Sex differences in the Buffalo Concussion Treadmill Test in adolescents with acute sport-related concussion

Quality of Life in Adolescent Athletes With Sport-Related Concussion Prescribed Heart Rate-Targeted Aerobic Exercise Within 10 Days of Injury

Individualized aerobic exercise treatment prescribed within 10 days of injury facilitates recovery in adolescents after sport-related concussion (SRC) and reduces incidence of persisting post-concussive symptoms (PPCSs) beyond 4 weeks. The effect of aerobic exercise treatment on quality of life symptoms is, however, unknown. This planned secondary aim of a published randomized controlled trial found that while adolescents prescribed aerobic exercise recovered faster, there was no difference on the Pediatric Quality of Life (PedsQL) questionnaire scores during the 4-week intervention period. Nevertheless, adolescents who experienced PPCS reported significantly worse initial visit (within 10 days of injury) symptoms on the PedsQL than those who recovered within 4 weeks. Higher scores on the PedsQL correlated with greater initial visit concussion symptom burden and more abnormalities on a concussion-relevant visio-vestibular examination. Thus, the PedsQL captures the clinical severity of concussion and is prognostic of risk for delayed recovery when administered early after SRC in adolescents.

Feasibility of superimposed supine cycling and lower body negative pressure as an effective means of prolonging exercise tolerance in individuals experiencing persisting post-concussive symptoms: Preliminary results

To examine the feasibility, utility and safety of superimposed lower body negative pressure (LBNP) and tilt during supine cycling in individuals suffering from persisting post-concussive symptoms (PPCS). Eleven individuals aged 17-31 (6 females/5 males) participated in two randomized separate visits, 1 week apart. A ramp-incremental test was performed during both visits until volitional failure. Visits included no pressure (control) or LBNP at -40 Torr (experimental) with head-up tilt at 15 degrees (females) or 30 degrees (males). Transcranial Doppler ultrasound was utilized to quantify middle cerebral artery velocity (MCAv), while symptom reports were filled out before and 0, 10, and 60 min post-exertion. Ratings of exertion and overall condition followed similar trends for participants across both tests. The relative increase in MCAv was blunted during the experimental condition (8%) compared to control (24%), while a greater heart rate (17 beats/min) was achieved during the LBNP condition (P = 0.047). Symptom severity at the 0 and 10 min post-exertion time points displayed negligible-to-small effect sizes between conditions (Wilcoxon's r < 0.11). Symptom reporting was lower at the 60 min post-exertion time point with these displaying a moderate effect size (Wilcoxon's r = 0.31). The combination of LBNP and tilt during supine cycling did not change the participants' subjective interpretation of the exertional test but attenuated the hyperpnia-induced vasodilatory MCAv response, while also enabling participants to achieve a higher heart rate during exercise and reduced symptoms 1 h later. As this protocol is safe and feasible, further research is warranted in this area for developing PPCS treatment options. HIGHLIGHTS: What is the central question of this study? What are the feasibility, safety and utility of combining head-up tilt with lower body negative pressure during supine cycling for blunting the increase in cerebral blood velocity seen during moderate-intensity exercise in individuals experiencing persisting post-concussion symptoms? What is the main finding and its importance? Although no differences were found in symptoms between conditions within the first 10 min following exertion, symptom severity scores showed a clinically meaningful reduction 60 min following the experimental condition compared to the non-experimental control condition.

Use of the Buffalo Concussion Treadmill Test in community adult patients with mild traumatic brain injury

BACKGROUND

The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown.

OBJECTIVE

Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI-related symptoms, and BCTT duration.

DESIGN

Prospective, observational, longitudinal.

SETTING

Academic medical center.

PARTICIPANTS

Thirty-seven adults treated in a level 1 trauma center emergency department with mTBI;  24 uninjured controls (UC).

INTERVENTIONS

N/A.

MAIN MEASURES

Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15-minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration.

RESULTS

Persons with mTBI discontinued earlier than UC at 1-week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI-related intolerance was 55.6% at 1 week (36.1% for mTBI-related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age-predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI-related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39-61%) and physical exertion (9-26%). Shorter duration was associated with higher body mass index (r = -0.42 - -0.45), shorter height (r = 0.22-0.29), female gender (r = -0.26 - -0.27), and greater RPQ symptoms (r = -0.28 - -0.47).

CONCLUSION

The BCTT exacerbates mTBI-related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes.

The Buffalo Concussion Treadmill and Bike Tests in People With Mild-to-Moderate Traumatic Brain Injury: An Exploratory Clinical Audit

OBJECTIVE

To assess the performance on the Buffalo Concussion Treadmill and Bike Tests in nonathletic people following a mild-to-moderate traumatic brain injury.

SETTING

An outpatient rehabilitation clinic.

PARTICIPANTS

Forty-nine patients with mild-to-moderate traumatic brain injury who underwent the Buffalo Concussion Treadmill or Bike Test as usual clinical care.

DESIGN

A retrospective clinical audit.

MAIN MEASURES

Demographics and brain injury-specific clinical data, Depression Anxiety Stress Scale; Rivermead Post-Concussion Symptom Questionnaire, and performance outcomes on the Buffalo Concussion Treadmill or Bike Test.

RESULTS

Forty-nine patients (mean age: 33.7 ± 13.0 years), on average 56.2 ± 36.4 days post-injury, completed the Buffalo Concussion Treadmill or Bike Test. Fourteen patients stopped the test due to symptom exacerbation with a mean test duration of 8.1 ± 4.5 minutes, reaching an age-predicted maximum heart rate of 72.9% ± 12.4% and reporting a rating of perceived exertion of 13.4 ± 2.2. Those who terminated the test for other reasons had a significantly longer test duration (14.0 ± 4.7 minutes, P = .01), with a higher age-predicted maximum heart rate (83.3% ± 12.8%, P = .01) and rating of perceived exertion (17.0 ± 2.5, P = .01). Within the group who stopped for other reasons, 10 were due to symptoms deemed unrelated to the injury at the time of the test and 2 were stopped by the therapist for safety reasons. A significant but weak correlation between heart rate and rating of perceived exertion existed only for those who terminated the test for other reasons ( r = 0.38, P = .02). Overall, a shorter test duration was associated with higher scores of both self-reported depression ( r = -0.41, P < .01) and late postconcussion symptoms ( r = -0.40, P < .01).

CONCLUSION

The Buffalo Concussion Treadmill or Bike Test can be used in the nonathletic mild-to-moderate traumatic brain injury population to differentiate between those who experience symptom exacerbation during exercise and those who do not based on symptom exacerbation, test duration, and poor perception of exertion. Further research is required to determine whether other reasons for test termination are related to the injury.

Sensitivity and Specificity of Exercise Intolerance on Graded Exertion Testing for Diagnosing Sport-Related Concussion: A Systematic Review and Exploratory Meta-Analysis

Abstract There is no single gold standard test to diagnose sport-related concussion (SRC). Concussion-related exercise intolerance, that is, inability to exercise to the individual's appropriate level due to exacerbation of concussion-like symptoms, is a frequent finding in athletes early after SRC that has not been systematically evaluated as a diagnostic test of SRC. We performed a systematic review and proportional meta-analysis of studies that evaluated graded exertion testing in athletes after SRC. We also included studies of exertion testing in healthy athletic participants without SRC to assess specificity. Pubmed and Embase were searched in January 2022 for articles published since 2000. Eligible studies included those that performed graded exercise tolerance tests in symptomatic concussed participants (> 90% of subjects had an SRC, seen within 14 days of injury), at the time of clinical recovery from SRC, in healthy athletes, or both. Study quality was assessed using the Newcastle-Ottawa Scale. Twelve articles met inclusion criteria, most of which were of poor methodological quality. The pooled estimate of incidence of exercise intolerance in participants with SRC equated to an estimated sensitivity of 94.4% (95% confidence interval [CI]: 90.8, 97.2). The pooled estimate of incidence of exercise intolerance in participants without SRC equated to an estimated specificity of 94.6% (95% CI: 91.1, 97.3). The results suggest that exercise intolerance measured on systematic testing within 2 weeks of SRC may have excellent sensitivity for helping to rule in the diagnosis of SRC and excellent specificity for helping to rule out SRC. A prospective validation study to determine the sensitivity and specificity of exercise intolerance on graded exertion testing for diagnosing SRC after head injury as the source of symptoms is warranted.

Role of biomarkers and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion: a systematic review

OBJECTIVE

Determine the role of fluid-based biomarkers, advanced neuroimaging, genetic testing and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion (SRC).

DESIGN

Systematic review.

DATA SOURCES

Searches of seven databases from 1 January 2001 through 24 March 2022 using keywords and index terms relevant to concussion, sports and neurobiological recovery. Separate reviews were conducted for studies involving neuroimaging, fluid biomarkers, genetic testing and emerging technologies. A standardised method and data extraction tool was used to document the study design, population, methodology and results. Reviewers also rated the risk of bias and quality of each study.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they: (1) were published in English; (2) represented original research; (3) involved human research; (4) pertained only to SRC; (5) included data involving neuroimaging (including electrophysiological testing), fluid biomarkers or genetic testing or other advanced technologies used to assess neurobiological recovery after SRC; (6) had a minimum of one data collection point within 6 months post-SRC; and (7) contained a minimum sample size of 10 participants.

RESULTS

A total of 205 studies met inclusion criteria, including 81 neuroimaging, 50 fluid biomarkers, 5 genetic testing, 73 advanced technologies studies (4 studies overlapped two separate domains). Numerous studies have demonstrated the ability of neuroimaging and fluid-based biomarkers to detect the acute effects of concussion and to track neurobiological recovery after injury. Recent studies have also reported on the diagnostic and prognostic performance of emerging technologies in the assessment of SRC. In sum, the available evidence reinforces the theory that physiological recovery may persist beyond clinical recovery after SRC. The potential role of genetic testing remains unclear based on limited research.

CONCLUSIONS

Advanced neuroimaging, fluid-based biomarkers, genetic testing and emerging technologies are valuable research tools for the study of SRC, but there is not sufficient evidence to recommend their use in clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020164558.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Practical Management: A Standardized Aerobic Exercise Program for Adolescents With Concussion in the Absence of Graded Exercise Testing

ABSTRACT

Aerobic exercise is safe and beneficial for adolescent athletes recovering from sport-related concussion (SRC). The results of systematic graded exercise testing are used to create individualized, subsymptom heart rate threshold (HRt) aerobic exercise treatment programs for adolescents after SRC. Many clinicians, however, do not have access to graded exercise tests. This article presents a safe, systematic, evidence-based exercise program that clinicians can prescribe, progress, and modify to help manage acute pediatric SRC without the need for formal exercise testing. The exercise prescription accounts for sex and days since injury but not age because our analysis indicates age does not significantly affect the HRt on graded exercise testing. This article provides clinicians without access to graded exercise testing a viable option for prescribing exercise treatment to adolescents in the early phase after SRC.

Efficacy of aerobic exercise following concussion: a narrative review

Concussion is a type of mild traumatic brain injury which results in symptoms within the physical, cognitive, emotional, and sleep domains. Historically, guidelines established by expert opinion have recommended rest during the initial stages of recovery following a concussion until symptom resolution. However, recent recommendations have shifted to advise an initial period of 24-48 h of rest immediately following concussion with the gradual introduction of light-to-moderate intensity aerobic exercise thereafter. Given the relatively recent transition in recommendations, the aim of this review is to provide an overview of the current literature on the efficacy of aerobic exercise following concussion. The current literature is limited to studies assessing the impact of standardized aerobic exercise following concussion. Upon review, literature suggests participating in aerobic exercise below the point of symptom exacerbation is safe in both the acute and chronic post-concussion symptom stages of recovery and does not delay time to medical clearance. Future large-scale randomized controlled trials assessing the impact of aerobic exercise and differences between males and females would help support the current evidence suggesting aerobic exercise could improve time to recovery following concussion and identify any sex differences in response. As well, future studies with the purpose of identifying optimal aerobic exercise volume and intensity in the treatment of concussion could improve the specificity of the current guidelines.

The Role of Age, Sex, Body Mass Index, and Sport Type on the Dynamic Exertion Test in Healthy Athletes: A Cross-Sectional Study

BACKGROUND

The dynamic exertion test (EXiT) was developed to help inform return to play after sport-related concussion, but some factors may threaten the internal validity of EXiT and affect clinical interpretation.

OBJECTIVE

To compare age, sex, BMI, and sport types across EXiT physiological [pre-EXiT and post-EXiT percentage of maximum heart rate (HR %max) and blood pressure (BP)], performance (change-of-direction task completion time and committed errors), and clinical [symptoms and rating of perceived exertion (RPE)] outcomes among healthy adolescents and adults.

STUDY DESIGN

Cross-sectional.

METHODS

Eighty-seven participants ( F = 55, 37.4%) reported symptoms and RPE during the EXiT, which consists of a 12-minute treadmill running protocol, and the dynamic circuit, ball toss, box shuffle (SHUF) and carioca (CAR), zig zag (ZZ), proagility (PA), and arrow agility (AA) tasks. Independent samples t tests were conducted for pre-EXiT and post-EXiT HR %max and BP and change-of-direction task completion time and Mann-Whitney U tests for errors, symptoms, and RPE. A series of 1-way analysis of variance (ANOVAs) and Kruskal-Wallis H tests were conducted to compare collision, contact, and noncontact sport types.

RESULTS

Adolescents had lower completion time across AA ( P = 0.01) and male athletes lower than female athletes on CAR, ZZ, PA, and AA ( P < 0.04). Male athletes reported greater RPE after the SHUF, CAR, and AA ( P < 0.03). HR %max , errors, and symptoms were equivocal across all subgroups ( P > 0.05).

CONCLUSION

Age and sex should be considered in the interpretation of performance and clinical, but not physiological, EXiT outcomes. The EXiT is a standardized exercise assessment and generalizable to healthy athletes.

Identifying Trends of Dysautonomia Signs and Symptoms Associated with Protracted Concussion Recovery during the Buffalo Concussion Treadmill Test: A Retrospective Study

Objective:

To identify trends of provoked dysautonomia signs and symptoms during the Buffalo Concussion Treadmill Test (BCTT).

Subjects:

This is a retrospective cohort study of 101 patient charts post-concussion who were screened for suspected dysautonomia.

Methods:

Patients with suspected dysautonomia were assessed for exercise intolerance using a BCTT. Symptoms and rate of perceived exertion were recorded on a standardized form. Digital pulse oximetry was used to collect heart rate (HR) and oxygen saturation. Descriptive analyses were conducted on BCTT results.

Results:

Of 101 patient charts, 57 were excluded from analysis, including four patients who completed the BCTT by asymptomatically reaching the target HR zone for their estimated HR max. The remaining 44 patients demonstrated: 35 (79.5%) poor HR stabilization defined as a drop or plateau in HR during exercise, 28 (63.8%) exacerbated concussion symptoms, 13 (29.5%) autonomic nervous system response such as hot flushed sensation, 12 (27.3%) rebound symptoms during recovery phases, and 8 (18.2%) desaturation of 90% or below. The mean delta (80% expected HR max – 80% achieved HR max) on the initial test was 80.66 (± 23.08) beats per minute.

Conclusions:

This study is the first to identify trends of signs and symptoms during the BCTT in an expanded population with suspected dysautonomia after concussion. Future studies are indicated to validate these findings and contribute to development of modified termination criteria for the BCTT in individuals with suspected dysautonomia associated with protracted concussion recovery.

Identifying Trends of Dysautonomia Signs and Symptoms Associated with Protracted Concussion Recovery during the Buffalo Concussion Treadmill Test: A Retrospective Study

OBJECTIVE

To identify trends of provoked dysautonomia signs and symptoms during the Buffalo Concussion Treadmill Test (BCTT).

SUBJECTS

This is a retrospective cohort study of 101 patient charts post-concussion who were screened for suspected dysautonomia.

METHODS

Patients with suspected dysautonomia were assessed for exercise intolerance using a BCTT. Symptoms and rate of perceived exertion were recorded on a standardized form. Digital pulse oximetry was used to collect heart rate (HR) and oxygen saturation. Descriptive analyses were conducted on BCTT results.

RESULTS

Of 101 patient charts, 57 were excluded from analysis, including four patients who completed the BCTT by asymptomatically reaching the target HR zone for their estimated HR max. The remaining 44 patients demonstrated: 35 (79.5%) poor HR stabilization defined as a drop or plateau in HR during exercise, 28 (63.8%) exacerbated concussion symptoms, 13 (29.5%) autonomic nervous system response such as hot flushed sensation, 12 (27.3%) rebound symptoms during recovery phases, and 8 (18.2%) desaturation of 90% or below. The mean delta (80% expected HR max â€" 80% achieved HR max) on the initial test was 80.66 (± 23.08) beats per minute.

CONCLUSIONS

This study is the first to identify trends of signs and symptoms during the BCTT in an expanded population with suspected dysautonomia after concussion. Future studies are indicated to validate these findings and contribute to development of modified termination criteria for the BCTT in individuals with suspected dysautonomia associated with protracted concussion recovery.