Concussion Treatment Research Articles

A THREE DIMENSIONAL NEURO-CBT MODEL FOR MILD-MODERATE BRAIN INJURY

Objective(i) To introduce a Neuro-Cognitive-Behavioural assessment framework and formulation model to guide the treatment of concussion, mild-moderate brain injury. (ii) To present the potential of these as automated, interactive computerised...

Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes?

The current treatment of concussion or mild traumatic brain injury (mTBI) is primarily based on expert consensus. Most clinical practice guidelines advise cognitive and physical rest after injury including withdrawal from normal life activities such as school attendance, sports participation, and technology use until symptoms resolve. Some individuals who sustain an mTBI experience persistent physical, cognitive, and mental health problems. Activity restriction itself may contribute to protracted recovery and other complications. Williamson's Activity Restriction Model of Depression, formulated more than 20 years ago, is central to this hypothesis. We review research evidence for potential harms of prolonged activity restriction and report an mTBI case as an example of how an "activity restriction cascade" can unfold. According to this model, psychological consequences of removal from validating life activities, combined with physical deconditioning, contribute to the development and persistence of postconcussive symptoms after mTBI in some youth. A modification to mTBI guidelines that emphasizes prompt reengagement in life activities as tolerated is encouraged.

Welcome to the June 2015 Issue of the IJTMB

This issue of the IJTMB offers two articles, a research article describing a survey of the massage profession in Australia, and a practice article of a case study of massage for mild traumatic brain injury/concussion. The first article provides a snapshot of the state of a profession in a given area in a given time—who is practicing, their education and income levels, and the stability of the population. I have been reading profession-level survey reports and articles since 2000, and believe the information in them to be critical to the profession from several perspectives. Comparison between locales and data shifts over time shows effects on the profession resulting from regulation and differences or changes in standards, and in population beliefs about the value of the profession. In addition to assessing common practitioner descriptors, authors of this article also focus on the integration of research into the profession. Their reflections on whether active interest in research is one determinant of successful practice or a proxy representing the practitioner’s overall professionalism captures an intriguing concept that has a number of implications for the development of the profession, and leaves us to wonder if practice success would be changed by increasing access to—and interest in— research. I hope more studies about the state of the profession include questions like these. I would like to see a global comparative study like this: How do local education, integration of research into practice, and health care integration relate to and affect the use, accessibility, and practice of massage? Sylvia Burns’ article on concussion treatment shows the importance of both training and experience on successful outcomes. Critically, massage is likely not the first line of treatment that would be considered for concussion, and some etiologies of concussion complications or damage would not be prime candidates for massage. The outcomes of this case study strongly indicate that, for some instances, massage is exactly the right intervention. I would like to see more studies of this nature, and an increased focus, likely from a composite view of multiple case studies and expert experience, on how one might identify likely responders to massage for concussion. Taking advantage of opportunities, such as the American Academy of Neuroscience call as recommended in the article, is an excellent way to start focus on the next stage of work. Finally, I would like to thank the volunteers who contribute to the success of this Journal: our Manuscript Review Board and the International Advisory Council. The Manuscript Review Board comprises the many people who register as researchers or content experts to provide feedback on submitted articles— a critical way of developing rigor in published researched. A journal such as the IJTMB requires a large pool of reviewers who are able to occasionally jump in for an intense few hours of work. If you believe your research or clinical experience may be of value for reviewing articles, please send me an email introducing yourself and your interest in reviewing for the Journal. Enjoy this issue of the IJTMB. Antony Porcino, PhD, HSI Executive Editor, IJTMB.

Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis.

Concussion literature and treatment guidelines are inconclusive regarding the role of sex in symptom reporting at baseline and post-concussion. Although empirical evidence is lacking, it is generally regarded that females have a more severe symptomatic presentation than males at all time-points on the concussion spectrum. Our objective was to determine whether differences exist between males and females at baseline (pre-season/before concussion) or post-concussion for self-reported (1) prevalence of individual symptoms and (2) total symptom scores in high school and college athletes. Systematic review and meta-analysis of observational cohort studies; level of evidence, 1. A computerized search of the PubMed, SPORTDiscus, CINAHL, and Scopus databases was performed. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Criteria for inclusion were (1) self-report of symptoms at any time within the concussion spectrum, including baseline and after concussion, (2) study sample included high school and/or collegiate athletes aged 12-26 years, (3) concussions occurred during participation in sport, and (4) symptom reporting was separated by sex. The Quality Assessment Tool for Cohort Studies, Q-Coh, was utilized for quality assessment. Twenty-one studies met the criteria for inclusion: seventeen had good quality and four, acceptable quality. At baseline, females had significantly higher odds than males of reporting the individual symptoms of vision/hearing problems, headache/migraine, difficulty concentrating, energy/sleep disturbances, and emotional disturbances. Post-concussion, only one symptom demonstrated significant differences between males and females, with females demonstrating lower odds of reporting confusion than males. Statistically, at baseline and post-concussion, females had significantly higher total symptom scores on the Post-Concussion Scale (PCS) and the Sport Concussion Assessment Tool 2 (SCAT2), but when the standard mean difference was interpreted after back-transformation, these results were clinically insignificant. The symptomatic presentation of males and females, most notably the prevalence of specific symptoms, is very divergent. Females had higher total symptom scores at baseline and post-concussion, however, clinically this cannot be interpreted as a meaningful difference. It is possible that these differences can be explained by normal hormonal changes associated with the menstrual cycle. The implications of these findings are that symptomatic presentation during an individual female's menstrual cycle needs to be taken into consideration post-concussion when making return-to-play decisions, as returning to a completely asymptomatic level may not be a reasonable expectation.

Facial Injury - Men’s Soccer

HISTORY: 19 year old healthy college soccer player who came to came to the sideline with head pain, pressure behind his left eye after being elbowed in the left forehead. He complained of nausea, tiredness, fogginess. He denied loss of consciousness. He mentioned to the coach, “It feels like I have a dent in my head.” He described pain behind left eye with lateral gaze. As sideline evaluation continued, he began having hematemesis. PHYSICAL EXAMINATION: Gen: Slightly dazed appearing, answering slowly but appropriately, no decreased level of consciousness. HEENT: L forehead with sulcus, painful to palpation, just over eyebrow. PERRL, EOMI but pain with leftward lateral gaze. Gross visual acuity and visual fields intact. Nares without trauma or bleeding. Oropharynx clear. TMs clear. Neck: Full ROM, no midline tenderness to palpation. DIFFERENTIAL DIAGNOSIS: 1. Facial fracture 2. Intracranial bleed 3. Ocular injury 4. Concussion 5. Facial contusion TESTS AND RESULTS: Non-contrast CT head: Mildly displaced left frontal sinus fractures associated with soft tissue swelling. Non-displaced fracture extending through the roof of the left orbit associated with some intraorbital gas. No acute intracranial abnormality. FINAL WORKING DIAGNOSIS: 1. Depressed Frontal Sinus Fracture 2. Superior Orbital Fracture 3. Concussion TREATMENT AND OUTCOMES: 1. Placed on prophylactic antibiotics, referred to ENT for surgical management 2. Open reduction and internal fixation of fracture 3. Concussion management including return to cardiovascular exercise at two weeks when cleared by surgeon for this activity 4. Expected return to contact sports at 3 months (+/- mask)

Quantitative Assessment Of Parental Knowledge And Attitudes Toward Pediatric Sports-related Concussions

PURPOSE: Sports-related concussions are a growing concern in youth sports. Parents of young athletes play a major role in both identifying concussive symptoms and managing at-home recovery, but they are often unaware of the consequences of concussions and recommended management techniques. This study assessed the knowledge and attitudes toward sports-related concussions among parents living in Los Angeles, California. We expected to identify significant gaps in parental knowledge and characterize parent populations most in need of concussion-related education. We predicted that knowledge and attitudes would be better among parents with increased educational attainment and prior sports- and concussion-related experience. METHODS: Participants included parents and caregivers of children brought to Children’s Hospital Los Angeles and its four satellite clinics for evaluation of musculoskeletal or mild traumatic brain injuries. Participants completed a validated questionnaire that measured knowledge of concussion symptoms as well as attitudes regarding medical diagnosis and post-concussion sports participation. The survey also assessed previous sports- and concussion-related experience. RESULTS: 214 parents and caregivers were surveyed over an 8-month period. Participants scored an average of 18.4 (maximum=25) on the Concussion Knowledge Index and 63.1 (maximum=75) on the Concussion Attitude Index. Attitudes were significantly safer among Caucasian females, and knowledge increased with household income and education level. Previous experience playing sports did not affect knowledge or attitudes, but parents who reported suffering from an undiagnosed concussion during childhood had significantly better concussion knowledge than those who did not. CONCLUSION: The present study is the first to comprehensively examine parent knowledge and attitudes toward concussions using a validated assessment tool. Results suggest that parents with low income and education levels may benefit from additional concussion-related education. Ongoing efforts to understand parental knowledge and attitudes will inform the development of a strategic and tailored approach to the prevention and treatment of pediatric concussions.

Concussion in Sport: Conceptual and Ethical Issues

The issue of concussion in sport is a matter of global public interest that is currently under dispute by educational, legal, and medical professionals and scientists. In this article we discuss the problem from philosophical, bioethical, and sports ethical perspectives. We articulate conceptual differences in approaches to definition and therefore diagnosis of concussion. We critically review similarities and differences in the leading consensus statements that guide the treatment of concussion diagnosis and treatment in sports. We then present a series of ethical problems including issues that relate to paternalistic intervention in the lives of athletes in order to prevent harm to athletes, conflicting and competing interests, and confidentiality.

Take steps to protect against concussion liability beyond athletics

Lawsuits and media coverage have brought greater attention to concussion prevention and treatment in contact sports. But not all concussions occur in competitive sports. And the proper response plan, regardless of how the concussion occurred, can extend to the classroom.

Concussion and football: a review and editorial.

The issue of concussion in football is of substantial interest to players, coaches, fans, and physicians. In this article, we review specific cultural hindrances to diagnosis and treatment of concussion in football. We review current trends in management and identify areas for improvement. We also discuss the obligations that physicians, particularly neurosurgeons and neurologists, have toward brain-injured football players and the larger societal role they may play in helping to minimize football-associated brain injury.

Injury-related predictors of symptom severity following sports-related concussion

Introduction: Decisions regarding return to play after sports-related concussion partially revolve around athletes’ self-reported symptoms. Given this emphasis on symptoms, it would be beneficial to be able to identify characteristics that could predict which athletes may be susceptible to developing an increase in postconcussion symptoms following head injury. The purpose of this study was to describe the symptoms that athletes endorse immediately following concussion and to determine what impact injury-related characteristics have on the development of postconcussion symptoms within the first week following concussion. Method: Participants included 54 collegiate athletes who sustained concussions and were referred to our concussion management program for postconcussion testing. The main outcome measures included the Post-Concussion Symptom Scale and an interview querying athletes’ retrospective symptoms over time, starting immediately postinjury. Results: Descriptive statistics revealed that the most common immediate symptoms following concussion include dizziness (endorsed by 83.6% of the sample), headache (65.5%), feeling in a fog (61.8%), and visual disturbance (60.0%). Logistic regression analyses indicated that retrograde and anterograde amnesia, as well as loss of consciousness, were not significantly predictive of postconcussion symptoms within one week following concussion (p > .05). However, the total symptom score assessed immediately postinjury, in addition to endorsing immediate headache symptoms following concussion, reliably predicted a higher level of symptom reporting in the first week following concussion (p < .05). Finally, receiver-operating characteristic (ROC) curve analysis, using 80% sensitivity to predict the high postconcussion symptom group, established cutoff scores of 7.5 for the immediate total symptom score and 0.5 for immediate headache. Conclusions: These findings demonstrate the importance of evaluating symptoms immediately following concussion. Athletes who endorse more immediate postconcussion symptoms, especially headache symptoms, may be at risk for greater and more severe postconcussion symptoms within the first week following concussion. The present findings have implications for the management and treatment of sports-related concussions.

The Utilization of Biomechanics to Understand and Manage the Acute and Long-term Effects of Concussion

The acute and long-term effects of concussive and subconcussive head impacts on brain health have gained tremendous attention over the past five years. The treatment and management of concussion involves multiple providers from multiple disciplines and backgrounds. Varied backgrounds and approaches to assessing cognitive and motor function before and post-concussion are limiting factors in the efficient and effective management of concussion as discipline-specific rating scales and assessments serve as a barrier to effective patient hand-offs between providers. Combining principles of motor behavior with biomechanical approaches to data analysis has the potential to improve the continuity of care across the multiple providers managing athletes with concussion. Biomechanical measures have been developed and validated using mobile devices to provide objective and quantitative assessments of information processing, working memory, set switching, and postural stability. These biomechanical outcomes are integral to a clinical management algorithm, the Concussion Care Path, currently used across the Cleveland Clinic Health System. The objective outcomes provide a common data set that all providers in the spectrum of care can access which facilitates communication and the practice of medicine and in understanding the acute and long-term effects of concussion and subconcussive exposure on neurological function.

Chapter 4 - The neuropathology of traumatic brain injury

Traumatic brain injury, a leading cause of mortality and morbidity, is divided into three grades of severity: mild, moderate, and severe, based on the Glasgow Coma Scale, the loss of consciousness, and the development of post-traumatic amnesia. Although mild traumatic brain injury, including concussion and subconcussion, is by far the most common, it is also the most difficult to diagnose and the least well understood. Proper recognition, management, and treatment of acute concussion and mild traumatic brain injury are the fundamentals of an emerging clinical discipline. It is also becoming increasingly clear that some mild traumatic brain injuries have persistent, and sometimes progressive, long-term debilitating effects. Evidence indicates that a single traumatic brain injury can precipitate or accelerate multiple age-related neurodegenerations, increase the risk of developing Alzheimer's disease, Parkinson's disease, and motor neuron disease, and that repetitive mild traumatic brain injuries can provoke the development of a tauopathy, chronic traumatic encephalopathy. Clinically, chronic traumatic encephalopathy is associated with behavioral changes, executive dysfunction, memory loss, and cognitive impairments that begin insidiously and progress slowly over decades. Pathologically, chronic traumatic encephalopathy produces atrophy of the frontal and temporal lobes, thalamus, and hypothalamus, septal abnormalities, and abnormal deposits of hyperphosphorylated tau (τ) as neurofibrillary tangles and disordered neurites throughout the brain. The incidence and prevalence of chronic traumatic encephalopathy and the genetic risk factors critical to its development are currently unknown. Chronic traumatic encephalopathy frequently occurs as a sole diagnosis, but may be associated with other neurodegenerative disorders, including Alzheimer's disease, Lewy body disease, and motor neuron disease. Currently, chronic traumatic encephalopathy can be diagnosed only at autopsy; however, promising efforts to develop imaging, spinal fluid, and peripheral blood biomarkers are underway to diagnose and monitor the course of disease in living subjects.

Premorbid predictors of postconcussion symptoms in collegiate athletes

Introduction: In recent years, the sports community has been faced with the challenge of determining when it is safe to return concussed athletes to play. Given that return-to-play decisions are partially dependent upon athletes’ endorsement of symptoms, better understanding what factors contribute to the presence of symptoms following concussion is crucial. The purpose of the present study was to better characterize the symptoms that athletes endorse at baseline and to determine what impact various premorbid (or preinjury) characteristics have on the presence and severity of postconcussion symptoms in the acute injury period following concussion. Method: Two groups of participants with similar ages and levels of education were examined: athletes at baseline (N = 702) and postconcussion (N = 55). Athletes were administered a comprehensive battery of neuropsychological tests, consisting of neurocognitive and neurobehavioral measures, at both time periods. The main outcome measure was the Post-Concussion Symptoms Scale (PCSS). A factor analysis was conducted on the participants’ baseline PCSS data to determine the factor structure of the PCSS, and separate logistic regression analyses were conducted that examined the baseline PCSS symptom clusters (derived from the factor analysis), demographic variables, and baseline neurocognitive variables as predictors of dichotomized postconcussion PCSS total scores (i.e., low versus high symptom reporting following concussion). Results: Four distinct clusters emerged from the factor analysis measuring cognitive, physical, affective, and sleep symptoms. Logistic regression results indicated that the physical and affective symptom clusters at baseline reliably predicted athletes’ postconcussion symptom group, as did sex and the neurocognitive composite score. Conclusions: These findings show that certain baseline characteristics of athletes confer risk for greater symptomatology postconcussion. Knowledge of these risk factors can assist the management and treatment of sports-related concussion.

In search of evidence-based treatment for concussion: characteristics of current clinical trials

Objective: To assess the characteristics of current clinical trials investigating the treatment of concussion.Background: Recent systematic literature reviews have concluded that there is minimal evidence to support any specific treatment for concussion, including the principles of return-to-activity protocols such as type or duration of rest.Design/methods: Clinical trial data was extracted from Clinicaltrials.gov and seven additional World Health Organization primary registries. The trial databases were accessed up until 3 October 2013. This study used search terms of ‘concussion’ or ‘mild traumatic brain injury’ (mTBI) and filtered for interventional trials. Trials that were terminated, already published or not interventional trials of concussion/mTBI were excluded.Results: Of the 142 concussion/mTBI interventional clinical trials identified, 71 met inclusion criteria. Trials had a median estimated enrolment of 60 participants. There was a wide-range of treatments studied, including cognitive/behavioural therapies (28.2%), medications (28.2%), devices (11.3%), dietary supplements (8.5%), return-to-activity/rest (1.4%) and others (22.4%). Heterogeneity among trials for concussion identification/diagnosis and primary outcomes utilized was evident. Symptom-based questionnaires (39.4%) and neuropsychological tests (28.2%) were the most common outcome measures.Conclusions: Diverse, potentially promising therapeutics are currently being studied for the treatment of concussion. However, several deficiencies were identified including a paucity of trials addressing return-to-activity principles. Also, small sample size and trial heterogeneity may threaten scientific evaluation and subsequent clinical application.

Concussion treatment after combat trauma: Development of a telephone based, problem solving intervention for service members

Military service members (SMs) and veterans who sustain mild traumatic brain injuries (mTBI) during combat deployments often have co-morbid conditions but are reluctant to seek out therapy in medical or mental health settings. Efficacious methods of intervention that are patient-centered and adaptable to a mobile and often difficult-to-reach population would be useful in improving quality of life. This article describes a new protocol developed as part of a randomized clinical trial of a telephone-mediated program for SMs with mTBI. The 12-session program combines problem solving training (PST) with embedded modules targeting depression, anxiety, insomnia, and headache. The rationale and development of this behavioral intervention for implementation with persons with multiple co-morbidities is described along with the proposed analysis of results. In particular, we provide details regarding the creation of a treatment that is manualized yet flexible enough to address a wide variety of problems and symptoms within a standard framework. The methods involved in enrolling and retaining an often hard-to-study population are also highlighted.

Utility of a sports medicine model in military combat concussion and musculoskeletal restoration care.

Combat-related concussions are significant sources of injury and morbidity among deployed military service members. Musculoskeletal injury also is one of the most prevalent battle and nonbattle-related deployed injury types. Both injuries threaten the service member's physical condition as well as unit and mission readiness due to reduced duty status or evacuation from military theater of operations. In August 2010, the Concussion Restoration Care Center (CRCC) was established at Camp Leatherneck, Afghanistan, to address the need for consistent and specialized evaluation and care of concussion and musculoskeletal injury. This performance improvement effort examined evaluation and treatment of concussion and musculoskeletal injury at the CRCC. Among 4,947 military personnel evaluated at the CRCC between August 2010 and May 2013, 97.9% were returned to duty and retained in theater. Members averaged 10 to 12 days of limited duty status to achieve complete recovery. Concussion injury was secondary to blast injury in 90% of cases. Sport/recreation, occupational, and other accidental injuries each represented 30% of the musculoskeletal injuries with only 10% reported as result of combat. The utilization patterns and outcome measures demonstrate the success and utility of a multidisciplinary clinical model of care for these two types of injuries in the far-forward deployed setting.

Protracted recovery from a concussion: a focus on gender and treatment interventions in an adolescent population.

Background:Several studies have demonstrated that age and sex may influence concussion recovery time frames, with female athletes and adolescents being potentially more susceptible to a protracted recovery course. Currently, limited work has examined the influence sex may have on concussion management strategies and treatment interventions, especially for younger individuals suffering persistent concussion symptoms and cognitive dysfunctions.Hypothesis:Female athletes are prescribed more treatment interventions than male athletes during a protracted recovery from a concussion.Study Design:Descriptive epidemiology study.Level of Evidence:Level 4.Methods:Data were retrospectively collected for adolescent athletes presenting to a sports medicine concussion clinic between September 2010 and September 2011.Results:A total of 266 adolescent athletes were evaluated and treated for concussion. Female athletes had a longer recovery course (P = 0.002) and required more treatment interventions (P < 0.001) for their symptoms and dysfunction. Female athletes were more likely to require academic accommodations (P < 0.001), vestibular therapy (P < 0.001), or medication (P < 0.001).Conclusion:Medical providers should be aware that during the recovery course, adolescent female athletes may require a management plan that will most likely include additional treatment interventions beyond the standard cognitive and physical rest.Clinical Relevance:Treatment interventions are more commonly prescribed for adolescent female athletes than for adolescent male athletes during a protracted recovery from a concussion. This highlights the need for identifying evidence-based clinical management guidelines that focus on sex, especially when dealing with persistent concussion symptoms and cognitive dysfunctions.

Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment

Primary objective: To present a novel pathophysiological approach to acute concussion and post-concussion syndrome (PCS).Research design: Review of the literatureMethods and procedures: PubMed searches were performed to identify articles related to the pathophysiology and treatment of concussion and PCS. Relevant articles that contributed to the primary objective of the paper were included.Main outcome and results: This paper presents an evidence-based approach to acute concussion and PCS that focuses on the identification of specific post-concussion disorders (PCDs) caused by impairments in global brain metabolism (Physiologic PCD) or neurological sub-system dysfunction (Vestibulo-ocular PCD and Cervicogenic PCD) that can be distinguished by features of the clinical history, physical examination and treadmill exercise testing. This novel approach also allows for the initiation of evidence-based, multi-disciplinary therapeutic interventions that can improve individual symptoms and promote efficient neurological recovery.Conclusion: Future studies incorporating neuro-imaging and exercise science techniques are underway at the author’s institutions to validate this novel pathophysiological approach to acute concussion and PCS.

Examining prescribed rest as treatment for adolescents who are slow to recover from concussion

Objective: Rest is a widely recommended treatment for concussion, but its utility is unclear following the acute stage of recovery. This study examined the effects of 1-week of prescribed rest in concussed adolescent athletes.Method: Participants were 13 adolescent athletes with persistent symptoms following a concussion. More than three-quarters (77%) had self-reported ADHD, learning disability or two prior concussions. All completed ImPACT® at another facility, but none completed a period of comprehensive rest prior to examination at a specialty practice. Three time points of test data were compared, to control for possible spontaneous recovery: Test 1 (external facility), Test 2 (before prescribed rest) and Test 3 (following prescribed rest).Results: Repeated measures ANOVAs revealed a significant effect of prescribed rest on all ImPACT® composite scores and the total symptom score. Post-hoc analyses revealed no significant differences between Time 1 and Time 2, whereas significant differences were present after prescribed rest. Following prescribed rest, having two or more reliably improved cognitive test scores or having improved symptoms was present in eight of the 13 patients (61.5%).Conclusions: A substantial percentage of adolescents with persistent symptoms following concussion showed improvement in symptoms and cognitive functioning following education, reassurance and 1-week of prescribed rest.

The history of neurosurgical treatment of sports concussion.

Concussion has a long and interesting history spanning at least the 5 millennia of written medical record and closely mirrors the development of surgery and neurosurgery. Not surprisingly, much of the past and present experimental head injury and concussion work has been performed within neurosurgically driven laboratories or by several surgically oriented neurologists. This historical review chronicles the key aspects of neurosurgical involvement in sports concussion as related to the diagnosis, treatment, mitigation, and prevention of injury using the example of American football. In addition, we briefly trace the developments that led to our current understanding of the biomechanical and neurophysiological basis of concussion.