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Clinical Management of Sport-Related Concussion: Developing a Roadmap to a Successful Outcome

Kevin Guskiewicz and Elizabeth Teel

In order to promote the most successful outcomes following concussion, a multifaceted team of individuals is required for appropriate injury diagnosis and management. This review explores the primary roles of sports medicine personnel in the concussion diagnosis and management process. We will discuss the psychometric properties, including sensitivity, specificity, and clinical utility, of on-field/sideline, laboratory, and neurophysiological assessment tools. Additionally, we will discuss the roles of other kinesiology experts in concussion management and recovery, and their importance to concussion research. By developing a thorough and consistent roadmap for concussion management, clinicians and researchers will be capable of providing athletes with the most successful outcomes.

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

Ashley L. Santo, Melissa L. Race, and Elizabeth F. Teel

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.

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Infraspinatus Cross-Sectional Area and Shoulder Range of Motion Change Following Live-Game Baseball Pitching

Brett S. Pexa, Eric D. Ryan, Elizabeth E. Hibberd, Elizabeth Teel, Terri Jo Rucinski, and Joseph B. Myers

Context: Following a baseball pitching bout, changes can occur to glenohumeral range of motion that could be linked to injury. These effects are in part due to the posterior shoulder’s eccentric muscle activity, which can disrupt muscle contractile elements and lead to changes in muscle cross-sectional area (CSA), as measured by ultrasound. Objective: To assess changes in muscle CSA, and range of motion immediately before and after pitching, and days 1 to 5 following pitching. Design: Repeated measures. Setting: Satellite athletic training room. Patients: Ten elite college baseball pitchers participating in the fall season (age: 18.8 [1.2] y, height: 189.2 [7.3] cm, mass: 93.1 [15.3] kg, 8 starters, 2 long relievers). Intervention: A pitching bout of at least 25 pitches (63.82 [17.42] pitches). Main Outcome Measures: Dominant and nondominant infraspinatus CSA, as measured by ultrasound, and glenohumeral range of motion including internal rotation (IRROM), external rotation (ERROM), and total rotation range of motion (TROM) before pitching, after pitching, and days 1 to 5 following the pitching bout. Results: Dominant limb CSA significantly increased day 1 after pitching, and returned to baseline on day 2 (P < .001). Dominant and nondominant TROM did not change until day 5 (4.4°, P < .001) and day 3 (4.5°, P < .001), respectively, where they increased. Dominant IRROM was significantly decreased for 3 days (day 1: 1.9°, P < .001; day 2: 3.1°, P < .001; day 3: 0.3°, P < .001) following pitching and returned to baseline on day 4, with no such changes in the nondominant limb. Dominant external rotation significantly increased immediately post pitching (4.4°, P < .001) but returned to baseline by day 1. Conclusions: The results of the study demonstrate that infraspinatus CSA does not recover until 2 days following pitching, and IRROM does not recover until 4 days following pitching. Baseball pitching elicits damage to the posterior shoulder muscle architecture, resulting in changes to physical characteristics that last up to 4 days following pitching.

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Comparison of Concussion Sideline Screening Measures Across Varying Exertion Levels Within Simulated Games

Rebecca L. Dubas, Elizabeth F. Teel, Melissa C. Kay, Eric D. Ryan, Meredith A. Petschauer, and Johna K. Register-Mihalik

Context: Currently, there is no gold standard to evaluate the effect of varying game-like exertion states on Sport Concussion Assessment Tool 3rd Edition (SCAT-3) outcomes. Baseline assessments may occur before, during, or after physical activity, while postinjury evaluations predominantly occur following physical activity. Thus, clinicians may be comparing postinjury evaluations completed following exertion to baseline evaluations completed following varying levels of rest or exertion, which may not be a valid method for clinical decision making. Objective: To determine the effect of various physical exertion levels on sideline concussion assessment outcomes and reliability. Design: Within-subjects, repeated measures. Setting: Field. Participants: Physically active participants (N = 36) who regularly participate in basketball activity. Intervention: Subjects participated in 2 simulated basketball games, completing a symptom checklist, Standardized Assessment of Concussion, and Balance Error Scoring System before game play, during halftime, and at the completion of each simulated game. Pulse rate was assessed as a proxy of physical exertion. Main Outcome Measures: Total symptom, Standardized Assessment of Concussion, and Balance Error Scoring System scores. Results: Physical exertion did not significantly predict symptom, Standardized Assessment of Concussion, or Balance Error Scoring System scores, although a trend toward higher symptom scores was observed for females (ß = 0.03, P = .09). All assessments had poor to moderate reliability across sessions (.15 < interclass correlation coefficient [2,1] < .60). Conclusion: Low- to moderate-intensity physical activity did not have a significant effect on clinical concussion sideline assessments; however, the low test–retest reliability observed prevents strong conclusions on these relationships. The poor overall reliability does not allow for clear recommendations for what state of baseline physical exertion (ie, rested or exerted) provides optimal data to make postinjury clinical decisions, although baseline concussion assessments completed at rest have the most valid and conservative normative values for injury comparison.

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Balance Error Scoring System Reliability and Validity When Performed With Ice Skates

Jason P. Mihalik, Elizabeth F. Teel, Robert C. Lynall, and Erin B. Wasserman

In equipment-heavy sports, there is a growing need to evaluate players in the condition in which they participate. However, the psychometric properties of the Balance Error Scoring System (BESS) while wearing skates remains unknown. Seventy-four adolescent male hockey players completed the BESS with and without skates. A subset was reevaluated at the conclusion of the season. The BESS while wearing skates resulted in a mean of 15 more total errors than the traditional administration (t73 = 14.94, p < .001; ES = 1.95) and demonstrated low test-retest reliability. The BESS should be administered in the traditional manner (without skates).

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A Randomized Controlled Trial Investigating the Feasibility and Adherence to an Aerobic Training Program in Healthy Individuals

Elizabeth F. Teel, Stephen W. Marshall, L. Gregory Appelbaum, Claudio L. Battaglini, Kevin A. Carneiro, Kevin M. Guskiewicz, Johna K. Register-Mihalik, and Jason P. Mihalik

Context: Concussion management is moving from passive rest strategies to active interventions, including aerobic exercise therapy. Little information is available regarding the feasibility and adherence of these programs. Objectives: To determine whether an aerobic exercise training program intended for rehabilitation in people with concussion is feasible. Healthy, nonconcussed subjects were studied in this phase 1 trial. Design: Phase 1 parallel-group, randomized controlled trial in a sample of healthy (nonconcussed), recreationally active university students. Setting: Laboratory. Patients: 40 healthy university students. Methods: Participants were equally randomized to acute concussion therapy intervention (ACTIVE) training or nontraining groups. All participants completed maximal cardiopulmonary exercise tests on a stationary cycle ergometer at 2 test sessions approximately 14 days apart. During this 2-week study period, ACTIVE training participants completed six 30-minute cycling sessions, progressing from 60% to 80% of the participant’s individualized maximal oxygen consumption. A subset of participants (NACTIVE = 12, Nnontraining = 11) wore physical activity monitors throughout the 2-week study period. Main Outcomes Measures: Study protocol and randomization effectiveness, exercise safety and adherence, and progressive intensity of the ACTIVE training procedures. Results: No adverse events occurred during any exercise sessions. Twelve ACTIVE training participants (60%) completed all training sessions, and every participant completed at least 4 sessions. Heart rate increased throughout the training period (P < .001), but symptom changes and training adherence remained stable despite the progressively increasing workload. ACTIVE training participants completed approximately 30 additional minutes of physical activity on training sessions days, although that was not statistically significant (P = .20). Conclusions: University-aged students were adherent to the ACTIVE training protocol. Future research should investigate the safety and feasibility of aerobic training programs in acutely concussed individuals to determine their appropriateness as a clinical rehabilitation strategy.