potentially related to concussion recovery involving early physical activity and rest: (mtbi OR mild traumatic brain injury OR brain concussion OR cerebral concussion OR mild concussion OR moderate concussion OR severe concussion OR cerebral trauma OR minor head trauma OR mild head injury OR SRC OR src OR
Landon Lempke, Abbis Jaffri, and Nicholas Erdman
Corey P. Ochs, Melissa C. Kay, and Johna K. Register-Mihalik
Clinical Scenario: Collision sports are often at higher risk of concussion due to the physical nature and style of play. Typically, initial clinical recovery occurs within 7 to 10 days; however, even this time frame may result in significant time lost from play. Little has been done in previous research to analyze how individual game performance may be affected upon return to play postconcussion. Focused Clinical Question: Upon return-to-play clearance, how does sport-related concussion affect game performance of professional athletes in collision sports? Summary of Key Findings: All 3 studies included found no significant change in individual performance of professional collision-sport athletes upon returning to play from concussive injury. One of the studies indicated that there was no difference in performance for NFL athletes who did not miss a single game (returned within 7 d) and those who missed at least 1 game. One study indicated that although there was no change in performance of NFL players upon returning to play from sustained concussion, there was a decline in performance in the 2 weeks before the diagnosed injury and appearing on the injury report. The final study indicated that there was no difference in performance or style of play of NHL athletes who missed time due to concussive injury when compared with athletes who missed games for a noninjury factor. Clinical Bottom Line: There was no change in performance upon return from concussive injury suggesting that players appear to be acutely recovered from the respective concussion before returning to play. This suggests that current policies and management properly evaluate and treat concussed athletes of these professional sports. Strength of Recommendation: Grade C evidence exists that there is no change in individual game performance in professional collision-sport athletes before and after suffering a concussion.
Caroline Westwood, Carolyn Killelea, Mallory Faherty, and Timothy Sell
Context: Concussions are consequence of sports participation. Recent reports indicate there is an increased risk of lower-extremity musculoskeletal injury when returning to sport after concussion suggesting that achieving “normal” balance may not fully indicate the athlete is ready for competition. The increased risk of injury may indicate the need to refine a screening tool for clearance. Objective: Assess the between-session reliability and the effects of adding a cognitive task to static and dynamic postural stability testing in a healthy population. Setting: Clinical laboratory. Participants: Twelve healthy subjects (6 women; age 22.3 [2.9] y, height 174.4 [7.5] cm, weight 70.1 [12.7] kg) participated in this study. Design: Subjects underwent static and dynamic postural stability testing with and without the addition of a cognitive task (Stroop test). Test battery was repeated 10 days later. Dynamic postural stability testing consisted of a forward jump over a hurdle with a 1-legged landing. A stability index was calculated. Static postural stability was also assessed with and without the cognitive task during single-leg balance. Variability of each ground reaction force component was averaged. Main Outcome Measures: Interclass correlation coefficients (ICC2,1) were computed to determine the reliability. Standard error of measure, mean standard error, mean detectable change, and 95% confidence interval were all calculated. Results: Mean differences between sessions were low, with the majority of variables having moderate to excellent reliability (static .583–.877, dynamic .581–.939). The addition of the dual task did not have any significant effect on reliability of the task; however, generally, the ICC values improved (eyes open .583–.770, dual task .741–.808). Conclusions: The addition of a cognitive load to postural stability assessments had moderate to excellent reliability in a healthy population. These results provide initial evidence on the feasibility of dual-task postural stability testing when examining risk of lower-extremity musculoskeletal injury following return to sport in a concussed population.
Steven Nagib and Shelley W. Linens
Clinical Scenario: Every year, millions of people suffer a concussion. A significant portion of these people experience symptoms lasting longer than 10 days and are diagnosed with postconcussion syndrome. Dizziness is the second most reported symptom associated with a concussion and may be a predictor of prolonged recovery. Clinicians are beginning to incorporate vestibular rehabilitation therapy (VRT) in their postconcussion treatment plan, in order to address the dysfunctional inner ear structures that could be causing this dizziness. Focused Clinical Question: Can VRT help postconcussion syndrome patients experiencing prolonged dizziness by improving their perceived disability? Summary of Key Findings: Three studies were included: 1 randomized control trial, 1 retrospective chart review, and 1 exploratory study. The randomized control trial compared cervical spine therapy alone to cervical spine therapy in conjunction with VRT to obtain medical clearance for sport. The chart review explored VRT as a treatment for reducing dizziness and improving balance and gait dysfunction. The exploratory study implemented VRT in conjunction with light aerobic exercise to improve perceived disability associated with dizziness postconcussion. All 3 studies found statistically significant decreases (improvements) in Dizziness Handicap Index scores. Clinical Bottom Line: There is preliminary evidence suggesting that VRT can improve perceived disability in patients with postconcussion syndrome experiencing prolonged dizziness. There is a decrease (improvement) in Dizziness Handicap Index scores across all 3 studies. VRT is a relatively safe treatment option, with no adverse reactions or case reports. Strength of Recommendation: There is level 2 and level 3 evidence supporting the use of VRT to treat patients suffering from dizziness postconcussion.
Eric Schussler, Ryan S. McCann, Nicholas Reilly, Thomas R. Campbell, and Jessica C. Martinez
The effect of subconcussive impacts on balance are not well known. The purpose of this study is to determine the effect of subconcussive impacts on dynamic balance over the course of a rugby season. Significant negative linear correlations were found between total peak linear acceleration and dominant leg (r = −.585, p = .046) and bilateral score (r = −.615, p = .033); also between total impacts over 10g and dominant leg (r = −.653, p = .021), nondominant leg (r = −.687, p = .014), and the combined total (r = −.731, p = .007). Results indicate subconcussive impacts may affect dynamic balance over the course of a competitive season of women’s collegiate rugby.
Nicholas Hattrup, Hannah Gray, Mark Krumholtz, and Tamara C. Valovich McLeod
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.
Tyler A. Wood, Jake M. Tablerion, Randy A. Ballard, Jerrad Zimmerman, and Jacob J. Sosnoff
There is minimal biomechanical research examining head impacts in noncollision sport, such as diving. This pilot study quantified the number of head impacts and magnitude of linear head acceleration in collegiate divers. Three participants wore instrumented swim caps for 10 practice sessions. A total of 1,271 dives were recorded and analyzed. Acceleration at impact ranged from 24.1g to 33.3g for 1-m dives and from 31.6g to 38.4g for 3-m dives. Simple main effects were observed for dive type (p > .001) and dive distance (p > .001). The current data suggest diving athletes experience considerable head acceleration, yet more research is needed to understand the potential implications.
Jeffrey G. Caron, Gordon A. Bloom, and Andrew Bennie
There is a need to improve concussion education and prevention efforts for youth athletes and those responsible for their care. The purpose of this study was to understand Canadian high school coaches’ insights and perceptions of concussions. Using a case study design, eight high school coaches were interviewed and the data were analysed using a hierarchical content analysis. Findings indicated that participants primarily acquired information about concussions through their own experiences as athletes and parents, and from reports in the sports media. The coaches’ felt their role with concussions was to teach athletes safety techniques during practices and competitions and to encourage them to accurately report their concussion symptoms. In addition, participants forwarded a number of recommendations to improve the dissemination of information to coaches. Results from this study will add to a limited body of concussion research with youth sport coaches. Participants’ insights provide researchers and clinicians with information about coaches’ perceived role with sport-related concussions.
Katrina G. Ritter, Matthew J. Hussey, and Tamara C. Valovich McLeod
Clinical Scenario: Patients who experience prolonged concussion symptoms can be diagnosed with postconcussion syndrome (PCS) when those symptoms persist longer than 4 weeks. Aerobic exercise protocols have been shown to be effective in improving physical and mental aspects of health. Emerging research suggests that aerobic exercise may be useful as a treatment for PCS, where exercise allows patients to feel less isolated and more active during the recovery process. Clinical Question: Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies relevant to the clinical question were selected. Of the 4 studies, 1 study was a randomized control trial and 3 studies were case series. All 4 studies investigated aerobic exercise protocol as treatment for PCS. Three studies demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled subsymptomatic aerobic exercise program. One study showed a decrease in symptoms in the aerobic exercise group compared with the full-body stretching group. Clinical Bottom Line: There is moderate evidence to support subsymptomatic aerobic exercise as a treatment of PCS; therefore, it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill test, Balke protocol, or rating of perceived exertion, as mentioned in this critically appraised topic, should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that the aerobic exercise protocol is more effective than the current standard of care in treating PCS.
Christopher P. Tomczyk, George Shaver, and Tamerah N. Hunt
Clinical Scenario: Anxiety is a mental disorder that affects a large portion of the population and may be problematic when evaluating brain injuries such as concussion. The reliance of cognitive testing in concussion protocols call for the examination of potential cognitive alterations commonly seen in athletes with anxiety. Focused Clinical Question: Does anxiety affect neuropsychological assessments in healthy college athletes? Summary of Key Findings: Three studies were included: 1 cross-sectional study and 2 prospective cohort studies. One study examined the effect of a range of psychological issues on concussion baseline testing in college athletes. Another study examined the effect of anxiety on reaction time both before and after sport competition in college-aged athletes. The final study examined the effects of psychosocial issues on reaction time during demanding tasks in college athletes. The first study reported slower simple and complex reaction times in athletes with anxiety. The second study found that athletes with high trait anxiety have slower reaction times both before and after competition. The third study reported that demanding tasks led to increased state anxiety which slowed reaction time. Overall, all 3 studies support the adverse effect anxiety can have on cognitive testing in athletes. Clinical Bottom Line: College athletes who present with anxiety at baseline may be susceptible to decreased performance on neuropsychological assessments. Strength of Recommendation: There is level B evidence that anxiety in healthy college athletes can impact neuropsychological assessments, and level C evidence that anxiety at baseline concussion assessment impacts neuropsychological testing in college athletes.