS score, and days to clinic), PPT unexpectedly was associated with 1.21 (95% CI: 1.05, 1.41) additional recovery days compared with HEP. One reason for this could be related to patients adhering to the number of a priori prescribed PT sessions which may or may not have aligned with the patient’s symptom resolution. Future research should explore this hypothesis while aiming to evaluate the effect of PPT versus HEP using a randomized design. If confirmed, these findings are encouraging for patients who could not otherwise access or afford specialty rehabilitation.
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Mohai A, Gifford J, Herkt R, Parker A, Toder A, Dixon D, Kennedy E. A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools. Phys Ther Sport 2022; 57:95-104. [PMID: 35963133 DOI: 10.1016/j.ptsp.2022.07.010] [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: 03/15/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND It can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear. OBJECTIVE To identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event. DESIGN Scoping review. METHOD A structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described. RESULTS The structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination. CONCLUSION Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.
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Affiliation(s)
| | - Jack Gifford
- School of Physiotherapy, University of Otago, New Zealand
| | - Rebecca Herkt
- School of Physiotherapy, University of Otago, New Zealand
| | - Alexia Parker
- School of Physiotherapy, University of Otago, New Zealand
| | - Aiden Toder
- School of Physiotherapy, University of Otago, New Zealand
| | - Dave Dixon
- Southern District Health Board, New Zealand
| | - Ewan Kennedy
- School of Physiotherapy, University of Otago, New Zealand
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Davenport M, Condon B, Lamoureux C, Phipps Johnson JL, Chen J, Rippee MA, Zentz J. The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach. Health Serv Insights 2022; 15:11786329221114759. [PMID: 36034733 PMCID: PMC9411741 DOI: 10.1177/11786329221114759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Objective: The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting. Study design: Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction. Results: Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form. Conclusion: The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.
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Affiliation(s)
- Maria Davenport
- Department of Rehabilitation Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Bill Condon
- Department of Rehabilitation Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Claude Lamoureux
- Department of Rehabilitation Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie L Phipps Johnson
- Department of Rehabilitation Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie Chen
- Center for Concussion Management, The University of Kansas Health System, Kansas City, KS, USA
| | - Michael A Rippee
- Department of Neurology, The University of Kansas Health System, Kansas City, KS, USA
| | - Jennifer Zentz
- Director of Ambulatory Operations, UT Southwestern Medical Center, Dallas, TX, USA
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Farrell G, Wang S, Chapple C, Kennedy E, Gisselman AS, Sampath K, Cook C, Tumilty S. Dysfunction of the stress response in individuals with persistent post-concussion symptoms: a scoping review. PHYSICAL THERAPY REVIEWS 2022. [DOI: 10.1080/10833196.2022.2096195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Gerard Farrell
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, Dunedin, New Zealand
| | - Sizhong Wang
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, Dunedin, New Zealand
| | - Cathy Chapple
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, Dunedin, New Zealand
| | - Ewan Kennedy
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, Dunedin, New Zealand
| | | | - Kesava Sampath
- Centre for Health and Social Practice, Waikato Institute of Technology-Rotokauri Campus, Hamilton, Waikato, New Zealand
| | | | - Steve Tumilty
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, Dunedin, New Zealand
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Fuller C, Falvey É, Schneider K. Reliability of a neck strength test in schoolboy rugby players. Musculoskelet Sci Pract 2022; 60:102566. [PMID: 35644049 DOI: 10.1016/j.msksp.2022.102566] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND In rugby union, a bracing mechanism of the neck and trunk is normally adopted in contact situations where high linear and angular forces are produced, which may contribute to the risk for sports-related concussion (SRC). OBJECTIVES To examine the feasibility of and test-retest reliability, both inter-rater and intra-rater reliability, of a novel neck strength test in schoolboy rugby players and to summarize neck strength values for this cohort, including rugby position-specific estimates. MATERIALS AND METHODS 52 male schoolboy rugby union players completed the neck strength test protocol twice, eight days apart using a novel device. RESULTS Intra-class correlation coefficients (ICCs) were good to excellent for test-retest reliability (range from 0.86 to 0.92) in all four directions. Intra-rater (ICCs range from 0.706 to 0.981) and inter-rater (ICCs range from 0.669 to 0.982) ranges were calculated. Significant differences were identified between forwards and backs for non-normalised force measures but no significant difference when normalised to bodyweight. The flexor:extensor ratio was 0.68 (SD 0.2) for forwards, 0.71 (SD 0.16) for backs and 0.67 (SD 0.16) for the cohort. DISCUSSION & CONCLUSION While there is limited direct evidence to support a direct link between neck strength and SRC risk at present, investigating the relationship of neck strength, stiffness and impact anticipation might be a useful direction for further research. In conclusion, we describe a portable, user-friendly and safe neck strength test with good-to-excellent test-retest reliability, and intra-, inter-rater reliability. Test-retest ICC values compare favourably to gold standard fixed-frame dynamometry and are superior to hand-held dynamometry.
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Affiliation(s)
- Colm Fuller
- Sports Medicine Research Department, Sports Surgery Clinic, Dublin, Ireland; College of Medicine and Health, University College Cork, Cork, Ireland.
| | - Éanna Falvey
- Sports Medicine Research Department, Sports Surgery Clinic, Dublin, Ireland; College of Medicine and Health, University College Cork, Cork, Ireland; World Rugby, World Rugby House 8-10 Lower Pembroke Street, Dublin 2, Ireland
| | - Kathryn Schneider
- Sport Injury Prevention Research Centre and Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Roelke MB, Jewell VD, Radomski MV. Return-to-Activity: Exploration of Occupational Therapy in Outpatient Adult Concussion Rehabilitation. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2022; 42:333-343. [PMID: 35848427 DOI: 10.1177/15394492221108649] [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: 11/16/2022]
Abstract
Literature is sparse related to how occupational therapy advances symptom management and role-activity resumption after concussion. We aim to describe the occupational therapy process of evaluation and intervention for adults with a history of concussion(s) and persisting symptoms. The qualitative descriptive study used focus groups of expert occupational therapy practitioners across practice settings. Content analysis with a deductive strategy, open coding, and an unconstrained matrix was used to determine the process portion of a logic model outlining how expert practitioners framed their approach to rehabilitation. Thirteen expert occupational therapy practitioners informed the development of a logic model describing the occupational therapy process linking resources to activities of evaluation and intervention enabling people to return to their everyday life roles at their highest capacity. This study yields a description of how occupational therapy practitioners, across practice settings, aid individuals in returning to everyday activities and life roles after concussion(s).
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Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion. Clin J Sport Med 2022; 32:400-407. [PMID: 34342297 DOI: 10.1097/jsm.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the factor structure of the Sport Concussion Assessment Tool-5 (SCAT5) symptom scale in adolescents on their initial presentation to a concussion clinic within the typical recovery period after concussion (ie, <30 days). We hypothesize that the SCAT5 symptoms represent various clinically meaningful groups. A secondary purpose was to examine the effects of sex on the factor structure of the SCAT5 symptom scale. STUDY DESIGN Retrospective cross-sectional analysis. SETTING Tertiary, institutional. PATIENTS Nine hundred eighty-one adolescents (45% women) aged between 13 and 18 years. INDEPENDENT VARIABLES Adolescents completed the SCAT5 symptom scale. MAIN OUTCOME MEASURES The factor structure of SCAT5 examined using a principal axis factor analysis. RESULTS A 5-factor structure model explained 61% of the variance in symptoms. These 5 factors are identified as Energy (17%), Mental Health (13%), Migrainous (13%), Cognitive (9%), and Vestibulo-Ocular (9%). A similar 5-factor model emerged for each sex, and the proportion of variance in symptoms explained by the 5-factor model was comparable between the sexes. CONCLUSIONS The findings of this report indicate that the SCAT5 symptoms aggregated into 5 delineated factors, and these factors were largely consistent across the sexes. The delineation of symptoms into 5 factors provides preliminary validation for the presence of different concussion phenotypes. Confirmatory factor analysis is warranted to examine the applicability and clinical utility of the use of the 5-factor structure in a clinical setting.
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Eagle SR, Manderino L, Collins M, Kegel N, Fazio-Sumrok V, Mucha A, Kontos AP. Characteristics of concussion subtypes from a multidomain assessment. J Neurosurg Pediatr 2022; 30:107-112. [PMID: 35453113 DOI: 10.3171/2022.3.peds2267] [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: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the best combination of clinical variables associated with concussion subtypes using a multidomain assessment comprising medical history; symptoms; and cognitive, ocular, and vestibular impairment in a cohort of patients presenting to a concussion specialty clinic. METHODS Adolescent patients (n = 293) completed demographics and medical history, Concussion Clinical Profiles Screening, Immediate Post-Concussion Assessment and Cognitive Testing, and vestibular ocular motor screening at their first visit (mean 7.6 ± 7.8 days postinjury) to a concussion specialty clinic. Each participant was adjudicated to have one or more subtype (anxiety/mood, cognitive, migraine, ocular, and vestibular) by a healthcare professional based on previously published criteria. A series of backward, stepwise logistic regressions were used to identify significant predictors of concussion subtypes, and predictive probabilities from the logistic regression models were entered into area under the receiver operating characteristic curve (AUC) models. RESULTS Each of 5 logistic regression models predicting primary subtypes accounted for 28%-50% of the variance (R2 = 0.28-0.50, p < 0.001) and included 2-8 significant predictors per model. Each of the models significantly differentiated the primary subtype from all other subtypes (AUC = 0.76-0.94, p < 0.001). CONCLUSIONS These findings suggest that each concussion subtype can be identified using specific outcomes from a multidomain assessment. Clinicians can employ such an approach to better identify and monitor recovery from subtypes as well as guide interventions.
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Affiliation(s)
- Shawn R Eagle
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania; and
| | - Lisa Manderino
- 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Collins
- 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nathan Kegel
- 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Anne Mucha
- 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony P Kontos
- 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Worts PR, Haider MN, Mason JR, Schatz P. Norm-Based Cutoffs as Predictors of Prolonged Recovery After Adolescent Sport-Related Concussion. Clin J Sport Med 2022; 32:e391-e399. [PMID: 34173784 DOI: 10.1097/jsm.0000000000000952] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify predictors of prolonged recovery (ie, >28 days) using patient demographic factors and healthy, norm-based cutoffs on a multimodal test battery in adolescents after sport-related concussions (SRCs). DESIGN Retrospective cohort. Patients were deemed recovered after successful completion of return-to-play/school protocols and received medical clearance. SETTING Community concussion clinic. PATIENTS Male and female adolescent student athletes diagnosed with a SRC and evaluated within 1 week of injury. INDEPENDENT VARIABLES Patient demographics, medical history, injury description, computerized neurocognitive testing, vestibular/ocular testing, and symptoms at initial clinical visit. MAIN OUTCOME MEASURES Performance on clinical testing to predict recovery duration, classified as normal (<28 days) or prolonged (>28 days). RESULTS A total of 201 adolescent student athletes (age = 15.3 ± 1.4 years) were included (female 35%). Average recovery duration for the entire cohort was 22.3 ± 13.3 days, with 22% (n = 45) of adolescent student athletes taking >28 days to recover. The final model was 88.3% accurate in classifying normal and prolonged recovery. Predictor variables included sex, loss of consciousness, history of ocular disorder, history of concussion, performance on visual motor speed composite, visual motion sensitivity symptom provocation and near point of convergence distance, number-naming total time, and symptom count. CONCLUSIONS These findings suggest that using norm-based cutoffs from cognitive, oculomotor, and vestibulo-ocular testing and symptom reporting, clinicians can accurately predict a prolonged recovery (sensitivity = 81%) and normal recovery (specificity = 83%) in an adolescent, SRC cohort.
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Affiliation(s)
- Phillip R Worts
- Tallahassee Orthopedic Clinic, Tallahassee, Florida.,Department of Nutrition, Food, and Exercise Sciences, the Florida State University, Tallahassee, Florida.,Florida State University Institute of Sports Sciences and Medicine, Tallahassee, Florida
| | - Mohammad N Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Justin R Mason
- Department of Occupational Therapy, University of Florida, Gainesville, Florida; and
| | - Philip Schatz
- Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania
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45
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Hicks SD, Leddy J, Lichak BP, Onks C, Dretsch M, Tennant P, Haider MN, Olympia RP, Zuckerman SL, Loeffert J, Loeffert AC, Monteith C, Master CL. Defining Biological Phenotypes of Mild Traumatic Brain Injury Using Saliva MicroRNA Profiles. J Neurotrauma 2022; 39:923-934. [PMID: 35412857 PMCID: PMC9248343 DOI: 10.1089/neu.2022.0018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Concussion is a heterogeneous injury that relies predominantly on subjective symptom reports for patient assessment and treatment. Developing an objective, biological test could aid phenotypic categorization of concussion patients, leading to advances in personalized treatment. This prospective multi-center study employed saliva micro-ribonucleic acid (miRNA) levels to stratify 251 individuals with concussion into biological subgroups. Using miRNA biological clusters, our objective was to assess for differences in medical/demographic characteristics, symptoms, and functional measures of balance and cognition. The miRNAs that best defined each cluster were used to identify physiological pathways that characterized each cluster. The 251 participants (mean age: 18 ± 7 years; 57% male) were optimally grouped into 10 clusters based on 22 miRNA levels. The clusters differed in age (χ2 = 19.1, p = 0.024), days post-injury at the time of saliva collection (χ2 = 22.6; p = 0.007), and number of prior concussions (χ2 = 17.6, p = 0.040). The clusters also differed in symptom reports for fatigue (χ2 = 17.7; p = 0.039), confusion (χ2 = 22.3; p = 0.008), difficulty remembering (χ2 = 22.0; p = 0.009), and trouble falling asleep (χ2 = 17.2; p = 0.046), but not objective balance or cognitive performance (p > 0.05). The miRNAs that defined concussion clusters regulate 16 physiological pathways, including adrenergic signaling, estrogen signaling, fatty acid metabolism, GABAergic signaling, synaptic vesicle cycling, and transforming growth factor (TGF)-β signaling. These results show that saliva miRNA levels may stratify individuals with concussion based on underlying biological perturbations that are relevant to both symptomology and pharmacological targets. If validated in a larger cohort, miRNA assessment could aid individualized, biology-driven concussion treatment.
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Affiliation(s)
- Steven D. Hicks
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Address correspondence to: Steven D. Hicks, MD, PhD, Departmentt of Pediatrics, Penn State College of Medicine, 500 University Drive, Hershey PA 17033, USA
| | - John Leddy
- Department of Sports Medicine, SUNY Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Orthopedics, State University of New York at Buffalo, Buffalo, New York, USA
| | - Brooke P. Lichak
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Cayce Onks
- Department of Family Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Department of Orthopaedics and Rehabilitation, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Michael Dretsch
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington, USA
| | | | - Mohammad Nadir Haider
- Department of Sports Medicine, SUNY Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Orthopedics, State University of New York at Buffalo, Buffalo, New York, USA
| | - Robert P. Olympia
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Department of Emergency Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Scott L. Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jayson Loeffert
- Department of Family Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Department of Orthopaedics and Rehabilitation, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Andrea C. Loeffert
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Chuck Monteith
- Department of Sports Medicine, Colgate University, Hamilton, New York, USA
| | - Christina L. Master
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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46
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Kashif M, Manzoor N, Safdar R, Khan H, Farooq M, Wassi A. Effectiveness of sustained natural apophyseal glides in females with cervicogenic headache: A randomized controlled trial. J Back Musculoskelet Rehabil 2022; 35:597-603. [PMID: 34542060 DOI: 10.3233/bmr-210018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cervicogenic headache (CGH) is a common condition that results in significant disability. To treat this dysfunction, Mulligan described sustained natural apophyseal glides (SNAGs) as a manual therapy approach. However, only inconclusive short-term evidence exists for treating CGH with SNAGs. OBJECTIVE The present study aims to investigate the effect of SNAGs in the treatment of CGH. METHODS Fourty female patients ranging from 20 to 40 years with CGH were randomly assigned to two groups: 20 in a treatment group and 20 in a control group. SNAGs were applied to the treatment group while the control group received placebo treatment. Both groups received their respective treatment for 20 minutes, alternately three times per week, for a total of 12 times in four weeks. The outcome measures were the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). Participants were assessed at baseline and at the end of each week. The data was analyzed using SPSS version 20. Independent t-testing was used to reveal changes between groups. One-way ANOVA was used to determine changes within groups. The level of significance was P< 0.05. RESULTS Twenty participants (100%) in the treatment group and 17 (85%) in the control group had a history of headache aggravation with active movements or passive head positioning. There was no significant difference at baseline (p> 0.05), indicating that both groups were homogeneous at the time of recruitment. The p value (p< 0.05) showed a significant difference in pain and level of disability at three and four weeks (p< 0.05) in patients treated with SNAGs. However, the cervical range of motion (ROM) showed a statistically significant improvement in flexion and extension in the treatment group (p< 0.05) while there was no significant improvement in side flexion and rotation ROM in both groups (p> 0.05). CONCLUSION This study found that SNAGs were effective in reducing pain and neck disability and improved ROM in females with CGH.
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47
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Eagle SR, Kissinger-Knox AM, Feder A, Manderino L, Preszler J, Womble MN, Elbin RJ, Collins M, Kontos AP. Temporal Differences in Concussion Symptom Factors in Adolescents following Sports-Related Concussion. J Pediatr 2022; 245:89-94. [PMID: 35157844 DOI: 10.1016/j.jpeds.2022.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate temporal differences in concussion symptoms up to 30 days following a sports-related concussion. STUDY DESIGN Adolescent and young adult athletes (n = 782) were separated based on time since injury at presentation as Early (0-7 days; n = 321, age: 15.4 ± 1.9 years, 51.7% female), Middle (8-14 days; n = 281, age: 15.8 ± 2.2 years, 54.8% female), and Late (15-30 days; n = 180, age: 15.6 ± 1.8 years, 52.8% female). All participants completed the 22-item Post-Concussion Symptom Scale at first visit. A confirmatory factor analysis was completed separately for each time since injury cohort using a 4-component model reported previously. RESULTS The confirmatory factor analysis model fit was acceptable for Early, Middle, and Late (using cognitive-migraine-fatigue, affective, sleep, and somatic factors). Both affective (change = 0.30; P = .01; Cohen d = 0.30) and sleep (change = 0.51; P ≤ .001; Cohen d = 0.47) factors were significantly greater in the Late group compared with the Early, but not Middle, groups. The previously reported 4-factor symptom model, including cognitive-migraine-fatigue, affective, somatic, and sleep factors, was appropriate for adolescents up to 30 days' postinjury. However, adolescents who presented between 15 and 30 days' postinjury reported greater affective and sleep symptoms than those who presented within 1 week. CONCLUSIONS Clinicians should consider these temporal differences when evaluating concussion symptoms in adolescents, as greater affective and sleep symptoms can be predictive of prolonged recovery/persistent complications.
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Affiliation(s)
- Shawn R Eagle
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA.
| | | | - Abigail Feder
- Northside Hospital Concussion Institute, Atlanta, GA
| | - Lisa Manderino
- UPMC Freddie Fu Sports Medicine Concussion Program, Pittsburgh, PA
| | | | | | - Robert J Elbin
- Office for Sport Concussion Research, Department of Health, Human Performance, & Recreation, University of Arkansas, Fayetteville, AR
| | - Michael Collins
- Office for Sport Concussion Research, Department of Health, Human Performance, & Recreation, University of Arkansas, Fayetteville, AR
| | - Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA; Office for Sport Concussion Research, Department of Health, Human Performance, & Recreation, University of Arkansas, Fayetteville, AR
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48
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Wen X, Yang Y, Li Y, Liu T, Liu Y, Wang X, Lu F, Yu C, Xu N. Effects of acupuncture treatment on posttraumatic headache after traumatic brain injury in patients: A protocol for systematic review. Medicine (Baltimore) 2022; 101:e29158. [PMID: 35550465 PMCID: PMC9276099 DOI: 10.1097/md.0000000000029158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Posttraumatic headache (PTH) after traumatic brain injury (TBI) is a common clinical symptom, which refers to a headache that occurs after TBI. Acupuncture is often used for the treatment of such patients in China, and significant clinical effects have been achieved. However, to date, its efficacy has not been methodically evaluated. The purpose of this systematic review is to provide evidence to prove the effectiveness of acupuncture in the treatment of PTH in patients with TBI. METHODS This systematic review will be conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols. The following electronic databases will be searched from their inception to February 2022: PubMed, Web of Science, Embase, PsycINFO, the Cochrane Library, and Chinese databases such as Chinese Biomedical Literature (CBM), Chinese Medical Current Content (CMCC), Chinese Scientific Journal Database (VIP), WanFang Database, and China National Knowledge Infrastructure (CNKI). No language restrictions will be applied to the search strategy. Randomized controlled trials and cohort and case-control studies that met the inclusion and exclusion criteria will be included in this study. The meta-analysis will be performed using RevMan 5.3 software. Each session of this systematic review will be conducted independently by 2 members. RESULTS This review evaluates the efficacy of acupuncture in the treatment of PTH after TBI. CONCLUSION This review provides substantial evidence for the clinical application of acupuncture in PTH treatment after TBI. ETHICS AND DISSEMINATION Since the data in this study will be retrieved from published trials, therefore the Patient Consent Statement and Ethical Approval are not required. We will disseminate our results by publishing the research in a peer-reviewed journal. TRAIL REGISTRATION NUMBER The protocol was registered in INPLASY (INPLASY 202220073).
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Affiliation(s)
- Xi Wen
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yang Yang
- Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Yunhai Li
- The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tong Liu
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Liu
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoyin Wang
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangyi Lu
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chanzhen Yu
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nenggui Xu
- Guangzhou University of Chinese Medicine, Guangzhou, China
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Abstract
PURPOSE OF REVIEW Mild traumatic brain injury (mTBI) is a significant public health concern for children. This review summarizes recent literature on early symptoms and neuropsychiatric and neuropsychological outcomes following pediatric mTBI and highlights factors that predict prolonged recovery. Evidence-based recommendations for assessment and treatment are also discussed. RECENT FINDINGS Whereas most children recover within 1 month after mTBI, 10-30% of children experience lingering neuropsychiatric or neuropsychological symptoms 3 months or more after injury. For the subset who experience prolonged recovery, new or worsening emotional and behavioral symptoms are the most frequent concerns. Recent research has suggested that specific factors, including preinjury mental health concerns, female sex, and family characteristics, are associated with increased risk of experiencing prolonged recovery. Early management includes reassurance, brief rest (1-3 days), and gradual return to typical activities. When symptoms linger for more than 4 weeks, evaluation in a specialty clinic is recommended and multimodal therapies are considered. Active recovery models, which include gradual return to aerobic exercise and cognitive behavioral approaches, are promising for the management of prolonged symptoms. SUMMARY A minority of children with mTBI experience prolonged neuropsychiatric or neuropsychological concerns. While our understanding of pediatric mTBI is growing, and recommendations for assessment and management have been developed, many gaps remain.
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50
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Langevin P, Fremont P, Fait P, Dubé MO, Bertrand-Charette M, Roy JS. Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomised Clinical Trial. J Neurotrauma 2022; 39:487-496. [PMID: 35102743 DOI: 10.1089/neu.2021.0508] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The objective of this study was to compare the effects of a cervicovestibular rehabilitation program combined with symptom-limited aerobic exercise (SLAE) program to a SLAE program alone in adults with persistent symptoms following mild traumatic brain injury (mTBI) on severity of symptoms and other indicators of clinical recovery. In this single-blind, parallel-group randomised clinical trial, 60 adults with persistent symptoms following mTBI were randomly assigned to: 1) a 6-week SLAE program or 2) a 6-week cervicovestibular rehabilitation program combined with SLAE program. All participants took part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), time to return to function, and physical cervical and vestibular measures. Nonparametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes. For PCSS, NPRS, NDI, HDI, DHI and return to function, there were no group-by-time interactions at any time-points follow-up (p>0.05); clinically significant time effects were however observed (p0.05). There were group-by-time interactions at weeks 6 and 12 for vestibulo-ocular reflex (p0.003) and the cranio-vertebral mobility (p0.001) measures in favor of the cervicovestibular rehabilitation group. The study indicates that a cervicovestibular rehabilitation program combined with SLAE was not superior to a SLAE program alone in term of symptoms and functional level improvement but resulted in improved physical cervical and vestibular function. Keywords: mild traumatic brain injury, rehabilitation, neck pain, dizziness, headache.
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Affiliation(s)
- Pierre Langevin
- Université Laval Faculté de médecine, 12369, Quebec, Quebec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale, 560498, Quebec City, Quebec, Canada;
| | - Pierre Fremont
- Université Laval, 4440, Department of Rehabilitation, Quebec, Quebec, Canada;
| | - Philippe Fait
- Université du Québec à Trois-Rivières UQTR, Departement of Physical Activity Science, Trois-Rivières, Quebec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale, 560498, Quebec City, Quebec, Canada;
| | - Marc-Olivier Dubé
- Université Laval Faculté de médecine, 12369, Quebec City, Quebec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale, 560498, Quebec City, Quebec, Canada;
| | - Michael Bertrand-Charette
- Université Laval Faculté de médecine, 12369, Quebec City, Quebec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale, 560498, Quebec City, Quebec, Canada;
| | - Jean-Sébastien Roy
- Université Laval Faculté de médecine, 12369, Quebec City, Quebec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale, 560498, Quebec City, Quebec, Canada;
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