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Sharma B, Koelink E, DeMatteo C, Noseworthy MD, Timmons BW. The Concussion, Exercise, and Brain Networks (ConExNet) study: a cohort study aimed at understanding the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. BMC Sports Sci Med Rehabil 2024; 16:133. [PMID: 38886815 PMCID: PMC11184857 DOI: 10.1186/s13102-024-00926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Recent scientific evidence has challenged the traditional "rest-is-best" approach for concussion management. It is now thought that "exercise-is-medicine" for concussion, owing to dozens of studies which demonstrate that sub-maximal, graded aerobic exercise can reduce symptom burden and time to symptom resolution. However, the primary neuropathology of concussion is altered functional brain activity. To date, no studies have examined the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. In addition, although exercise is now more widely prescribed following concussion, its cardiopulmonary response is not yet well understood in this population. Our study has two main goals. The first is to understand whether there are exercise-induced resting state functional brain activity differences in children with concussion vs. healthy controls. The second is to profile the physiological response to exercise and understand whether it differs between groups. METHODS We will perform a single-center, controlled, prospective cohort study of pediatric concussion at a large, urban children's hospital and academic center. Children with sport-related concussion (aged 12-17 years) will be recruited within 4-weeks of injury by our clinical study team members. Key inclusion criteria include: medical clearance to exercise, no prior concussion or neurological history, and no implants that would preclude MRI. Age- and sex-matched healthy controls will be required to meet the same inclusion criteria and will be recruited through the community. The study will be performed over two visits separated by 24-48 h. Visit 1 involves exercise testing (following the current clinical standard for concussion) and breath-by-breath gas collection using a metabolic cart. Visit 2 involves two functional MRI (fMRI) scans interspersed by 10-minutes of treadmill walking at an intensity calibrated to Visit 1 findings. To address sub-objectives, all participants will be asked to self-report symptoms daily and wear a waist-worn tri-axial accelerometer for 28-days after Visit 2. DISCUSSION Our study will advance the growing exercise-concussion field by helping us understand whether exercise impacts outcomes beyond symptoms in pediatric concussion. We will also be able to profile the cardiopulmonary response to exercise, which may allow for further understanding (and eventual optimization) of exercise in concussion management. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Bhanu Sharma
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Imaging Research Centre, St. Joseph's Healthcare, Hamilton, ON, Canada
- Department of Electrical & Computer Engineering, McMaster University, Hamilton, ON, Canada
| | - Eric Koelink
- Department of Pediatric Emergency Medicine, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Carol DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - Michael D Noseworthy
- Imaging Research Centre, St. Joseph's Healthcare, Hamilton, ON, Canada
- Department of Electrical & Computer Engineering, McMaster University, Hamilton, ON, Canada
- McMaster School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
- Department of Medical Imaging, McMaster University, Hamilton, ON, Canada
| | - Brian W Timmons
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada.
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Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms. Curr Neurol Neurosci Rep 2022; 22:171-181. [PMID: 35175543 DOI: 10.1007/s11910-022-01183-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI. RECENT FINDINGS Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.
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Mollica A, Dey A, Cairncross M, Silverberg N, Burke MJ. Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches. Semin Neurol 2022; 42:168-181. [PMID: 35114694 DOI: 10.1055/s-0041-1742143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.
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Affiliation(s)
- Adriano Mollica
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ayan Dey
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Molly Cairncross
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Noah Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Phybrata Sensors and Machine Learning for Enhanced Neurophysiological Diagnosis and Treatment. SENSORS 2021; 21:s21217417. [PMID: 34770729 PMCID: PMC8587627 DOI: 10.3390/s21217417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022]
Abstract
Concussion injuries remain a significant public health challenge. A significant unmet clinical need remains for tools that allow related physiological impairments and longer-term health risks to be identified earlier, better quantified, and more easily monitored over time. We address this challenge by combining a head-mounted wearable inertial motion unit (IMU)-based physiological vibration acceleration (“phybrata”) sensor and several candidate machine learning (ML) models. The performance of this solution is assessed for both binary classification of concussion patients and multiclass predictions of specific concussion-related neurophysiological impairments. Results are compared with previously reported approaches to ML-based concussion diagnostics. Using phybrata data from a previously reported concussion study population, four different machine learning models (Support Vector Machine, Random Forest Classifier, Extreme Gradient Boost, and Convolutional Neural Network) are first investigated for binary classification of the test population as healthy vs. concussion (Use Case 1). Results are compared for two different data preprocessing pipelines, Time-Series Averaging (TSA) and Non-Time-Series Feature Extraction (NTS). Next, the three best-performing NTS models are compared in terms of their multiclass prediction performance for specific concussion-related impairments: vestibular, neurological, both (Use Case 2). For Use Case 1, the NTS model approach outperformed the TSA approach, with the two best algorithms achieving an F1 score of 0.94. For Use Case 2, the NTS Random Forest model achieved the best performance in the testing set, with an F1 score of 0.90, and identified a wider range of relevant phybrata signal features that contributed to impairment classification compared with manual feature inspection and statistical data analysis. The overall classification performance achieved in the present work exceeds previously reported approaches to ML-based concussion diagnostics using other data sources and ML models. This study also demonstrates the first combination of a wearable IMU-based sensor and ML model that enables both binary classification of concussion patients and multiclass predictions of specific concussion-related neurophysiological impairments.
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Wu YN, Stark C, Gravel J, White M, Avery J, Enis T, Cantu RC. Effects of Interval-Training Exercise on People Who Have Had Persistent Post-Concussive Symptoms for Less Than One Year: A Pilot Study. J Neurotrauma 2020; 38:573-581. [PMID: 33096965 DOI: 10.1089/neu.2019.6915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study is to examine the effects of a 12-session moderate intensity-interval-training program with blood flow restriction (BFR) and body cooling (BC) on people who have had persistent post-concussive symptoms (PPCS) for <1 year. A single-blind randomized controlled trial of interval-training exercise with BFR and BC was conducted. Twenty-five adults with PPCS were assigned to the experimental group (n = 14) or the control group (n = 11). Both groups rode a recumbent elliptical machine for 21 min at moderate intensity (65% predicted maximum heart rate) twice a week for 6 weeks, but only the experimental group received BFR and BC while riding. The variances of overall PPCS scale scores and their sub-domain scores for individuals during the 6-week intervention and 6-week follow-up period were calculated. During the intervention, the fluctuation of overall symptom severity, severity in the cognitive domain and severity in the mood domain were significantly less in the experimental group (p = 0.03; p = 0.02; p = 0.02). During the follow-up period, the number of symptoms remained more stable in the experimental group (p = 0.02), and a trend toward less fluctuation of symptom severity (p = 0.05) was also observed. The reduced number of symptoms in the cognitive and sleep domains remained more stable in the experimental group following the intervention (p = 0.007; p = 0.02). The severity of mood and sleep symptoms also remained more stable during the follow-up period in the experimental group (p = 0.04). More stable recovery was found in individuals who exercised using BFR and BC than in those who underwent exercise without BFR and BC. Moderate intensity-interval-training exercise with BFR and BC alleviated post-concussive symptoms in people who have had PPCS <1 year.
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Affiliation(s)
- Yi-Ning Wu
- Department of Physical Therapy and Kinesiology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Caroline Stark
- Department of Physical Therapy and Kinesiology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Jessica Gravel
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Matthew White
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Josh Avery
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Terrie Enis
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Robert C Cantu
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
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DeWitt D, Prough DS. Introduction to the Special Issue on Translation. J Neurotrauma 2020; 37:2351-2352. [PMID: 32838667 DOI: 10.1089/neu.2020.7390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Douglas DeWitt
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Donald S Prough
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas, USA
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Mollica A, Safavifar F, Fralick M, Giacobbe P, Lipsman N, Burke MJ. Transcranial Magnetic Stimulation for the Treatment of Concussion: A Systematic Review. Neuromodulation 2020; 24:803-812. [PMID: 33184973 DOI: 10.1111/ner.13319] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/11/2020] [Accepted: 10/26/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Post-concussive symptoms (PCSs) are common, disabling, and challenging to manage. Evolving models of concussion pathophysiology suggest evidence of brain network dysfunction that may be amenable to neuromodulation. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential novel treatment option for PCSs. OBJECTIVES To systematically review rTMS trials for the treatment of symptoms following concussion/mild traumatic brain injury (mTBI). MATERIALS AND METHODS We conducted a systematic review of Pubmed/Medline, Embase, and PsychINFO databases were searched up to May 19, 2020. Studies were included if they were prospective rTMS treatment studies of patients with mTBI/concussion. Variables including patient demographics, study design, rTMS protocol parameters, primary outcome measures, and efficacy data were extracted and qualitatively synthesized. rTMS methodology and study quality were also evaluated. RESULTS Of the 342 studies identified, 11 met eligibility criteria and were included for synthesis. Forty-one percent of patients were female and age ranged from 18 to 65 (average age = 38.5 years). Post-concussive depression (seven studies) and headache (four studies) were the most commonly investigated symptoms. The majority of trials were sham-controlled with randomized control trial (RCT) designs, but all were small pilot samples (n < 30). Methodological heterogeneity and a low number of identified trials precluded quantitative meta-analysis. Regarding rTMS for post-concussive depression, positive results were found in two out of four studies with depression as a primary outcome, and all three studies that assessed depression as a secondary outcome. All four rTMS studies for post-concussive headache reported positive results. CONCLUSIONS rTMS for the treatment of concussion/mTBI shows promising preliminary results for post-concussive depression and headache, symptoms that otherwise have limited effective treatment options. More studies with larger sample sizes are needed to further establish potential efficacy.
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Affiliation(s)
- Adriano Mollica
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Farnaz Safavifar
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael Fralick
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Matthew J Burke
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Furlan JC, Radan MM, Tator CH. A Scoping Review of Registered Clinical Studies on Mild Traumatic Brain Injury and Concussion (2000 to 2019). Neurosurgery 2020; 87:891-899. [DOI: 10.1093/neuros/nyaa151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/16/2020] [Indexed: 12/16/2022] Open
Abstract
Abstract
BACKGROUND
While many patients with mild traumatic brain injury (mTBI) or concussion recover completely, prolonged postconcussion symptoms remain a challenge for patients and an opportunity for clinical research. This has led to numerous research initiatives over the last 2 decades.
OBJECTIVE
To review the characteristics of clinical studies on management of mTBI/concussion; and to examine their definitions of mTBI/concussion.
METHODS
This scoping review included all clinical studies on diagnosis and management of patients with mTBI/concussion registered at www.clinicaltrials.gov from 2000 to June/2019. The terms “mild TBI/concussion” were used for the primary search. Definitions of mTBI/concussion were obtained from the protocols. When a definition was missing in the website, the study's investigators were contacted for clarification.
RESULTS
There were 225 interventional and 95 observational studies. Most of the studies are focused on treatment (54.7%) or diagnosis (37.5%), while 3.4% examined preventive measures, 2.8% evaluated prognostic instruments, and 1.6% developed registries. Most of the studies in this American database were single-center initiatives led by American and Canadian institutions. The definitions of mTBI/concussion differed widely among 109 studies.
CONCLUSION
The results of this review suggest that most of the clinical studies are focused on diagnosis and non-pharmacological therapies for patients with mTBI/concussion. The large number of differing definitions of mTBI/concussion among the studies creates significant limitations when comparing studies. The requirements for registering research protocols on mTBI/concussion should include the necessity to state the definition being used. There is a need for consensus on a uniform definition of concussion.
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Affiliation(s)
- Julio C Furlan
- Lyndhurst Centre, KITE – Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Michael M Radan
- Lyndhurst Centre, KITE – Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Charles H Tator
- Krembil Brain Institute and Division of Neurosurgery, and Canadian Concussion Centre, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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Fralick M, Sy E, Hassan A, Burke MJ, Mostofsky E, Karsies T. Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:144-151. [PMID: 30419085 DOI: 10.1001/jamaneurol.2018.3487] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Concussion is the most common form of traumatic brain injury (TBI). While most patients fully recover within 1 week of injury, a subset of patients might be at a higher risk of suicide. Objective To assess the risk of suicide after concussion. Data Sources We performed a systematic search of Medline (PubMed), Embase, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS) from 1963 to May 1, 2017. We also searched Google Scholar and conference proceedings and contacted experts in the field to seek additional studies. Study Selection Studies that quantified the risk of suicide, suicide attempt, or suicidal ideation after a concussion and/or mild TBI were included. Studies that included children and adults, including military and nonmilitary personnel, were included. Two authors independently reviewed all titles and abstracts to determine study eligibility. Data Extraction and Synthesis Study characteristics were extracted independently by 2 trained investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Study data were pooled using random-effects meta-analysis. Main Outcomes and Measures The primary exposure was concussion and/or mild TBI, and the primary outcome was suicide. Secondary outcomes were suicide attempt and suicidal ideation. Results Data were extracted from 10 cohort studies (n = 713 706 individuals diagnosed and 6 236 010 individuals not diagnosed with concussion and/or mild TBI), 5 cross-sectional studies (n = 4420 individuals diagnosed and 11 275 individuals not diagnosed with concussion and/or mild TBI), and 2 case-control studies (n = 446 individuals diagnosed and 8267 individuals not diagnosed with concussion and/or mild TBI). Experiencing concussion and/or mild TBI was associated with a 2-fold higher risk of suicide (relative risk, 2.03 [95% CI, 1.47-2.80]; I2 = 96%; P < .001). In 2 studies that provided estimates with a median follow-up of approximately 4 years, 1664 of 333 118 individuals (0.50%) and 750 of 126 114 individuals (0.59%) diagnosed with concussion and/or mild TBI died by suicide. Concussion was also associated with a higher risk of suicide attempt and suicide ideation. The heightened risk of suicide outcomes after concussion was evident in studies with and without military personnel. Conclusions and Relevance Experiencing concussion and/or mild TBI was associated with a higher risk of suicide. Future studies are needed to identify and develop strategies to decrease this risk.
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Affiliation(s)
- Michael Fralick
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Now with Eliot Phillipson Clinician Scientist Training Program, Department of Medicine, University of Toronto, Ontario, Canada
| | - Eric Sy
- College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada.,Department of Critical Care, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Adiba Hassan
- Antiviral Research Center, Department of Medicine, University of California, San Diego
| | - Matthew J Burke
- Cognitive Neurology Unit, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Mostofsky
- Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Todd Karsies
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Holmes G, Clacy A, Salmon PM. Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby. ERGONOMICS 2019; 62:1485-1494. [PMID: 31390942 DOI: 10.1080/00140139.2019.1654134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 07/20/2019] [Indexed: 06/10/2023]
Abstract
The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.
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Affiliation(s)
- Glenn Holmes
- Sunshine Coast Mind & Neuroscience - Thompson Institute, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
| | - Amanda Clacy
- Sunshine Coast Mind & Neuroscience - Thompson Institute, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
| | - Paul M Salmon
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast , Sippy Downs , Queensland , Australia
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Atif H, Hicks SD. A Review of MicroRNA Biomarkers in Traumatic Brain Injury. J Exp Neurosci 2019; 13:1179069519832286. [PMID: 30886525 PMCID: PMC6410383 DOI: 10.1177/1179069519832286] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/29/2019] [Indexed: 12/13/2022] Open
Abstract
There is growing public concern surrounding traumatic brain injury (TBI). TBI can cause significant morbidity, and the long-term sequelae are poorly understood. TBI diagnosis and management rely on patient-reported symptoms and subjective clinical assessment. There are no biologic tools to detect mild TBI or to track brain recovery. Emerging evidence suggests that microRNAs (miRNAs) may provide information about the injured brain. These tiny epigenetic molecules are expressed throughout the body. However, they are particularly important in neurons, can cross the blood-brain barrier, and are securely transported from cell to cell, where they regulate gene expression. miRNA levels may identify patients with TBI and predict symptom duration. This review synthesizes miRNA findings from 14 human studies. We distill more than 291 miRNAs to 17 biomarker candidates that overlap across multiple studies and multiple biofluids. The goal of this review is to establish a collective understanding of miRNA biology in TBI and identify clinical priorities for future investigations of this promising biomarker.
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Affiliation(s)
| | - Steven D Hicks
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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An Evidence-Based Objective Study Protocol for Evaluating Cardiovascular and Cerebrovascular Indices Following Concussion: The Neary Protocol. Methods Protoc 2019; 2:mps2010023. [PMID: 31164604 PMCID: PMC6481075 DOI: 10.3390/mps2010023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction: The prevalence and incidence of sport-related concussion have continued to increase over the past decade, and researchers from various backgrounds strive for evidenced-based clinical assessment and management. When diagnosing and managing a concussion, a battery of tests from several domains (e.g., symptom reporting, neurocognitive, physiology) must be used. In this study, we propose and develop an objective, evidence-based protocol to assess the pathophysiology of the brain by using non-invasive methods. Methods: Contact sport athletes (n = 300) will be assessed at the beginning of the season in a healthy state to establish baseline values, and then prospectively followed if a mild traumatic brain injury (mTBI) occurs on approximately days 1–2, 3–5, 7–10, 21, 30, and subsequently thereafter, depending on the severity of injury. The protocol includes spontaneous measurements at rest, during head postural change, controlled breathing maneuvers for cerebrovascular reactivity, a neurovascular coupling stimuli, and a baroreflex/autoregulation maneuver. Physiological data collection will include cerebral blood flow velocity, cerebral oxygenation, respiratory gases for end-tidal oxygen and carbon dioxide, finger photoplethysmography for blood pressure, seismocardiography for cardiac mechanics, and electrocardiography. Conclusion, Limitations, and Ethics: The protocol will provide an objective, physiological evidence-based approach in an attempt to better diagnose concussion to aid in return-to-play or -learn. Ethics approval has been granted by the University Research Ethics Board.
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Clair R, Levin Allen S, Goodman A, McCloskey G. Gender differences in quality of life and symptom expression during recovery from concussion. APPLIED NEUROPSYCHOLOGY-CHILD 2019; 9:206-214. [PMID: 30822135 DOI: 10.1080/21622965.2018.1556102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pediatric concussion is a significant health concern for parents, medical providers, and schools. This study was designed to gain insight into gender differences in perspectives of children and adolescents recovering from concussion. Specifically, the study explored whether males and females reported different symptom loads for physical symptoms and quality of life after concussion. The Pediatric Life After Concussion Evaluation Scale (PLACES) and the Post Concussion Symptom Scale (PCSS) were completed by 277 participants ages 9-21, with a mean age of 14.8 years. The sample was 47.5% female and 52.5% male. The study showed that overall, females reported more physical and somatic symptoms (Total PCSS, p = .001), worse quality of life during recovery (PLACES, p = .008), difficulty with cognition (p = .001), and elevated emotional symptoms than males (p = .02). When an interaction between gender and time since injury was considered, there were significant interactions for the PCSS, with females experiencing higher physical and cognitive symptom load during the period spanning 1-12 weeks (1-4 weeks: M = 33.18, SD = 27.03; 5-11 weeks: M = 15.0, SD = 16.76). However, for those individuals experiencing symptoms for longer than 12 weeks, males expressed a higher physical and cognitive symptom load (M = 32.36, SD = 26.59). Findings indicate that there are gender differences in the expression of symptoms and perceptions of quality of life after concussion.
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Affiliation(s)
- Ruta Clair
- Department of Psychology, Cabrini University, Radnor, Pennsylvania, USA
| | - Sarah Levin Allen
- Department of Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Arlene Goodman
- Saint Peter's Sports medicine Institute, Somerset, New Jersey, USA
| | - George McCloskey
- Department of Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
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Sullivan KA, Kaye SA, Blaine H, Edmed SL, Meares S, Rossa K, Haden C. Psychological approaches for the management of persistent postconcussion symptoms after mild traumatic brain injury: a systematic review. Disabil Rehabil 2019; 42:2243-2251. [DOI: 10.1080/09638288.2018.1558292] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Karen A. Sullivan
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Sherrie-Anne Kaye
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Hannah Blaine
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Shannon L. Edmed
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Susanne Meares
- Department of Psychology, Macquarie University, Sydney, Australia
- Brain Injury Rehabilitation Services, Westmead Hospital, Sydney, Australia
| | - Kalina Rossa
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Catherine Haden
- Library, Queensland University of Technology, Brisbane, Australia
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Polinder S, Cnossen MC, Real RGL, Covic A, Gorbunova A, Voormolen DC, Master CL, Haagsma JA, Diaz-Arrastia R, von Steinbuechel N. A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury. Front Neurol 2018; 9:1113. [PMID: 30619066 PMCID: PMC6306025 DOI: 10.3389/fneur.2018.01113] [Citation(s) in RCA: 200] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022] Open
Abstract
Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.
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Affiliation(s)
- Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maryse C Cnossen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ruben G L Real
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Anastasia Gorbunova
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Daphne C Voormolen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Emergency Medicine, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
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DeWitt DS, Hawkins BE, Dixon CE, Kochanek PM, Armstead W, Bass CR, Bramlett HM, Buki A, Dietrich WD, Ferguson AR, Hall ED, Hayes RL, Hinds SR, LaPlaca MC, Long JB, Meaney DF, Mondello S, Noble-Haeusslein LJ, Poloyac SM, Prough DS, Robertson CS, Saatman KE, Shultz SR, Shear DA, Smith DH, Valadka AB, VandeVord P, Zhang L. Pre-Clinical Testing of Therapies for Traumatic Brain Injury. J Neurotrauma 2018; 35:2737-2754. [PMID: 29756522 PMCID: PMC8349722 DOI: 10.1089/neu.2018.5778] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Despite the large number of promising neuroprotective agents identified in experimental traumatic brain injury (TBI) studies, none has yet shown meaningful improvements in long-term outcome in clinical trials. To develop recommendations and guidelines for pre-clinical testing of pharmacological or biological therapies for TBI, the Moody Project for Translational Traumatic Brain Injury Research hosted a symposium attended by investigators with extensive experience in pre-clinical TBI testing. The symposium participants discussed issues related to pre-clinical TBI testing including experimental models, therapy and outcome selection, study design, data analysis, and dissemination. Consensus recommendations included the creation of a manual of standard operating procedures with sufficiently detailed descriptions of modeling and outcome measurement procedures to permit replication. The importance of the selection of clinically relevant outcome variables, especially related to behavior testing, was noted. Considering the heterogeneous nature of human TBI, evidence of therapeutic efficacy in multiple, diverse (e.g., diffuse vs. focused) rodent models and a species with a gyrencephalic brain prior to clinical testing was encouraged. Basing drug doses, times, and routes of administration on pharmacokinetic and pharmacodynamic data in the test species was recommended. Symposium participants agreed that the publication of negative results would reduce costly and unnecessary duplication of unsuccessful experiments. Although some of the recommendations are more relevant to multi-center, multi-investigator collaborations, most are applicable to pre-clinical therapy testing in general. The goal of these consensus guidelines is to increase the likelihood that therapies that improve outcomes in pre-clinical studies will also improve outcomes in TBI patients.
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Affiliation(s)
- Douglas S. DeWitt
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Bridget E. Hawkins
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - C. Edward Dixon
- Department of Neurological Surgery, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William Armstead
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cameron R. Bass
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Helen M. Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miami, Florida
| | - Andras Buki
- Department of Neurosurgery, Medical University of Pécs, Pécs, Hungary
| | - W. Dalton Dietrich
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Adam R. Ferguson
- Weill Institute for Neurosciences, Brain and Spinal Injury Center (BASIC), Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California
| | - Edward D. Hall
- Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky Medical Center, Lexington, Kentucky
| | - Ronald L. Hayes
- University of Florida, Virginia Commonwealth University, Banyan Biomarkers, Inc., Alachua, Florida
| | - Sidney R. Hinds
- United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | | | - Joseph B. Long
- Blast-Induced Neurotrauma Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - David F. Meaney
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stefania Mondello
- Department of Neurosciences, University of Messina, Via Consolare Valeria, Messina, Italy
| | - Linda J. Noble-Haeusslein
- Departments of Neurology and Psychology, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Samuel M. Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Donald S. Prough
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | | | - Kathryn E. Saatman
- Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, Lexington, Kentucky
| | - Sandy R. Shultz
- Department of Medicine, Melbourne Brain Center, The University of Melbourne, Parkville, Victoria, Australia
| | - Deborah A. Shear
- Brain Trauma Neuroprotection Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Douglas H. Smith
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alex B. Valadka
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Pamela VandeVord
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Liying Zhang
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
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17
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Rytter HM, Westenbaek K, Henriksen H, Christiansen P, Humle F. Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial. Brain Inj 2018; 33:266-281. [DOI: 10.1080/02699052.2018.1552022] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hana Mala Rytter
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | | | - Frank Humle
- Centre for Rehabilitation of Brain Injury, Copenhagen, Denmark
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18
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Sullivan KA, Hills AP, Iverson GL. Graded Combined Aerobic Resistance Exercise (CARE) to Prevent or Treat the Persistent Post-concussion Syndrome. Curr Neurol Neurosci Rep 2018; 18:75. [DOI: 10.1007/s11910-018-0884-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Baracks J, Casa DJ, Covassin T, Sacko R, Scarneo SE, Schnyer D, Yeargin SW, Neville C. Acute Sport-Related Concussion Screening for Collegiate Athletes Using an Instrumented Balance Assessment. J Athl Train 2018; 53:597-605. [PMID: 29897278 DOI: 10.4085/1062-6050-174-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Without a true criterion standard assessment, the sport-related concussion (SRC) diagnosis remains subjective. Inertial balance sensors have been proposed to improve acute SRC assessment, but few researchers have studied their clinical utility. OBJECTIVE To determine if group differences exist when using objective measures of balance in a sample of collegiate athletes with recent SRCs and participants serving as the control group and to calculate sensitivity and specificity to determine the diagnostic utility of the inertial balance sensor for acute SRC injuries. DESIGN Cross-sectional cohort study. SETTING Multicenter clinical trial. PATIENTS OR OTHER PARTICIPANTS We enrolled 48 participants with SRC (age = 20.62 ± 1.52 years, height = 179.76 ± 10.00 cm, mass = 83.92 ± 23.22 kg) and 45 control participants (age = 20.85 ± 1.42 years, height = 177.02 ± 9.59 cm, mass = 74.61 ± 14.92 kg) at 7 clinical sites in the United States. All were varsity or club collegiate athletes, and all participants with SRC were tested within 72 hours of SRC. MAIN OUTCOME MEASURE(S) Balance performance was assessed using an inertial balance sensor. Two measures (root mean square sway and 95% ellipse sway area) were analyzed to represent a range of general balance measures. Balance assessments were conducted in double-legged, single-legged, and tandem stances. RESULTS A main effect for group was associated with the root mean square sway measure ( F1,91 = 11.75, P = .001), with the SRC group demonstrating balance deficits compared with the control group. We observed group differences in the 95% ellipse sway area measure for the double-legged ( F1,91 = 11.59, P = .001), single-legged ( F1,91 = 6.91, P = .01), and tandem ( F1,91 = 7.54, P = .007) stances. Sensitivity was greatest using a cutoff value of 0.5 standard deviations (54% [specificity = 71%]), whereas specificity was greatest using a cutoff value of 2 standard deviations (98% [sensitivity = 33%]). CONCLUSIONS Inertial balance sensors may be useful tools for objectively measuring balance during acute SRC evaluation. However, low sensitivity suggests that they may be best used in conjunction with other assessments to form a comprehensive screening that may improve sensitivity.
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Affiliation(s)
- Joshua Baracks
- Upstate Concussion Center and ¶Department of Physical Therapy Education, Orthopedic Surgery, and Physiology, SUNY Upstate Medical University, Syracuse, NY
| | - Douglas J Casa
- Department of Kinesiology, Korey Stringer Institute, University of Connecticut, Storrs
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing
| | - Ryan Sacko
- Department of Physical Education and Athletic Training, University of South Carolina, Columbia
| | - Samantha E Scarneo
- Department of Kinesiology, Korey Stringer Institute, University of Connecticut, Storrs
| | - David Schnyer
- Department of Psychology, University of Texas, Austin
| | - Susan W Yeargin
- Department of Physical Education and Athletic Training, University of South Carolina, Columbia
| | - Christopher Neville
- Upstate Concussion Center and ¶Department of Physical Therapy Education, Orthopedic Surgery, and Physiology, SUNY Upstate Medical University, Syracuse, NY
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Kurowski BG, Wade S, Dexheimer JW, Dyas J, Zhang N, Babcock L. Feasibility and Potential Benefits of a Web-Based Intervention Delivered Acutely After Mild Traumatic Brain Injury in Adolescents: A Pilot Study. J Head Trauma Rehabil 2018; 31:369-378. [PMID: 26360000 PMCID: PMC4786468 DOI: 10.1097/htr.0000000000000180] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a paucity of evidence-based interventions for mild traumatic brain injury (mTBI). OBJECTIVE To evaluate the feasibility and potential benefits of an interactive, Web-based intervention for mTBI. SETTING Emergency department and outpatient settings. PARTICIPANTS Of the 21 adolescents aged 11 to 18 years with mTBI recruited from November 2013 to June 2014 within 96 hours of injury, 13 completed the program. DESIGN Prospective, open pilot. INTERVENTION The Web-based Self-Management Activity-restriction and Relaxation Training (SMART) program incorporates anticipatory guidance and psychoeducation, self-management and pacing of cognitive and physical activities, and cognitive-behavioral principles for early management of mTBI in adolescents. MAIN MEASURES Primary: Daily Post-Concussion Symptom Scale (PCSS). Secondary: Daily self-reported ratings of activities and satisfaction survey. RESULTS Average time from injury to baseline testing was 14.0 (standard deviation = 16.7) hours. Baseline PCSS was 23.6 (range: 0-46), and daily activity was 1.8 (range: 0-5.75) hours. Repeated-measures, generalized linear mixed-effects model analysis demonstrated a significant decrease of PCSS at a rate of 2.0 points per day that stabilized after about 2 weeks. Daily activities, screen time, and physical activity increased by 0.06 (standard error [SE] = 0.04, P = .09), 0.04 (SE = 0.02, P = .15), and 0.03 (SE = 0.02, P = .05) hours per day, respectively, over the 4-week follow-up. Satisfaction was rated highly by parents and youth. CONCLUSIONS Self-Management Activity-restriction and Relaxation Training is feasible and reported to be helpful and enjoyable by participants. Future research will need to determine the comparative benefits of SMART and ideal target population.
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Affiliation(s)
- Brad G. Kurowski
- Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shari Wade
- Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Judith W. Dexheimer
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jenna Dyas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nanhua Zhang
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lynn Babcock
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
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21
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Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial. J Head Trauma Rehabil 2018; 32:79-89. [PMID: 27120294 DOI: 10.1097/htr.0000000000000238] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents. SETTING Outpatient research setting. PARTICIPANTS Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms. DESIGN Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program. MAIN MEASURES The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described. RESULTS Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P = .044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean [SD] times per week = 4.42 [1.95] vs 5.85 [1.37], P < .0001) over the duration of the study. CONCLUSION Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit.
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23
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Chavez-Arana C, Catroppa C, Yáñez Téllez G, Godfrey C, Prieto-Corona B, de León MA, García A, Anderson V. Feasibility and effectiveness of a parenting programme for Mexican parents of children with acquired brain injury-Case report. Brain Inj 2017; 32:276-285. [DOI: 10.1080/02699052.2017.1394491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Clara Chavez-Arana
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Universidad Nacional Autónoma de México, FES Iztacala, Mexico City, Mexico
| | - Cathy Catroppa
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Royal Children’s Hospital, Child Neuropsychology, Melbourne, Victoria, Australia
| | | | - Celia Godfrey
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Royal Children’s Hospital, Child Neuropsychology, Melbourne, Victoria, Australia
| | | | - Miguel A. de León
- Iskalti Centre of Psychological and Educational Support S.C., Mexico City, Mexico
| | - Antonio García
- Unit of High Specialty “La Raza” IMSS, Paediatric Neurosurgery, Mexico City, Mexico
| | - Vicki Anderson
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Royal Children’s Hospital, Child Neuropsychology, Melbourne, Victoria, Australia
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24
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Thomas RE, Alves J, Vaska Mlis MM, Magalhaes R. Therapy and rehabilitation of mild brain injury/concussion: Systematic review. Restor Neurol Neurosci 2017; 35:643-666. [DOI: 10.3233/rnn-170761] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Roger E. Thomas
- Department of Family Medicine, Faculty of Medicine, Health Sciences Centre, University of Calgary, Calgary, AB, Canada
| | - Jorge Alves
- CEREBRO – Brain Health Center, Braga, Portugal
| | | | - Rosana Magalhaes
- Instituto de Psicologia e Ciências da Educação, Universidade Lusíada – Norte (Porto), Porto, Portugal
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25
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Dobney DM, Miller MB, Tufts E. Non-pharmacological rehabilitation interventions for concussion in children: a scoping review. Disabil Rehabil 2017; 41:727-739. [PMID: 29157025 DOI: 10.1080/09638288.2017.1400595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children. METHODS An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down's and Black criteria was conducted. RESULTS Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good. CONCLUSIONS The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy. Implications for rehabilitation Few studies have examined rehabilitation interventions for youth following concussion. Research ranging from rest to exercise highlights the uncertainty of the field. Low quality research limits the generalizability of results. The use of physical activity appears to be an emerging area of interest. Individualised, aerobic exercise should be used as part of clinical management.
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Affiliation(s)
- Danielle M Dobney
- a School of Physical and Occupational Therapy, Faculty of Medicine , McGill University , Montreal , Canada
| | - Matthew B Miller
- b Department of Exercise Science, Faculty of Arts and Science , Concordia University , Montreal , Canada
| | - Emily Tufts
- c Centennial College Libraries , Toronto , Canada
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26
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Leskowitz E. CranioSacral Therapy, Brain Injury, and American Football: Time for a Convergence. J Altern Complement Med 2017; 23:905-906. [PMID: 29111776 DOI: 10.1089/acm.2017.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Eric Leskowitz
- Integrative Medicine Task Force, Spaulding Rehabilitation Hospital , Charlestown, MA
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27
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Chávez C, Catroppa C, Hearps SJC, Yáñez-Téllez G, Prieto-Corona B, de León MA, García A, Sandoval-Lira L, Anderson V. Parenting program versus telephone support for Mexican parents of children with acquired brain injury: A blind randomized controlled trial. Contemp Clin Trials Commun 2017; 7:109-115. [PMID: 29696174 PMCID: PMC5898475 DOI: 10.1016/j.conctc.2017.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/11/2017] [Accepted: 06/20/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Acquired brain injury (ABI) during childhood typically causes behavior problems in the child and high levels of stress in the family. The aims of this study are: (1) to investigate the effectiveness and feasibility of a parenting intervention in improving behavior and self-regulation in Mexican children with ABI compared to telephone support; (2) to investigate the effectiveness and feasibility of a parenting intervention in improving parenting skills, parent self-efficacy and decreasing parental stress in parents of children with ABI compared to telephone support. Our secondary aims are (1) to explore the impact that parent characteristics have on the intervention outcomes; (2) to investigate if changes are maintained 3 months after the intervention. Methods The research design is a blind randomized controlled trial (RCT). Eligible participants include children with a diagnosis of ABI, between 6 and 12 years of age, and their parents. Sixty-six children and their parents will be randomly allocated to either a parenting program group or telephone support group. The parenting program involves six face-to-face weekly group sessions of 2.5 h each. Participants in the control group receive an information sheet with behavioral strategies, and six weekly phone calls, in which strategies to improve academic skills are provided. Children and their parents are evaluated by blind assessors before the intervention, immediately after the intervention and 3-months post-intervention. Discussion This study will be the first to evaluate the efficacy and feasibility of a parenting program for Mexican parents of children with ABI. Trial identifier ACTRN12617000360314.
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Key Words
- AARP, Abbreviated Acceptability Rating Profile-Parenting
- ABI, Acquired brain injury
- BRI, Behavior Regulation Index
- BRIEF, The Behavior Rating Inventory of Executive Function parent form
- BRIEF-A, The Behavior Rating Inventory of Executive Function Adult Self-report
- Behavior problems and self-regulation
- Brain injury
- CBCL, Child Behavior Checklist
- CG, Control group
- CT, Computed Tomography
- Children
- DGT, Delayed gratification task
- EC, Emotional control
- ECBI, Eyberg Child Behavior Inventory
- EFs, Executive functions
- ERCL, Emotion Regulation Checklist
- FBII, Family Burden Injury Interview
- GCS, Glasgow Coma Scale
- GEC, Global Executive Composite
- IAST, Inventory Anxiety State Trait
- IDB, Beck's Depression Inventory
- Intervention
- Iskalti, Iskalti Centre of Psychological and Educational Support
- MFFT, Matching Familiar Figure Test
- MI, Metacognition Index
- MRI, Magnetic resonance imaging
- PS, Parenting scale
- PSI, Parent stress index
- PSOC, Parent sense of competence
- RCT, Randomised controlled trial
- Rehabilitation
- SD, standard deviation
- SESBI, Sutter-Eyberg Behavior Inventory
- SR, Self-Regulation
- Signposts, Signposts for building better behaviour
- TEA-Ch 2, Test of Everyday Attention for Children Second Edition
- TRF, Teacher report form
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Affiliation(s)
- Clara Chávez
- Child Neuropsychology, Murdoch Childrens Research Institute, Victoria, Australia.,The University of Melbourne, Victoria, Australia.,Universidad Nacional Autónoma de México, FES Iztacala, Mexico City, Mexico
| | - Cathy Catroppa
- Child Neuropsychology, Murdoch Childrens Research Institute, Victoria, Australia.,The University of Melbourne, Victoria, Australia.,Royal Children's Hospital, Victoria, Australia
| | - Stephen J C Hearps
- Child Neuropsychology, Murdoch Childrens Research Institute, Victoria, Australia
| | | | | | - Miguel A de León
- Iskalti Centre of Psychological and Educational Support S.C., Mexico City, Mexico
| | - Antonio García
- Unit of High Specialty "La Raza" IMSS, Mexico City, Mexico
| | | | - Vicki Anderson
- Child Neuropsychology, Murdoch Childrens Research Institute, Victoria, Australia.,The University of Melbourne, Victoria, Australia.,Royal Children's Hospital, Victoria, Australia
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Lee HH, Lee WH, Seo HG, Han D, Kim Y, Oh BM. Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury. BRAIN & NEUROREHABILITATION 2017. [DOI: 10.12786/bn.2017.10.e3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Hyun Haeng Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dohyun Han
- Proteomics Core Facility, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Youngsoo Kim
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Cordingley D, Girardin R, Reimer K, Ritchie L, Leiter J, Russell K, Ellis MJ. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr 2016; 25:693-702. [PMID: 27620871 DOI: 10.3171/2016.5.peds16139] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objectives of this study were 2-fold: 1) to evaluate the safety, tolerability, and clinical use of graded aerobic treadmill testing in pediatric patients with sports-related concussion (SRC), and 2) to evaluate the clinical outcomes of treatment with a submaximal aerobic exercise program in patients with physiological post-concussion disorder (PCD). METHODS The authors conducted a retrospective chart review of pediatric patients (age < 20 years) with SRC who were referred to a multidisciplinary pediatric concussion program and underwent graded aerobic treadmill testing between October 9, 2014, and February 11, 2016. Clinical assessments were carried out by a single neurosurgeon and included clinical history taking, physical examination, and recording specific patient-reported concussion-related symptoms using the Post-Concussion Symptom Scale (PCSS). Graded aerobic treadmill testing using a modified Balke protocol for incremental increases in intensity was used as a diagnostic tool to assess physiological recovery, classify post-concussion syndrome (PCS) subtype, and reassess patients following treatment. Patients with a symptom-limited threshold on treadmill testing (physiological PCD) were treated with an individually tailored submaximal exercise prescription and multidisciplinary targeted therapies. RESULTS One hundred six patients (mean age 15.1 years, range 11-19 years) with SRC underwent a total of 141 treadmill tests. There were no serious complications related to treadmill testing in this study. Overall, 138 (97.9%) of 141 tests were well tolerated and contributed valuable clinical information. Treadmill testing confirmed physiological recovery in 63 (96.9%) of 65 patients tested, allowing successful return to play in 61 (93.8%). Treadmill testing was used to diagnose physiological PCD in 58 patients and cervicogenic PCD in 1 patient. Of the 41 patients with physiological PCD who had complete follow-up and were treated with tailored submaximal exercise prescription, 37 (90.2%) were classified as clinically improved and 33 (80.5%) successfully returned to sporting activities. Patients who did not respond or experienced an incomplete response to submaximal aerobic exercise treatment included 7 patients with migraine headaches and 1 patient with a postinjury psychiatric disorder. CONCLUSIONS Graded aerobic treadmill testing is a safe, tolerable, and clinically valuable tool that can assist in the evaluation and management of pediatric SRC. Future research is needed to confirm the clinical value of this tool in return-to-play decision making. Studies are also needed to understand the pathophysiology of physiological PCD and the effects of targeted treatment.
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Affiliation(s)
| | | | - Karen Reimer
- Pan Am Concussion Program.,Canada North Concussion Network;,Section of Physical Therapy, College of Rehabilitation Sciences, University of Manitoba; and
| | - Lesley Ritchie
- Pan Am Concussion Program.,Canada North Concussion Network;,Departments of 3 Clinical Health Psychology
| | - Jeff Leiter
- Pan Am Concussion Program.,Canada North Concussion Network;,Surgery
| | - Kelly Russell
- Canada North Concussion Network;,Pediatrics and Child Health.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael J Ellis
- Pan Am Concussion Program.,Canada North Concussion Network;,Surgery.,Pediatrics and Child Health.,Section of Neurosurgery, and.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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30
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Radhakrishnan R, Garakani A, Gross LS, Goin MK, Pine J, Slaby AE, Sumner CR, Baron DA. Neuropsychiatric aspects of concussion. Lancet Psychiatry 2016; 3:1166-1175. [PMID: 27889010 DOI: 10.1016/s2215-0366(16)30266-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/13/2016] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
Abstract
Over the past decade, concussion has become the most widely discussed injury in contact sports. However, concussions also occur in several other settings, such as non-contact sports, elderly individuals, young children, military personnel, and victims of domestic violence. Concussion is frequently undiagnosed as a cause of psychiatric morbidity, especially when the patient has no history of loss of consciousness or direct head trauma. Almost all of the extant literature focuses on traumatic brain injury and assumes that concussion is merely a mild form of traumatic brain injury, which has resulted in a lack of understanding about what concussion is, and how to diagnose, monitor, and treat its varied neuropsychiatric symptoms. In this Review, we address key issues so that the psychiatric clinician can better understand and treat patients with a clinical phenotype that might be the direct result of, or be exacerbated by, concussion. Future research needs to focus on prospective clinical trials in all affected patient populations (ie, those affected by concussion and those affected by various degrees of traumatic brain injury), the identification of reliable biomarkers that can be used to assist with diagnosis and treatment response, and the development of effective treatment interventions. Clearly differentiating concussion from traumatic brain injury is essential to achieve reliable and clinically relevant outcomes.
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Affiliation(s)
- Rajiv Radhakrishnan
- Yale University School of Medicine, New Haven, CT, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Amir Garakani
- Yale University School of Medicine, New Haven, CT, USA; Silver Hill Hospital, New Canaan, CT, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Lawrence S Gross
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Marcia K Goin
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Janet Pine
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Andrew E Slaby
- New York University, New York, NY, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - Calvin R Sumner
- Pearson North America, Boston, MA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA
| | - David A Baron
- University of Southern California, Los Angeles, CA, USA; Psychopharmacology Committee, Group for Advancement of Psychiatry, Dallas, TX, USA.
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31
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Impact of a State Law on Physician Practice in Sports-Related Concussions. J Pediatr 2016; 178:268-274. [PMID: 27597735 DOI: 10.1016/j.jpeds.2016.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/29/2016] [Accepted: 08/05/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine physician-reported adherence to and support of the 2010 Massachusetts youth concussion law, as well as barriers to care and clinical practice in the context of legislation. STUDY DESIGN Primary care physicians (n = 272) in a large pediatric network were eligible for a cross-sectional survey in 2014. Survey questions addressed key policy and practice provisions: concussion knowledge, state regulations and training, practice patterns, referrals, patient characteristics, and barriers to care. Analyses explored relationships between practice and policy, adjusting for physician demographic and practice characteristics. RESULTS The survey response rate was 64% among all responders (173 of 272). A total of 146 respondents who had evaluated, treated, or referred patients with a suspected sports-related concussion in the previous year were eligible for analysis. The vast majority (90%) of providers agreed that the current Massachusetts laws regarding sports concussions are necessary and support the major provisions. Three-quarters (74%) had taken a required clinician training course on concussions. Those who took training courses were significantly more likely to develop individualized treatment plans (OR, 3.6; 95% CI, 1.1-11.0). Physician training did not improve screening of youth with concussion for depression or substance use. Most physicians (77%) advised patients to refrain from computer, telephone, or television for various time periods. Physicians reported limited communication with schools. CONCLUSIONS Primary care physicians report being comfortable with the diagnosis and management of concussions, and support statewide regulations; however, adherence to mandated training and specific legal requirements varied. Broader and more frequent training may be necessary to align current best evidence with clinical care and state-mandated practice.
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Mutch WAC, Ellis MJ, Ryner LN, Ruth Graham M, Dufault B, Gregson B, Hall T, Bunge M, Essig M. Brain magnetic resonance imaging CO2 stress testing in adolescent postconcussion syndrome. J Neurosurg 2016; 125:648-60. [DOI: 10.3171/2015.6.jns15972] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
A neuroimaging assessment tool to visualize global and regional impairments in cerebral blood flow (CBF) and cerebrovascular responsiveness in individual patients with concussion remains elusive. Here the authors summarize the safety, feasibility, and results of brain CO2 stress testing in adolescents with postconcussion syndrome (PCS) and healthy controls.
METHODS
This study was approved by the Biomedical Research Ethics Board at the University of Manitoba. Fifteen adolescents with PCS and 17 healthy control subjects underwent anatomical MRI, pseudo-continuous arterial spin labeling MRI, and brain stress testing using controlled CO2 challenge and blood oxygen level–dependent (BOLD) MRI. Post hoc processing was performed using statistical parametric mapping to determine voxel-by-voxel regional resting CBF and cerebrovascular responsiveness of the brain to the CO2 stimulus (increase in BOLD signal) or the inverse (decrease in BOLD signal). Receiver operating characteristic (ROC) curves were generated to compare voxel counts categorized by control (0) or PCS (1).
RESULTS
Studies were well tolerated without any serious adverse events. Anatomical MRI was normal in all study participants. No differences in CO2 stimuli were seen between the 2 participant groups. No group differences in global mean CBF were detected between PCS patients and healthy controls. Patient-specific differences in mean regional CBF and CO2 BOLD responsiveness were observed in all PCS patients. The ROC curve analysis for brain regions manifesting a voxel response greater than and less than the control atlas (that is, abnormal voxel counts) produced an area under the curve of 0.87 (p < 0.0001) and 0.80 (p = 0.0003), respectively, consistent with a clinically useful predictive model.
CONCLUSIONS
Adolescent PCS is associated with patient-specific abnormalities in regional mean CBF and BOLD cerebrovascular responsiveness that occur in the setting of normal global resting CBF. Future prospective studies are warranted to examine the utility of brain MRI CO2 stress testing in the longitudinal assessment of acute sports-related concussion and PCS.
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Sobin L, Kopp R, Walsh R, Kellman RM, Harris T. Incidence of Concussion in Patients With Isolated Mandible Fractures. JAMA FACIAL PLAST SU 2016; 18:15-8. [PMID: 26448310 DOI: 10.1001/jamafacial.2015.1339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE This study examines the association between isolated mandible fractures and mild traumatic brain injury (mTBI). OBJECTIVE To determine the rates of mTBI in patients who have sustained isolated mandible fractures. DESIGN, SETTING, AND PARTICIPANTS A prospective study was conducted among patients who sustained isolated mandible fractures within 24 hours of presentation. Patients were administered the Military Acute Concussion Evaluation (MACE). Recorded data included demographics, time since injury, use of alcohol or illicit drugs, nonfacial pain, and mechanism of injury. All patients were evaluated in the emergency department of a level I trauma center between June 20, 2013, and June 20, 2014. In addition, discharge data from the Nationwide Inpatient Sample database was analyzed to identify current rates of patients with a diagnosis of both mandible fractures and concussions. MAIN OUTCOMES AND MEASURES Rates of concussion. Patients with a MACE score of less than 25 were considered to have mTBI. RESULTS Sixteen patients met the study criteria over a 1-year period. Fourteen patients (88%) were male, and mean age was 27.5 years. The mean time since injury was 11.25 hours (range, 3-21 hours). The mechanism of injury was assault in 12 patients (75%), sports in 2 patients (13%), all-terrain vehicle crash in 1 patient (6%), and biking in 1 patient (6%). Eight patients (50%) admitted to the use of alcohol, and none reported the use of illicit drugs. Eleven patients (69%) reported loss of consciousness. Twelve patients (75%) met criteria for concussion according to the MACE. Among these 12 patients, 7 (58%) admitted to the use of alcohol at the time of injury. There was no relationship between the rates of concussion and the use of alcohol. CONCLUSIONS AND RELEVANCE Mandible fractures are often sustained after high-force impacts during altercations between men. In our study, a 75% (12 of 16) rate of concussions associated with isolated mandible fractures was identified. Patients with isolated mandible fractures may benefit from being screened for concussion and referred to a concussion clinic. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Lindsay Sobin
- Department of Otolaryngology, State University of New York Upstate Medical Center, Syracuse2currently with the Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts
| | - Robert Kopp
- Department of Otolaryngology, State University of New York Upstate Medical Center, Syracuse
| | - Ronald Walsh
- Department of Otolaryngology, State University of New York Upstate Medical Center, Syracuse
| | - Robert M Kellman
- Department of Otolaryngology, State University of New York Upstate Medical Center, Syracuse
| | - Tucker Harris
- currently in private practice in Horseheads, New York
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Predictors for Return to Work in Subjects with Mild Traumatic Brain Injury. Behav Neurol 2016; 2016:8026414. [PMID: 26980942 PMCID: PMC4769738 DOI: 10.1155/2016/8026414] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/09/2015] [Accepted: 01/17/2016] [Indexed: 11/23/2022] Open
Abstract
Objective. To predict return to work (RTW) at 12 months for patients who either were sick-listed or were at risk to be sick-listed with persistent postconcussion symptoms (PCS) at six to eight weeks after injury. Method. A prospective cohort study of 151 patients with mild traumatic brain injury (MTBI) admitted consecutively to outpatient clinics at two University Hospitals in Norway. The study was conducted as part of a randomised clinical trial. Injury characteristics were obtained from the medical records. Sick leave data from one year before to one year after MTBI were obtained from the Norwegian Labour and Welfare Service. Self-report questionnaires were used to obtain demographic and symptom profiles. Results. We observed a significant negative association between RTW at 12 months and psychological distress, global functioning, and being sick-listed at two months after MTBI, as well as having been sick-listed the last year before injury. Conclusion. Psychological distress, global functioning postinjury, and the sick leave trajectory of the subjects were negative predictors for RTW. These findings should be taken into consideration when evaluating future vocational rehabilitation models.
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Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of suicide after a concussion. CMAJ 2016; 188:497-504. [PMID: 26858348 DOI: 10.1503/cmaj.150790] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community. METHODS We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion. RESULTS We identified 235,110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14-1.64). The increased risk applied regardless of patients' demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life. INTERPRETATION Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.
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Affiliation(s)
- Michael Fralick
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Deva Thiruchelvam
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Homer C Tien
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Donald A Redelmeier
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont.
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Brough D, Rothwell NJ, Allan SM. Interleukin-1 as a pharmacological target in acute brain injury. Exp Physiol 2015; 100:1488-94. [PMID: 26096539 DOI: 10.1113/ep085135] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 05/04/2015] [Accepted: 06/05/2015] [Indexed: 12/13/2022]
Abstract
NEW FINDINGS What is the topic of this review? This review discusses the latest findings on the contribution of inflammation to brain injury, how inflammation is a therapeutic target, and details of recent and forthcoming clinical studies. What advances does it highlight? Here we highlight recent advances on the role and regulation of inflammasomes, and the latest clinical progress in targeting inflammation. Acute brain injury is one of the leading causes of mortality and disability worldwide. Despite this, treatments for acute brain injuries are limited, and there remains a massive unmet clinical need. Inflammation has emerged as a major contributor to non-communicable diseases, and there is now substantial and growing evidence that inflammation, driven by the cytokine interleukin-1 (IL-1), worsens acute brain injury. Interleukin-1 is regulated by large, multimolecular complexes called inflammasomes. Here, we discuss the latest research on the regulation of inflammasomes and IL-1 in the brain, preclinical efforts to establish the IL-1 system as a therapeutic target, and the promise of recent and future clinical studies on blocking the action of IL-1 for the treatment of brain injury.
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Affiliation(s)
- David Brough
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Nancy J Rothwell
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Faculty of Life Sciences, University of Manchester, Manchester, UK
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