Concussion Treatment Research Articles

Concussions in Ice Hockey - Moving Toward Objective Diagnoses and Point-of-care Treatment: A Review.

The incidence of sport-related concussion coupled with a doubling of the participation rate in youth hockey over the past two decades provides impetus for the review of the most promising concussion treatment options. This narrative review summarizes the future treatment options for sport-related concussions in ice hockey, while acknowledging their generalizability to concussion in all sports. Symptom assessment, sign observation, as well as cognitive and balance testing, have historically been used to diagnose a concussion. These methods continue to improve, but the need for effective treatments is clear. Pharmacologic, transcranial light, and nutritional supplement treatment options for concussion warranting further investigation have been identified. Dimethyl fumarate is an immunomodulatory compound thought to trigger antioxidant gene expression. Memantine reduces apoptosis and astrogliosis by inhibiting the calcium influx into cells normally caused by glutamate's activation of N-methyl-D-aspartate receptors. Thioredoxin-mimetic peptides and transcranial photobiomodulation temper the effects of the energy crisis by acting as free radical scavengers. In addition, seven neuroprotective nutritional supplements have been identified: berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins. An estimated US $1.1 billion has been spent on unsuccessful traumatic brain injury clinical trials. As our ability to accurately diagnose concussion improves, dimethyl fumarate, memantine, thioredoxin-mimetic peptides, transcranial photobiomodulation, and nutritional supplements (berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins) warrant further preclinical and clinical examination in advancing the treatment of sport-related concussions.

Management and Treatment of Concussions via Tele-Concussion in a Pediatric Setting: Methodological Approach and Descriptive Analysis.

BackgroundApproximately 2 million children in the United States sustain a concussion annually, resulting in an economic impact as high as US $20 billion. Patients who receive treatment at concussion specialty clinics, versus primary care, experience faster recovery, thereby reducing patient burden and subsequent medical-related costs. Accessibility to specialty clinics is typically limited by the availability of in-office visits. This is particularly relevant in light of the severe acute respiratory syndrome coronavirus 2 pandemic and subsequent guidance to eliminate all non–medically necessary in-clinic visits. Telehealth has been used to effectively deliver in-clinic care across several disciplines including psychiatry, psychology, and neuropsychology. However, a model of telehealth delivered concussion assessment, treatment, and management has not been established.ObjectiveThe purposes of this paper are to describe a pediatric concussion specialty clinic’s experiences in delivering telehealth concussion services and to provide preliminary descriptive data on a sample of pediatric telehealth patients with concussions.MethodsThe specialty pediatric concussion clinic described here began providing telehealth services in 2019 and is part of the largest and fastest-growing telehealth hospital network in the United States. The clinical care process will be described, including accessing the telehealth platform, assessment during the initial appointment, injury management including communication with relevant patient stakeholders (eg, parent or guardians, athletic trainers), dissemination of rehabilitation exercises, and nature of follow-up visits. Descriptive data will include patient demographics, the radius of care, the time between the date of injury and initial visit, the average number of follow-up visits, and days until medically cleared for return-to-learn and return-to-play.ResultsThe analytic sample included 18 patients with concussions who were seen for all of their visits via telehealth between August 2019 and April 2020. The mean age of the sample was 14.5 (SD 2.5) years. The radius of care was a median of 17 (IQR 11.0-31.0) miles from the clinic with a median time between injury and the first visit of 21 (IQR 6.0-41.5) days. The mean number of visits was 2.2 (SD 0.8) with a median days between visits of 5.4 (IQR 3.0-9.3) to manage and treat the concussion. Of the 18 patients, 55.6% (n=10) were medically cleared for return-to-learn or -play in a median of 15.5 (IQR 11.0-29.0) days.ConclusionsLimited access to health care is a well-understood barrier for receiving quality care. Subsequently, there are increasing demands for flexibility in delivering concussion services remotely and in-clinic. This is the first paper to provide a clinically relevant framework for the assessment, management, and treatment of acute concussion via telehealth in a pediatric population.

A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents.

Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline. We used a randomized cohort study involving patients aged 12-18 who presented within 48h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1h, 48h, and 120h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally. Our data shows that there was a statistically significant decrease in the PCSS at 48h (p=0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely. Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

Utilizing the Biopsychosocial Model in Concussion Treatment: Post-Traumatic Headache and beyond.

To discuss recent literature concerning the application of the biopsychosocial model in the management of concussion and post-concussion headache. Current research suggests that the biopsychosocial model is applicable to the concussion management process, particularly management of post-concussion headache. Such application is best illustrated by current active treatment strategies such as exercise, multifaceted rehabilitation, and psychosocial interventions targeting improved patient outcomes. Overall, the biopsychosocial model has significant applications to the management of concussion, particularly post-concussion headache. Presentation and recovery following concussion and post-traumatic headache is multifaceted and includes the continuum of biological, psychological, and social considerations. In order to fully understand the widespread clinical utility and application of such models, there is a continued need for researcher, practitioner, and patient integration and collaboration to determine the most effective assessment and treatment strategies.

A-04 One Size Fits None: Neurobiologic-Specific Modifications For The Assessment, Diagnosis, and Treatment of Sport-Related Concussion

Abstract Objective The primary objective of this review paper is to introduce the underlying neurobiology of concussion symptoms, including relevant neuroanatomy, and to discuss these findings relative to the traditional homogenous model and a newer clinical profile model for sport-related concussion (SRC) assessment, conceptualization, and treatment. Method Empirical studies, meta-analyses, and consensus statements relevant to the assessment, conceptualization, and treatment of SRC were identified via systematic, but informal, procedures. This literature review focused on papers discussing the neuroanatomy and neurobiology of concussion symptoms and sequelae, as well as the exploration of new clinical treatment models for SRC. Results Exploration of the literature further supports the use of a clinical profiles-based SRC assessment and treatment protocol. Comparisons of traditional and new protocols show that a traditional assessment, conceptualization, and treatment model of SRC as a homogenous injury inadequately captures the individual injury experience and recovery trajectory. Conclusions This review confirms existing literature that the clinical profiles-based model best addresses the heterogeneous nature of sport-related concussion using a neurobiological and neuroanatomical approach to understanding SRC. Utilizing this model, clinicians can provide an individualized assessment, conceptualization, and treatment plan for SRC, leading to an improved clinical experience for athletes and better clinical outcomes.

A-36 Understanding Parental Knowledge of and Attitudes towards Youth Sport-Related Concussion

Abstract Objective The study objective was to examine parental knowledge of, and attitudes towards, youth sport-related concussion in a Canadian sample. Method A community sample of seventy-six families (n = 120 children) completed the study questionnaire comprised of demographic and sport history information, as well as questions about concussion knowledge (factual and perceived) and attitudes (i.e. concussion management and treatment attitudes). All participants had children actively involved in sport. Predominantly mothers completed the questionnaire (74%), and families ranged from one-to-three children (M age = 9 yr 5mth, SD = 2 yr 11mth). Results On average, parents achieved 76% accuracy on factual concussion knowledge (M = 21.19, SD = 2.55), with the majority (75%) perceiving their responses as accurate (perceived knowledge). Most parents displayed a favourable attitude toward concussion reporting and management (54/63; 85.7%). Families with low social risk status (SRS) had higher perceived knowledge compared to families with high SRS (t(60) = 2.29, p = .026), but not actual knowledge (p = .87). Mixed linear regression models were used to examine relationships between sociodemographic factors and concussion knowledge and attitudes. Higher SRS (F(1,74) = 9.60, p = .003) was related to lower perceived knowledge. Conclusions Families with higher SRS had less confidence in their youth sport-related concussion knowledge despite having accurate knowledge. Understanding sociodemographic factors associated with concussion attitudes and knowledge is an important first step for informing policies and keeping youth active in sports.

A-39 Vestibular And Ocular Motor Symptoms And Impairment Associated With Post-Concussion Anxiety

Abstract Objective The purpose of this study was to examine the relationship between vestibular and ocular motor symptoms, impairment and anxiety following sport-related concussion (SRC). Immediate post-injury assessments are predictive of symptoms and are prognostic for prolonged recovery. Although concussion is associated with increased likelihood of developing mental health issues, the relationship between post-concussion vestibular symptoms, impairment and anxiety is unknown. Method This study represented a sub-analysis of a randomized control-trial (RCT), conducted on a sample of 50 participants (40% male), aged 13–18 ([M] = 15.38, [SD] = 2.05) years within 7–21 days of a SRC between October 2018 and January 2020. Participants completed the Vestibular/Ocular Motor Screening (VOMS) and General Anxiety Disorder 7 (GAD-7) at initial visit, and 2 and 4 week follow-ups. Patients were categorized using GAD-7 scores as having mild, moderate or severe anxiety. Results Numerous positive correlations ranging from .28 to .52 among VOMS and GAD-7 scores were supported. The severe (99.6, 26.6) anxiety group scored highest on total VOMS followed by the moderate (76.5, 30.1), and mild (63.1, 45.9) anxiety groups (p = .006). Results of logistic regression indicated that total VOMS score was a significant predictor of GAD-7 generalized anxiety score (R = .389, r2 = .151 p = .001). Conclusions Higher scores on VOMS were associated with higher post-injury anxiety. Participants with higher VOMS scores following SRC may be at increased risk for developing anxiety symptoms. The current findings can help clinicians target concussion treatment to each specific patient based on their VOMS and GAD-7 scores in combination, rather than in isolation.

Sex‐Related Differences in the Effects of Sports‐Related Concussion: A Review

Sports-related concussion is a serious health challenge, and females are at higher risk of sustaining a sports-related concussion compared to males. Although there are many studies that investigate outcomes following concussion, females remain an understudied population, despite representing a large proportion of the organized sports community. In this review, we provide a summary of studies that investigate sex-related differences in outcome following sports-related concussion. Moreover, we provide an introduction to the methods used to study sex-related differences after sports-related concussion, including common clinical and cognitive measures, neuroimaging techniques, as well as biomarkers. A literature search inclusive of articles published to March 2020 was performed using PubMed. The studies were reviewed and discussed with regard to the methods used. Findings from these studies remain mixed with regard to the effect of sex on clinical symptoms, concussion-related alterations in brain structure and function, and recovery trajectories. Nonetheless, there is initial evidence to suggest that sex-related differences following concussion are important to consider in efforts to develop objective biomarkers for the diagnosis and prognosis of concussion. Additional studies on this topic are, however, clearly needed to improve our understanding of sex-related differences following concussion, as well as to understand their neurobiological underpinnings. Such studies will help pave the way toward more personalized clinical management and treatment of sports-related concussion.

Early Aerobic Exercise for the Treatment of Acute Pediatric Concussions

Sport-related concussion is a common injury that has garnered the attention of the media and general public because of the potential for prolonged acute symptoms and increased risk for long-term impairment. Currently, a growing body of evidence supports the use of various therapies to improve recovery after a concussion. A contemporary approach to managing concussion symptoms is to use aerobic exercise as treatment. To date, several studies on both pediatric and adult patients have established that controlled aerobic exercise is a safe and effective way to rehabilitate patients experiencing delayed recovery after concussion. However, less is known about the utility of an early exercise protocol for optimizing recovery after acute concussion and reducing the risk for persistent postconcussive symptoms, particularly in pediatric populations. Thus, the purpose of our paper was to review and evaluate the available literature on the implementation of aerobic exercise for the treatment of acute pediatric concussion.

Serum SNTF, a Surrogate Marker of Axonal Injury, Is Prognostic for Lasting Brain Dysfunction in Mild TBI Treated in the Emergency Department.

Mild traumatic brain injury (mTBI) causes persisting post-concussion syndrome for many patients without abnormalities on conventional neuroimaging. Currently, there is no method for identifying at-risk cases at an early stage for directing concussion management and treatment. SNTF is a calpain-derived N-terminal proteolytic fragment of spectrin (αII-spectrin1-1176) generated in damaged axons following mTBI. Preliminary human studies suggest that elevated blood SNTF on the day of mTBI correlates with white matter disruption and lasting brain dysfunction. Here, we further evaluated serum SNTF as a prognostic marker for persistent brain dysfunction in uncomplicated mTBI patients treated in a Level I trauma center emergency department. Compared with healthy controls (n = 40), serum SNTF increased by 92% within 24 h of mTBI (n = 95; p < 0.0001), and as a diagnostic marker exhibited 100% specificity and 37% sensitivity (AUC = 0.87). To determine whether the subset of mTBI cases positive for SNTF preferentially developed lasting brain dysfunction, serum levels on the day of mTBI were compared with multiple measures of brain performance at 90 days post-injury. Elevated serum SNTF correlated significantly with persistent impairments in cognition and sensory-motor integration, and predicted worse performance in each test on a case by case basis (AUC = 0.68 and 0.76, respectively). SNTF also predicted poorer recovery of cognitive stress function from 30 to 90 days (AUC = 0.79–0.90). These results suggest that serum SNTF, a surrogate marker for axonal injury after mTBI, may have potential for the rapid prognosis of lasting post-concussion syndrome and impaired functional recovery following CT-negative mTBI. They provide further evidence linking axonal injury to persisting brain dysfunction after uncomplicated mTBI. A SNTF blood test, either alone or combined with other markers of axonal injury, may have important utilities for research, prognosis, management and treatment of concussion.

Neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

Persistent Sport-Related Post-Concussion Syndrome is often diagnosed with any type of prolonged PCS symptoms. However, there are not specific diagnostic criteria for PPCS such that misdiagnosis often occurs. Further, the signs and symptoms of PCS overlap with other common illnesses such as depression, anxiety, migraines, ADHD and others. Misdiagnosis may lead to less than efficacious treatment, resulting in prolonged symptoms. This article will review relevant evidence-based literature on PCS, pointing out the lack of a systemic diagnostic framework. It will also provide evidence that highlights the multiple conflicting findings in the literature. This article will posit the BioPsychoSocial framework as the best diagnostic framework for understanding the impact of concussions on the person and to generate individualized and personal interventions. A narrative review of sport concussion-related articles was conducted, after extensive searches of relevant and non-relevant literature by each author, as well as articles recommended by colleagues. Articles varied from American Academy of Neurology Class I to IV for evaluation and critique. Class IV articles were reviewed, as there is much public misconception regarding sport and other concussion treatment that needed identification and discussion. Articles reviewed varied by quality of research design and methodology. Multiple symptoms, recovery patterns and rehabilitation treatment approaches are purported in the sport-related concussion literature. Current consensus data as well as the mixed and contradictory findings were explored. Persistent Sport-Related Post-Concussion Syndrome is a topic of great interest to both professionals and the general public. There is much misunderstanding about the etiology, causation, diagnostic formulations, symptom presentation, prolonging factors and treatment involved in this syndrome. This article posits an individualized multi-system diagnostic formulation, examining all relevant factors, as generating the best interventions for neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

PATIENT REPORT OUTCOME MEASURE USE FOR CONCUSSION AMONG HIGH SCHOOL ATHLETIC TRAINERS

Background:Recent recommendations suggest incorporating patient-report outcome measures (PROMs) into concussion assessment batteries. Utilizing PROMs provides information on the patient’s perspective and how the concussion may influence the patient’s health status. Past studies evaluating PROM use among athletic trainers (ATs) found varying practices and barriers to implementation. However, there is limited data on use of PROMs in managing concussion among adolescent patients.Hypothesis/Purpose:To describe the use of PROMs as part of concussion assessment and treatment practices of ATs working in middle and high school settings.Methods:An online survey regarding concussion treatment perceptions and practices was distributed to a convenience sample of 5000 ATs through the NATA Survey Research Program. The survey included personal and institutional demographics, healthcare provider access and referral practices, perceptions of concussion treatment, clinical practice characteristics of concussion treatment and PROM use. The survey was pilot tested and validated in a sample of ATs prior to distribution. Analysis of the PROM section was conducted using descriptive statistics (percentages, frequencies) for this study.Results:The survey was accessed by 304 ATs (6.1% access rate) and completed by 153 ATs (58.3% completion rate). Of those, 27.2% (n=57) were employed in the middle school or high school setting and were analyzed for this study. Just over half of respondents had <10 years of experience (52.7%, n=30). Only 35.1% (n=20) of ATs reported they use PROMs as part of their clinical management of concussion. Of those who use PROMs, 75% (n=15) indicated that they use them always or almost always. The most commonly used generic PROMs were the Short Form 12 or 36 (25%, n=5) and Patient Reported Outcomes Measurement Information System (25%, n=5) and the most common specific PROMs were the Headache Impact Test (45%, n=9) and Dizziness Handicap Inventory (15%, n=3). Figure 1 shows the level of self-reported confidence of those utilizing PROMs. Barriers for PROM use included it being too time consuming (24.6%, n=14/57), lacking a support structure (15.8%, n=9/57), and not familiar with PROMs (14%, n=8/57). Close to one-fourth (22.8%, n=13/57) of respondents would be willing to use PROMs, but lacked time.Conclusion:While the use of PROMs is recommended in the evaluation and treatment of adolescent athletes, just over one-third of ATs providing care to these patients, use PROMs. Educational efforts for ATs should look to increase their familiarity and confidence when using PROMs for concussion while suggesting strategies to incorporate PROMs into practice.Figure 1.Self -reported confidence in use of PROMs among ATs.

Concussion: Physical Therapy Treatment After Mild Traumatic Brain Injury.

A concussion is a mild traumatic brain injury caused by a sudden blow or jolt to the head. Any excessive force to the head is considered a "concussive event," even when a concussion hasn't been diagnosed. These concussive events can happen during sport or recreation, as a result of a fall or accident, or from an act of violence. Many people recover from these concussive events with rest and gradually get back to normal activities; for others, though, symptoms persist. The good news is that these symptoms may respond well to physical therapy. To ensure the best possible outcome, getting a thorough evaluation after a concussive event is very important. A clinical practice guideline on the evaluation and treatment of concussion, published in the April 2020 issue of JOSPT, emphasizes this point. J Orthop Sports Phys Ther 2020;50(4):178. doi:10.2519/jospt.2020.0503.

THE RELATIONSHIP BETWEEN ACUTE MOOD, SLEEP, AND SEX ON NEUROCOGNITIVE PERFORMANCE POST-CONCUSSION IN ADOLESCENTS

Background:Both sleep disturbance and mood changes are common symptoms post-concussion (Sell & Rubeor, 2017). Studies have found these symptoms are correlated with poorer performance on neurocognitive testing (Kontos et al., 2012 and Kostyun et al., 2015). In addition, Brown et al., (2015) showed that females report more symptoms at both baseline and post-concussion compared to males on the Post-Concussion Scale and the Sport Concussion Assessment Tool 2.Hypothesis/Purpose:The purpose of this study is to investigate how a patient’s sex, as well as self-reported acute mood and sleep symptoms are related to neurocognitive performance in individuals with concussion.Methods:Data were acquired through IRB-approved retrospective chart review. Composite scores from the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computerized evaluation and self-reported symptom scores on the Post-Concussion Symptom Scale were gathered for 1619 adolescents age 12-18 (49.3% female) who presented to a large metropolitan outpatient clinic for treatment of concussion.Results:Females endorsed higher overall symptoms (x=19.52, SD 19.37, median 13.0 for females; x=12.88, SD 15.89, median 7.0 for males; Mann-Whitney U Test p<0.001). This same pattern emerged for the mood and sleep symptom clusters (female mood mean=2.92, SD 4.51; male mood mean=1.64, SD 3.34; female sleep mean=1.59, SD 2.0; male sleep mean=1.11, SD 1.84; both Independent Samples Mann-Whitney U Tests ps<0.001).There were significant but modest negative correlations between mood symptoms and performance on verbal memory (r=-0.174), visual memory (r=-0.213), and visual motor speed (r=-0.146) composites (all ps<0.01). There was positive correlation between reaction time composite and mood symptoms (r=0.191). There were significant but modest negative correlations between sleep symptoms and performance on verbal memory (r=-0.171), visual memory (r=-0.184), and visual motor speed (r=-0.161) composites (all ps<0.01). There was a positive correlation between reaction time composite and sleep symptoms (r=0.196, p<0.01).Conclusion:Consistent with prior research, adolescent females reported more symptoms post-concussion, including total symptom score, mood symptoms, and sleep symptoms. Adolescents presenting with more mood and sleep symptoms demonstrated poorer performance on neurocognitive testing. However, given the modest nature of the correlation, a significant amount of variation in test performance is not explained by symptom report. Results from this study underscore the importance of a multidimensional concussion assessment that includes both symptom report and cognitive testing when working with pediatric athletes. This study also reinforces the importance of understanding potential effects of sleep, mood, and sex on concussion.

Introduction to Traumatic Brain Injury in Children

ABSTRACT Over the last decade, the reported rates of traumatic brain injury (TBI) have increased dramatically in all age groups, but particularly in children. However, these reports likely underestimate the scope of the problem for several reasons. There is no uniformly accepted definition of mild TBI (concussion). There are often no outward and obvious physical signs of TBI. Interpersonal and psychological issues, which may be significant, may be misdiagnosed or misinterpreted. And there is no uniformly accepted neuroimaging protocol. This presentation will outline the major issues surrounding the cause, diagnosis, and treatment of concussion, particularly in children.

A Multicenter Look at Multidisciplinary Youth Concussion/Mild Traumatic Brain Injury Programs: The Four Corners Youth Consortium (4CYC)

Abstract Introduction A 2013 Institute of Medicine report revealed a striking lack of data on youth concussion. The 4CYC is a group of self-funded centers committed to working together to better understand youth sports and brain health. Objectives The goal is to create a collaborative, multi-institutional partnership amongst academic centers with expertise in youth concussion care, research, and education. Methods Six sites provided baseline and clinical data, collected October 2014- September 2015. Subjects included pediatric (5-18.99 years) patients and athletes seen in outpatient treatment for concussion or preseason baseline assessments. The demographic data followed the NIH Common Data Elements (CDE) for pediatric TBI. Results We collected data from 687 baseline-testing encounters, 2803 new clinic encounters for concussion and 1672 follow-up visits. The types of encounters varied among the sites. Conclusions This paper demonstrates the feasibility for multiple academic, multidisciplinary concussion centers to combine clinical data on youth mTBI.

Challenges Faced by Collegiate Athletic Trainers, Part II: Treating Concussed Student-Athletes.

Conflict between athletic trainers (ATs) and other stakeholders can occur because of competing interests over medical decisions regarding concussion. However, we are unaware of any studies specifically exploring these situations across various collegiate athletic affiliations. To investigate the challenges faced by ATs when treating concussed student-athletes. Qualitative study. Online questionnaire. A total of 434 ATs (267 women, 166 men, 1 missing data; age = 27.73 ± 3.24 years, experience = 5.17 ± 2.67 years) completed the questionnaire (response rate = 14.47%). Our participants represented multiple employment settings within intercollegiate athletics. We sent an online questionnaire to 3000 ATs working in the collegiate and university setting across the United States. A survey expert verified face, content, and construct validity of the questionnaire in 2 rounds of review, and 3 ATs completed a content-validity tool before we finalized the survey. We analyzed the qualitative data using a general inductive approach and ensured trustworthiness through multiple-analyst triangulation and peer review. When we examined the responses from our participants regarding their work with student-athletes who had sustained concussions, we found 2 major themes, each with subthemes. First, educational efforts appeared to be only modestly effective because of a lack of honesty, noncompliant actions, and coach interference. Second, return to learn was challenging because of a lack of communication among stakeholders, athletes being anxious about needing accommodations, and difficulty convincing faculty to provide reasonable accommodations. Based on our findings, we recommend continued efforts to improve the culture surrounding concussion in collegiate athletes. Athletic trainers should include key stakeholders such as coaches, student-athletes, parents, faculty, and other educational administrators in their educational efforts to improve the policies and culture surrounding concussion treatment.

Clinical practice in occupational therapy for treatment of concussion in schoolboys: An integrative review

Rugby in South Africa is one of the fastest growing contact sports and schoolboys competing in rugby will sustain injuries such as concussions. Concussion protocol regulations indicate that young players be removed from play and training for two weeks as there are many misconceptions about the long-term implications of concussion. Concussion has been shown to impact on cognitive functioning and the ability to perform at school. Occupational therapy has a role in the intervention of occupational performance post-concussion in learners playing this contact sport. A clinical practice framework to provide guidelines for the occupational therapy intervention for schoolboy rugby players post-concussion in the South African setting is presented. The framework was based on the occupations, client factors, performance skills, performance patterns and context and environments in the Occupational Therapy Practice Framework III (OTPF III). Screening assessment including the learners, parents and teachers were suggested to determine the use of specific occupational performance assessments in education, social participation, activities of daily living and rest and sleep as well as client factor assessments to determine the outcomes of concussion. Intervention guidelines include the occupational therapy process approaches for Create/Promote, Establish/Restore, Maintain, Modify (compensate) and Prevent with a focus on create/promote; or promotion of safety in rugby. The assessments given in this framework are easily accessible in the South African setting and provide knowledge for all level of practitioners. The role of occupational therapy in reducing residual risks of concussion sustained while playing rugby at school and the long-term consequences of concussion on occupations needs to be researched further. Key words: concussion, schoolboy concussion, concussion management, occupational therapy management

A Review of MRI and Exercise Treatment for Improved Concussion Diagnosis and Recovery.

Concussions are a major health concern due to the unpredictable onset and resolution of debilitating post-concussion symptoms. This review discusses physiological, structural and functional brain changes post-concussion, novel non-invasive medical imaging techniques to improve diagnosis, and the role exercise could play in concussion recovery. After sustaining a concussion, about 50% of youth and 20% of adults have symptoms that last for more than a month. Understanding concussion severity has become consequential in recent years as professional sports leagues have acknowledged their harmful short- and long-term effects. Despite these effects, concussed children and adults continue to return to activity and sport prior to a full recovery. This premature return can be enabled because routine clinical medical imaging techniques are unable to detect post-concussion brain damage. However, there have been advances in MRI approaches that clearly indicate brain damage due to concussion. In terms of recovery, rest has been the long-standing prescribed concussion treatment; however, subsymptom exacerbating exercise has been shown to be a safe and effective treatment option. Novel controlled aerobic exercise interventions have improved concussion outcomes by reducing recovery time and symptom severity.

Increasing Incidence of Concussion: True Epidemic or Better Recognition?

To provide updated estimates of the incidence of concussion from all causes diagnosed by all physicians in a large jurisdiction, as previous studies have examined only single causes of injury or from smaller specific populations. Physician Billing and National Ambulatory Care Reporting System (NACRS) databases were used to identify all Ontario residents with a diagnosis of concussion (ICD-9 850.0 and ICD-10 S06.0) made by physicians between 2008 and 2016, excluding those with moderate to severe traumatic brain injury. In total, 1 330 336 people were diagnosed with a concussion between 2008 and 2016. The annual average was 147 815, and 79% were diagnosed in the emergency department. The average annual incidence was 1153 per 100 000 residents. Incidence varied by age, sex, and geography; children younger than 5 years had the highest incidence of concussion, more than 3600 per 100 000 individuals of that age group. Males had higher incidence than females except in older than 65 years age groups. There was a Pearson correlation (+0.669) between sustaining a concussion and living in rural locations. The annual incidence of approximately 1.2% of the population is the highest rate of concussion ever reported thorough sampling methods and may represent a closer estimate of the true picture of concussion. Findings may inform future concussion treatment and healthcare planning.