COACH CV: The Seven Clinical Phenotypes of Concussion

Adolescents With a High Burden of New-Onset Mood Symptoms After Sport-Related Concussion Benefit From Prescribed Aerobic Exercise, a Secondary Analysis of 2 Randomized Controlled Trials

OBJECTIVE

Approximately 20% of students with sport-related concussion (SRC) report new symptoms of anxiety and depression which may be associated with delayed recovery and increased risk for developing a mood disorder. Early prescribed aerobic exercise facilitates recovery in athletes with concussion-related exercise intolerance. We studied the effect of aerobic exercise treatment on new mood symptoms early after SRC.

DESIGN

Exploratory secondary analysis of 2 randomized controlled trials (RCT).

SETTING

Sports medicine clinics associated with UB (Buffalo, NY), CHOP (Philadelphia, PA), and Boston Children's Hospital (Boston, MA).

PARTICIPANTS

Male and female adolescents (aged 13-18 years) diagnosed with SRC (2-10 days since injury).

INTERVENTIONS

Participants were randomized to individualized targeted heart rate aerobic exercise (n = 102) or to a placebo intervention designed to mimic relative rest (n = 96).

MAIN OUTCOME MEASURES

Incidence of Persisting Post-Concussive Symptoms (PPCS, symptoms ≥28 days).

RESULTS

First RCT recruited from 2016 to 2018 and the second from 2018 to 2020. Of 198 adolescents, 156 (79%) reported a low burden (mean 1.2 ± 1.65/24) while 42 (21%) reported a high burden (mean 9.74 ± 3.70/24) of emotional symptoms before randomization. Intervention hazard ratio for developing PPCS for low burden was 0.767 (95% CI, 0.546-1.079; P = 0.128; β = 0.085) and for high burden was 0.290 (95% CI, 0.123-0.683; P = 0.005; β = 0.732).

CONCLUSIONS

High burden of mood symptoms early after injury increases risk for PPCS, but the sports medicine model of providing early targeted aerobic exercise treatment reduces it. Nonsports medicine clinicians who treat patients with a high burden of new mood symptoms after concussion should consider prescribing aerobic exercise treatment to reduce the risk of PPCS and a mood disorder.

Neck Symptoms and Associated Clinical Outcomes in Patients Following Concussion

OBJECTIVE

To examine the frequency and association of neck pain symptoms in patients with a concussion.

STUDY SETTING AND PARTICIPANTS

Three-hundred and thirty-one consecutively enrolled patients aged 9 to 68 years with a diagnosed concussion 1 to 384 days post-injury were enrolled at a concussion clinic from a single integrated healthcare system in Western Pennsylvania between 2019 and 2021.

DESIGN

Retrospective cohort analysis of prospectively collected concussion screening tool intake survey responses and clinical outcomes data. The primary outcome was self-reported neck pain or difficulty with neck movement on the Concussion Clinical Profiles Screening (CP Screen) tool, recovery time, and incidence of treatment referral. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) composite scores, Vestibular/Ocular Motor Screening (VOMS) item scores, type and severity of neck symptoms, mechanism of injury, time from injury to clinic presentation, medical history, and concussion symptom profile were secondary outcomes.

RESULTS

Of the 306 consecutively enrolled eligible patients in the registry, 145 (47%) reported neck pain, 68 (22.2%) reported difficulty moving their neck, and 146 (47.7%) reported either symptom. A total of 47 (15.4%) participants reported more severe neck symptoms, and this group took longer to recover (40 ± 27 days) than those not reporting neck symptoms (30 ± 28 days; U = 8316, P < .001). Stepwise logistic regression predicting more severe neck symptoms was significant (Nagelkerke R2 = 0.174, χ 2 = 9.315, P = .316) with older age ( P = .019) and mechanism of injury including motor vehicle collisions (MVCs) ( P = .047) and falls ( P = .044) as risk factors. MVCs and falls were associated with over 4 times and 2 times greater risk, respectively, for reporting more severe neck symptoms.

CONCLUSION

Neck pain and stiffness symptoms are common in patients with a concussion following high-energy mechanisms of injury including MVCs or falls from height. These symptoms are associated with prolonged recovery. Providers should evaluate neck symptoms and consider targeted treatment strategies to limit their effects in patients with a concussion.

Rehabilitation interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review protocol

INTRODUCTION

Mild traumatic brain injury (mTBI) is the most common form of TBI with many individuals suffering from symptoms suggestive of deficits in oculomotor function. Although the symptoms are often experienced transiently, almost 50% of individuals will experience persistent symptoms. Oculomotor deficits can last months after injury and decrease function and the ability to participate in work, school and sport. To date, rehabilitation interventions targeting oculomotor deficits in mTBI have been reported on in several studies with varying study designs; however, the effectiveness of these interventions on measures of oculomotor function has not been established. The purpose of this paper is to present a protocol for a systematic review that aims to examine the effectiveness of rehabilitation interventions for improving function in adults with oculomotor deficits after mTBI.

METHODS AND ANALYSIS

Systematic searches in Medline Ovid, EMBASE, PsycINFO, CINAHL and Scopus will be conducted to identify experimental studies published in English from each databases inception date to present, involving adult patients with mTBI and oculomotor deficits. Citations will be saved and managed in EndNote V.20. Two independent reviewers will identify eligible studies and perform data abstraction. Any discrepancies will be solved by discussion, and a third reviewer will be consulted if necessary. A meta-analysis will be conducted for outcomes reported in two or more studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines will be followed for reporting.

ETHICS AND DISSEMINATION

This study does not involve primary data collection; therefore, formal ethical approval by an institutional review board is not required. Final results will be disseminated through open-access peer-reviewed publications. Abstracts will be presented at suitable national and international conferences or workshops. Furthermore, important information will be shared with clinical authorities, clinicians and at affiliated research institution-based websites and relevant servers.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

Vision Quality of Life with Time Survey: Normative Data and Repeatability

Purpose

To develop a novel Vision Quality of Life (QoL) survey that emphasizes the amount of time a visual activity can be performed before symptoms occur.

Methods

The Vision Quality of Life with Time (VisQuaL-T) survey was developed with 10 daily activities and a list of common visual symptoms. Participants were recruited from a university campus. Participants were not excluded based on binocular impairments to obtain a normative dataset. Participants were instructed to denote when they first experience symptoms within certain time ranges. If participants did not engage in one of the 10 activities, they were instructed to denote "N/A". A composite score (range 0-3) was determined by only accounting for the questions that were answered.

Results

The normative data cohort had a sample size of 376 participants and the repeatability cohort had 54 participants. The normative, test, and retest datasets had a mean composite score of 2.47±0.54, 2.69±0.42, and 2.67±0.49 and 95% confidence interval of 2.38-2.71, 2.58-2.81, 2.54-2.80, respectively. There was good reliability and high correlation between the test and retest timepoints with an ICC of 0.825 and a Pearson correlation coefficient of 0.839 in the repeatability cohort. The normative data cohort showed good internal consistency with a Cronbach's alpha value of 0.803. Test and retest timepoints showed no statistical significance among the individual questions (p > 0.1).

Conclusion

A lower bound score of 2.4 can potentially be used to differentiate visually normal and symptomatic participants. Statistical analysis showed the survey is repeatable and reliable. Using time as a metric for assessing symptomology could be a useful method for identifying patients with QoL issues and for assessing effectiveness of binocular vision, accommodative, and eye movement treatments.

Primary Headaches and Physical Performance: A Professional Youth Female Soccer Team Study

The vast majority of the research on acute post-traumatic incidents in athletes focuses on migraines. Physical exercise might reduce the frequency of migraines as well as trigger a migraine attack. The objectives of the study were to evaluate primary headache prevalence in professional young female soccer players and to assess whether headaches are related to physical performance. To the best of our knowledge, this is the first study that has considered the relationship between primary headaches and physical performance assessment. The research was conducted in 19 females aged 12-17 from a professional youth soccer academy. Players completed a questionnaire about health status and then performed laboratory physical tests (e.g., cardiopulmonary tests, countermovement and squat jumps, handgrip, sit-and-reach tests). Subsequently, players were separated into a headache group and a headache-free control group. In the analysed group, eight female players (42%) suffered from primary headaches. Among the performance parameters, a significant result was found in terms of flexibility. Females from the headache group had higher results in the sit-and-reach test than females from the control group (p = 0.029). Flexibility as well as mobility in migraine patients is an area with significant potential for further investigation, as little research has been conducted to date.

Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes

OBJECTIVE

To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity.

METHODS

We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings.

RESULTS

3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity.

CONCLUSION

Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.While I agree with the use of the british spelling of Paediatric throughout, this groups actual name is with the American English Spelling.

Evaluation and Management of Pediatric Concussion in the Acute Setting

ABSTRACT

Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.

Critical Elements of Return to Learn for Students With Concussion: A Scoping Review

OBJECTIVE

To identify critical elements of return to learn (RTL) for students with concussion and examine the state of the peer-reviewed published literature through a scoping review.

METHODS

Three electronic databases were systematically searched, and reference lists screened for articles addressing components of RTL protocols and accommodations for students with concussion. In total, 100 articles met inclusion criteria, including 56 empirical studies and 44 expert articles.

RESULTS

Four key components to RTL protocols were identified: RTL teams, management approaches, outcome measurement, and accommodations. Both bodies of literature agree on the importance of RTL teams, but evidence for specific monitoring tools and management approaches is less robust. Accommodations have been better addressed by experts than empirical evaluation. Empirical studies are largely cross-sectional, and many are survey based. Just 24 include student perspectives. Publication of expert literature has declined in frequency, as empirical studies have become more common.

CONCLUSION

This scoping review describes the current landscape of RTL and provides guidance toward expanding the empirical literature to systematically determine best practices to serve students with concussion.

OculoMotor Assessment Tool Test Procedure and Normative Data

SIGNIFICANCE

This study establishes normative data and a testing procedure for the oculomotor assessment tool. The oculomotor assessment tool standardizes visual targets for the Vestibular/OculoMotor Screening assessment and provides additional metrics that may aid in the differentiation between those with normal and those with abnormal oculomotor function potentially caused by a concussion.

PURPOSE

This study aimed to assess the oculomotor endurance of healthy participants with no self-reported history of concussions using the oculomotor assessment tool.

METHODS

Healthy participants (n = 376, average age of 20.4 years, range of 11 to 34 years, with no self-reported history of concussions) were recruited to perform the following three tasks for 60 seconds each: (1) horizontal saccades, (2) vertical saccades, and (3) vergence jumps. The participants were instructed to alternate visual fixation between two targets for each of the tasks as fast as they could without overshooting or undershooting the visual target. The differences in the number of eye movements between the initial and latter 30 seconds of the 1-minute test were analyzed.

RESULTS

A statistical difference (P < .001) was observed in the number of eye movements for all three tasks (horizontal saccades [70 ± 15 for initial 30 seconds, 63 ± 13 for latter 30 seconds], vertical saccades [68 ± 14, 63 ± 13], and vergence jumps [43 ± 11, 39 ± 10]) between the initial and latter 30 seconds. No significant differences were identified in the number of eye movements or the change in eye movements between the initial and latter 30 seconds based on sex.

CONCLUSIONS

These results establish a normative database for various eye movements. These data could potentially be used to compare different patient populations who have binocular endurance dysfunctions potentially due to traumatic brain injury, such as patients with concussion(s).

Concussion Office Based Rehabilitation Assessment: A Novel Clinical Tool for Concussion Assessment and Management

The Concussion Office Based Rehabilitation Assessment (COBRA) is a novel tool constructed to ensure a comprehensive assessment of patients who may have sustained a concussion. The SCAT-5 (Sport Concussion Assessment Tool) has long been the gold standard for concussion assessment, however, it was designed as a sideline tool and its utility can be seen to decrease after a few days post-concussion. It also does not prompt evaluation of all the phenotypes of concussion. As such, the COBRA was created to assess the majority of potential manifestations of concussion in the office setting a day or two after an injury has been sustained. The COBRA utilizes the eight phenotypes of concussion as a guide to assess each of the potential biopsychosocial features that can be associated with these injuries and can be used to guide evidence-based treatments. Through early identification of concussion phenotypes, the clinician may start optimal treatment and hopefully prevent prolonged recovery and persisting symptoms.

Near Point of Convergence Deficits and Treatment Following Concussion: A Systematic Review

CONTEXT

Convergence dysfunction following concussion is common. Near point of convergence (NPC) is a quick and easy assessment that may detect oculomotor dysfunction such as convergence insufficiency (CI), but NPC measurements are rarely reported. Convergence dysfunction is treatable in otherwise healthy patients; the effectiveness of oculomotor therapy following concussion is unclear.

OBJECTIVES

The purpose of this article was to systematically review the literature and answer the following clinical questions: (1) Is performance on NPC negatively affected in patients diagnosed with a concussion compared with pre-injury levels or healthy controls? (2) In patients diagnosed with concussion, what is the effect of oculomotor/vision therapy on NPC break measurements?

EVIDENCE ACQUISITION

The search was conducted in CINAHL, SPORTDiscus, MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, convergence, vision, and rehabilitation. Literature considered for review included original research publications that collected measures of NPC break in concussion patients, with a pretest-posttest comparison or comparison with a healthy control group. A literature review was completed; 242 relevant articles were reviewed, with 18 articles meeting criteria for inclusion in the review.

EVIDENCE SYNTHESIS

Articles were categorized according to the clinical question they addressed. The patient or participant sample (number, sex, age, and health status), study design, instrumentation, or intervention used, and main results were extracted from each article.

CONCLUSIONS

The authors' main findings suggest that there is a moderate level of evidence that patients have impaired NPC up to several months postconcussion, and a low level of evidence that impairments can be successfully treated with oculomotor therapy. These findings should be cautiously evaluated; the studies are limited by weak/moderate quality, small sample sizes, varied methodology, and nonrandomized treatment groups. Future research should explore factors affecting convergence postconcussion and include randomized, controlled studies to determine if performing vision therapy improves visual measures and promotes recovery.

Early Controlled Exercise and Timing of Treatment Following Concussion: A Critically Appraised Topic

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.

Considerations for Diagnosis and Management of Concussion

Concussion is an ongoing concern for health care providers. The incidence rates continue to be high and the rate of recovery is variable due to potential risk factors. With no valid biomarkers, diagnosis and assessment of concussion remain a clinical challenge. The heterogeneity in presentation following injury provides an additional level of complexity, requiring the screening and evaluation of diverse body systems, including oculomotor, vestibular, autonomic, psychiatric, cervical, and cognitive symptoms. While a few tools, such as the Vestibular/Ocular Motor Screening and Balance Error Scoring System, have been developed specifically for concussion, the vast majority of tests are adapted from other conditions. Further complicating the process is the overlapping and interactive nature of the multiple domains of postconcussion presentation. This commentary illustrates how clinicians can conceptualize the multiple profiles that present following concussion and describes tools that are available to assist with screening and evaluation of each area. The multifaceted nature of concussion warrants broad clinical screening skills and an interdisciplinary approach to management. J Orthop Sports Phys Ther 2019;49(11):787-798. doi:10.2519/jospt.2019.8855.

Artificial intelligence as an emerging technology in the current care of neurological disorders

BACKGROUND

Artificial intelligence (AI) has influenced all aspects of human life and neurology is no exception to this growing trend. The aim of this paper is to guide medical practitioners on the relevant aspects of artificial intelligence, i.e., machine learning, and deep learning, to review the development of technological advancement equipped with AI, and to elucidate how machine learning can revolutionize the management of neurological diseases. This review focuses on unsupervised aspects of machine learning, and how these aspects could be applied to precision neurology to improve patient outcomes. We have mentioned various forms of available AI, prior research, outcomes, benefits and limitations of AI, effective accessibility and future of AI, keeping the current burden of neurological disorders in mind.

DISCUSSION

The smart device system to monitor tremors and to recognize its phenotypes for better outcomes of deep brain stimulation, applications evaluating fine motor functions, AI integrated electroencephalogram learning to diagnose epilepsy and psychological non-epileptic seizure, predict outcome of seizure surgeries, recognize patterns of autonomic instability to prevent sudden unexpected death in epilepsy (SUDEP), identify the pattern of complex algorithm in neuroimaging classifying cognitive impairment, differentiating and classifying concussion phenotypes, smartwatches monitoring atrial fibrillation to prevent strokes, and prediction of prognosis in dementia are unique examples of experimental utilizations of AI in the field of neurology. Though there are obvious limitations of AI, the general consensus among several nationwide studies is that this new technology has the ability to improve the prognosis of neurological disorders and as a result should become a staple in the medical community.

CONCLUSION

AI not only helps to analyze medical data in disease prevention, diagnosis, patient monitoring, and development of new protocols, but can also assist clinicians in dealing with voluminous data in a more accurate and efficient manner.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BACKGROUND

Concussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important.

OBJECTIVES

To determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery.

DESIGN

Longitudinal observational study.

METHODS

Pre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments.

RESULTS

There was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation.

CONCLUSIONS

While no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.