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Krista M. Hixson, Alex N. Allen, Andrew S. Williams and Tamara C. Valovich McLeod

Clinical Scenario:

Mild traumatic brain injury, or concussion, has been associated with physical, cognitive, and emotional sequelae. Little is understood in regard to many characteristics, such as anxiety, and their effect on post-concussion symptoms.

Clinical Question:

Is state anxiety, trait anxiety, or anxiety sensitivity a clinical predictor of symptoms in those presenting with mild traumatic brain injury or concussion?

Summary of Key Findings:

A literature search returned 3 possible studies; 3 studies met inclusion criteria and included. One study reported in athletes that greater social support was associated with decreased state-anxiety, lower state anxiety post-concussion was associated with increased social support, and that those with greater social support may experience reduced anxiety, regardless of injury type sustained. One study reported baseline trait anxiety in athletes was not significantly associated with post-concussion state anxiety, but that symptoms of depression at baseline was the strongest predictor for post-concussion state anxiety. Three studies reported that state and trait anxiety are not related to increased post-concussion symptom scores. One study reported that greater anxiety sensitivity is related to higher reported post-concussion symptom scores, which may manifest as somatic symptoms following concussion, and revealed that anxiety sensitivity may be a risk factor symptom development.

Clinical Bottom Line:

There is low-level to moderate evidence to support that anxiety sensitivity is linked to post-concussion symptoms. State and trait anxiety do not appear to be related to post-concussion symptoms alone. Post-concussion state anxiety may occur if post-concussion symptoms of depression are present or if baseline symptoms of depression are present. Better social support may improve state anxiety post-concussion.

Strength of Recommendation:

There is grade B evidence to support that state and trait anxiety are not risk factors for post-concussion symptom development. There is grade C evidence to support anxiety sensitivity as a risk factor for developing post-concussion symptoms.

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Lynda M. Mainwaring, Sean M. Bisschop, Robin E.A. Green, Mark Antoniazzi, Paul Comper, Vicki Kristman, Christine Provvidenza and Doug W. Richards

Despite suggestions that emotions influence recovery from injury, there is little research into the emotional sequelae of mild traumatic brain injury (MTBI), or “concussion,” in sport. This examination compares emotional functioning of college athletes with MTBI to that of uninjured teammates and undergraduates. A short version of the Profile of Mood States (POMS; Grove & Prapavessis, 1992) assessed baseline emotions in all groups, and serial emotional functioning in the MTBI and undergraduate groups. Whereas preinjury profiles were similar across groups, the MTBI group showed a significant postinjury spike in depression, confusion, and total mood disturbance that was not seen for the other groups. The elevated mood disturbances subsided within 3 weeks postinjury. Given that concussed athletes were highly motivated to return to play, these data could be used as a benchmark of normal emotional recovery from MTBI. Findings are discussed in relation to current literature on emotional reaction to injury and directions for future research.

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Andrea Cripps and Scott C. Livingston

Clinical Scenario:

A cerebral concussion is a traumatically induced transient disturbance of brain function characterized by a complex pathophysiologic process and is classified as a subset of mild traumatic brain injury. The occurrence of intracranial lesions after sport-related head injury is relatively uncommon, but the possibility of serious intracranial injury (ICI) should be included in the differential diagnosis. ICIs are potentially life threatening and necessitate urgent medical management; therefore, prompt recognition and evaluation are critical to proper medical management. One of the primary objectives of the initial evaluation is to determine if the concussed athlete has an acute traumatic ICI. Athletic trainers must be able promptly recognize clinical signs and symptoms that will enable them to accurately differentiate between a concussion (ie, a closed head injury not associated with significant ICI) and an ICI. The identification of predictors of intracranial lesions is, however, relatively broad.

Focused Clinical Question:

Which clinical examination findings (ie, clinical signs and symptoms) indicate possible intracranial pathology in individuals with acute closed head injuries?

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Eric S. Rawson, Mary P. Miles and D. Enette Larson-Meyer

these compounds could be recommended to athletes. Abbreviations: CFU = colony forming units; DOMS = delayed onset muscle soreness; GIT = gastrointestinal tract; mTBI = mild traumatic brain injury; PCr = phosphorylcreatine; PTH = parathyroid hormone; RDA = recommended dietary allowance; URTI = upper

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Janelle Prince, Eric Schussler and Ryan McCann

that utilized consistent, good-quality patient-rated evidence to drive their results. Search Strategy MeSH Terms Used to Guide Search Strategy • P opulation: athlete or concussion or head injury or brain injury or mild traumatic brain injury • I ntervention: submaximal exercise or submaximal physical

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David R. Howell, Thomas A. Buckley, Brant Berkstresser, Francis Wang and William P. Meehan III

symptoms following mild traumatic brain injury . Appl Neuropsychol Adult . 2016 ; 23 ( 6 ): 426 – 435 . PubMed ID: 27183274 doi:10.1080/23279095.2016.1172229 27183274 10.1080/23279095.2016.1172229 34. Bramley H , Henson A , Lewis MM , Kong L , Stetter C , Silvis M . Sleep disturbance

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John Strickland and Grant Bevill

. Gadd CW . Use of a weighted-impulse criterion for estimating injury hazard . Proceedings of the 10th Stapp Car Crash Conference ; SAE 660793. 1966 . 15. Iwamoto M , Kimpara H . Mild traumatic brain injury predictors based on angular accelerations during impacts . Ann Biomed Eng . 2012 ; 40

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Michael McCrea and Matthew R. Powell

This article reviews the essential components of a practical, evidenced-based approach to the management of sport-related concussion in an ambulatory care setting. The model presented is based on the core philosophy that concussion assessment and management be approached from the biopsychosocial perspective, which recognizes the medical/physiological, psychological, and sociological factors that influence recovery and outcome following concussion. Based on the biopsychosocial paradigm, we outline a care delivery model that emphasizes an interdisciplinary approach in which the clinical neuropsychologist is a key participant. We discuss the importance of nonmedical, psychoeducational interventions introduced during the acute phase to facilitate recovery after sport-related concussion. Finally, using the local experience of our “Concussion Clinic” as a backdrop, we offer two separate case studies that demonstrate the value of this model in evaluating and managing athletes after sport-related concussion. The overall objective of this paper is to provide an adaptable template that neuropsychologists and other healthcare providers can use to improve the overall care of athletes with sport-related concussion and civilians with mild traumatic brain injury.

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Jonathan G. Beckwith, Jeffrey J. Chu and Richard M. Greenwald

Although the epidemiology and mechanics of concussion in sports have been investigated for many years, the biomechanical factors that contribute to mild traumatic brain injury remain unclear because of the difficulties in measuring impact events in the field. The purpose of this study was to validate an instrumented boxing headgear (IBH) that can be used to measure impact severity and location during play. The instrumented boxing headgear data were processed to determine linear and rotational acceleration at the head center of gravity, impact location, and impact severity metrics, such as the Head Injury Criterion (HIC) and Gadd Severity Index (GSI). The instrumented boxing headgear was fitted to a Hybrid III (HIII) head form and impacted with a weighted pendulum to characterize accuracy and repeatability. Fifty-six impacts over 3 speeds and 5 locations were used to simulate blows most commonly observed in boxing. A high correlation between the HIII and instrumented boxing headgear was established for peak linear and rotational acceleration (r 2 = 0.91), HIC (r 2 = 0.88), and GSI (r 2 = 0.89). Mean location error was 9.7 ± 5.2°. Based on this study, the IBH is a valid system for measuring head acceleration and impact location that can be integrated into training and competition.

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Steven Rowson, Jonathan G. Beckwith, Jeffrey J. Chu, Daniel S. Leonard, Richard M. Greenwald and Stefan M. Duma

The high incidence rate of concussions in football provides a unique opportunity to collect biomechanical data to characterize mild traumatic brain injury. The goal of this study was to validate a six degree of freedom (6DOF) measurement device with 12 single-axis accelerometers that uses a novel algorithm to compute linear and angular head accelerations for each axis of the head. The 6DOF device can be integrated into existing football helmets and is capable of wireless data transmission. A football helmet equipped with the 6DOF device was fitted to a Hybrid III head instrumented with a 9 accelerometer array. The helmet was impacted using a pneumatic linear impactor. Hybrid III head accelerations were compared with that of the 6DOF device. For all impacts, peak Hybrid III head accelerations ranged from 24 g to 176 g and 1,506 rad/s2 to 14,431 rad/s2. Average errors for peak linear and angular head acceleration were 1% ± 18% and 3% ± 24%, respectively. The average RMS error of the temporal response for each impact was 12.5 g and 907 rad/s2.