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Carlie K. Elmer and Tamara C. Valovich McLeod

therapy and its effect on symptoms in children and adolescents with diagnosed concussions. Focused Clinical Question Does CBT reduce concussion symptoms among children and adolescents following mild traumatic brain injury? Search Strategy A comprehensive search of PubMed, CINAHL, MEDLINE, SPORTDiscus

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

Traumatic brain injury (TBI) is a public health concern. TBI is common in sports and can be difficult to diagnose. Concussion, a form of mild traumatic brain injury (mTBI), can be defined as “a complex pathophysiological process” 1 in which damage occurs to the brain, causing a wide variety of

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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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Michael W. Kirkwood, David R. Howell, Brian L. Brooks, Julie C. Wilson, and William P. Meehan III

that he has edited that cover TBI-related topics: (1) Mild Traumatic Brain Injury in Children and Adolescents, (2)  Validity Testing in Child and Adolescent Assessment, and (3)  Neuropsychology Study Guide & Board Review (First and Second Editions) . Dr D.R.H. has received research support from the

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Gary B. Wilkerson, Dustin C. Nabhan, and Ryan T. Crane

slows processing of neural signals, which may result from either mild traumatic brain injury 1 or loss of proprioceptive afference following musculoskeletal injury. 2 Detection of subtle impairment of neural processing capabilities currently relies on advanced neuroimaging and electrophysiological

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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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Shawn R. Eagle, Patrick J. Sparto, Cynthia L. Holland, Abdulaziz A. Alkathiry, Nicholas A. Blaney, Hannah B. Bitzer, Michael W. Collins, Joseph M. Furman, and Anthony P. Kontos

concussion . J Head Trauma Rehabil . 2016 ; 31 ( 4 ): 262 – 268 . 10.1097/HTR.0000000000000176 15. Cossette I , Ouellet M-C , McFadyen BJ . A preliminary study to identify locomotor-cognitive dual tasks that reveal persistent executive dysfunction after mild traumatic brain injury . Arch Phys Med