The gaming of concussions: a unique intervention in postconcussion syndrome

Interventions to Improve the Occupational Performance of Youth With Persistent Postconcussion Symptoms: A Systematic Review

IMPORTANCE

Persistent postconcussion symptoms (PPCS) may negatively affect youth's occupational performance in activities of daily living, education, play and leisure, social participation, and rest and sleep.

OBJECTIVE

This review provides occupational therapists with evidence related to interventions for youth with PPCS.

DATA SOURCES

Searches were performed in Embase, PubMed, SportDiscus, CINAHL, and Web of Science.

STUDY SELECTION AND DATA COLLECTION

Inclusion criteria were as follows: studies published in English from January 1, 2013, to February 7, 2023; youth ages 3 to 18 yr old; PPCS for at least 2 wk after injury; interventions within the scope of occupational therapy; and outcomes related to areas of occupation. All levels of evidence (1-5) were included and graded for quality using the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence. This review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

FINDINGS

Twenty articles met inclusion criteria (7 randomized controlled trials, 1 nonrandomized controlled group design, 3 single-group designs, 5 case series, and 4 single-subject designs). Interventions reviewed were active rehabilitation, vision-related interventions, psychoeducation, cognitive-behavioral therapy (CBT) techniques, the Cognitive Orientation to daily Occupational Performance (CO-OP), and music therapy. Strong evidence supports CBT, with significant clinical outcomes in sleep and education. Moderate strength of evidence supports psychoeducation and active rehabilitation for improving functional outcomes. More evidence is needed to make clinical recommendations regarding vision-related interventions, the CO-OP, and music therapy.

CONCLUSIONS AND RELEVANCE

Occupational therapists should consider CBT, psychoeducation, and active rehabilitation to improve occupational performance among youth with PPCS. Plain-Language Summary: Some youth will have persistent symptoms that do not resolve within 2 weeks after a concussion. Because of these persistent symptoms, they may have difficulty completing everyday activities. This review evaluated evidence addressing the ability of youth with persistent postconcussion symptoms (PPCS) to complete everyday activities. The authors found that cognitive-behavioral therapy, psychoeducation (aimed at helping youth understand and cope with their concussion symptoms), and active rehabilitation (aerobic and coordination exercises, such as jumping jacks and ball skills) should be considered when working with youth (ages 3-18 years) with PPCS. Using these interventions in occupational therapy sessions may improve the ability of youth to complete their everyday activities after a concussion.

Vestibular dysfunction amongst adolescents: what do we know? A review

BACKGROUND

Vestibular dysfunction in children is a debilitating condition that results in countless pernicious effects, such as motor development delay, poor academic performance and psychosocial impairment. Yet, research pertaining to vestibular and balance disorders amongst adolescents is still lacking and remains an enigma.

METHODS

This paper outlines novel emerging aetiological factors contributing to vestibular dysfunction amongst adolescents by appraising published articles through a narrative review.

RESULTS

Underlying aetiological factors of vestibular dysfunction can be identified among adolescents with thorough evaluation. Proper diagnostic evaluation of vestibular dysfunction is imperative in providing optimal care and guiding appropriate treatment strategies. The available literature demonstrated multifactorial aetiological factors that contribute to vestibular dysfunction in adolescents.

CONCLUSION

Outlining the underlying aetiological factors of vestibular dysfunction is vital to ensure that patients receive appropriate care and treatment.

Application of colored filters in patients post-traumatic brain injury: A review

BACKGROUND: Tinted lenses have been used to manage visual discomfort and photosensitivity in patients with migraines, benign essential blepharospasm (BEB) and epilepsy. OBJECTIVES: The purpose of this review is to examine the existing clinical research regarding the use of colored filters among patients recovering from traumatic brain injuries. METHODS: A review of English articles from PubMed, Embase from embase.com, Web of Science, APA PsycINFO (OVID), Scopus, and Cochrane Central Register of Controlled Trials with publication years from date of inception to June 10, 2021 was performed. Articles were first screened by title and abstract, followed by full-text review. The search strategy resulted in 7819 results. The final analysis included seven articles which discussed the use of tinted lenses in patients post-traumatic brain injury. RESULTS: While there is a paucity of information related to the therapeutic use of tinted lenses to mitigate post-traumatic light sensitivity and migraines, patients will subjectively report improved symptoms, specifically with precision tints or FL-41. CONCLUSION: Further studies are needed to understand the mechanism of action as well as objective and subjective benefits of tinted lenses in patient post-traumatic brain injury.

A Nonliquid Crystal Display Screen Computer for Treatment of Photosensitivity and Computer Screen Intolerance in Post-Concussion Syndrome

Liquid crystal display (LCD) screens refresh at a rate of 60 times per second, which can be perceived by concussed individuals who have photosensitivity, leading to computer intolerance. A non-LCD computer screen that refreshes at a much lower rate could relieve this photosensitivity and computer screen intolerance in patients with post-concussion syndrome (PCS). Twenty-nine patients with PCS, computer intolerance, and photosensitivity performed a reading task for a maximum of 30 min, with an LCD computer or a non-LCD device, and were given a comprehension test after completion of the reading task. The Sport Concussion Assessment Tool 3 was administered before and after each reading task. Symptom scores, amount of time spent reading, and performance on the comprehension tests were compared between the two devices. Patients also completed a self-report questionnaire of their subjective experience. The LCD screen computer produced significantly greater symptom exacerbation (median difference = 5, W = 315, p < 0.01) and a greater number of symptoms (median difference = 1, W = 148, p < 0.01) than the non-LCD screens. The non-LCD screen resulted in a longer symptom-free reading time (median = 48 sec, W = 147, p < 0.01), but not a greater number of words read (median = 281, W = 148, p = 0.098). Females were more likely to have greater symptom exacerbation with the LCD screen (U = 14.0, p < 0.01). No significant difference was found in performance on the comprehension test. Subjective reports showed that the non-LCD experience was more favorable, and most patients stated they would recommend this device for other patients with PCS. This study is the first to show the clinical utility of non-LCD screen computers in the management of photosensitivity and computer screen intolerance in patients with PCS. The non-LCD screen computer has the potential to facilitate return-to-work or return-to-school in concussed individuals.

Vision rehabilitation interventions following mild traumatic brain injury: a scoping review

Purpose: To broadly examine the literature to identify vision interventions following mild traumatic brain injury. Objectives are to identify: (1) evidence-informed interventions for individuals with visual dysfunction after mild traumatic brain injury; (2) professions providing these interventions; (3) gaps in the literature and areas for further research. Methods: A scoping review was conducted of four electronic databases of peer-reviewed literature from the databases earliest records to June 2017. Articles were included if the study population was mild traumatic brain injury/concussion and a vision rehabilitation intervention was tested. Two independent reviewers screened articles for inclusion, extracted data, and identified themes. Results: The initial search identified 3111 records. Following exclusions, 22 articles were included in the final review. Nine studies evaluated optical devices, such as corrective spectacles, contact lenses, prisms, or binasal occlusion. Two studies assessed vision therapy. Ten studies examined vision therapy using optical devices. One study investigated hyperbaric oxygen therapy. Optometrists performed these interventions in most of the studies. Future research should address quality appraisal of this literature, interventions that include older adult and pediatric populations, and interdisciplinary interventions. Conclusions: There are promising interventions for vision deficits following mild traumatic brain injury. However, there are multiple gaps in the literature that should be addressed by future research. Implications for Rehabilitation Mild traumatic brain injury may result in visual deficits that can contribute to poor concentration, headaches, fatigue, problems reading, difficulties engaging in meaningful daily activities, and overall reduced quality of life. Promising interventions for vision rehabilitation following mild traumatic brain injury include the use of optical devices (e.g., prism glasses), vision or oculomotor therapy (e.g., targeted exercises to train eye movements), and a combination of optical devices and vision therapy. Rehabilitation Professionals (e.g., optometrists, occupational therapists, physiotherapists) have an important role in screening for vision impairments, recommending referrals appropriately to vision specialists, and/or assessing and treating functional vision deficits in individuals with mild traumatic brain injury.

Non-pharmacological rehabilitation interventions for concussion in children: a scoping review

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.

Functional Magnetic Resonance Imaging and Oculomotor Dysfunction in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is a significant cause of disability, especially when symptoms become chronic. This chronicity is often linked to oculomotor dysfunction (OMD). To our knowledge, this is the first prospective study to localize aberrations in brain function between mTBI cohorts, by comparing patients with mTBI with OMD with an mTBI control group without OMD, using task and resting-state functional magnetic resonance imaging (fMRI). Ten subjects with mTBI who had OMD (OMD group) were compared with nine subjects with mTBI who had no findings of OMD (control group). These groups were determined by a developmental optometrist using objective testing for OMD. The (convergence) task fMRI data demonstrated significantly decreased brain activity, measured as decreases in the blood oxygen level dependent (BOLD) signal, in the OMD group compared with the control group in three brain regions: the left posterior lingual gyrus, the bilateral anterior lingual gyrus and cuneus, and the parahippocampal gyrus. When doing a seed-based resting state fMRI analysis in the lingual/parahippocampal region, a large cluster covering the left middle frontal gyrus and the dorsolateral pre-frontal cortex (Brodmann areas 9 and 10), with decreased functional correlation in the OMD group, was identified. Together these observations provide evidence for neural networks of interactions involving the control of eye movement for visual processing, reading comprehension, spatial localization and navigation, and spatial working memory that appear to be decreased in mTBI patients with OMD compared with mTBI patients without OMD. The clinical symptomatology associated with post-traumatic OMD correlates well with these MRI findings.

Colored Glasses to Mitigate Photophobia Symptoms Posttraumatic Brain Injury

CONTEXT

  After a concussion or mild traumatic brain injury (mTBI), patients often suffer from light sensitivity, or photophobia, which contributes to decreased quality of life post-mTBI. Whereas sunglasses may provide some relief from photophobia, they are not practical indoors or in low light. A light-mitigation strategy can be easily used indoors as needed to optimize the relief. We have found that many photophobic patients experience relief using colored sunglasses.

OBJECTIVE

  To provide the athletic trainer with a means and method to assess whether an athlete is suffering from photophobia after concussion and to determine if colored glasses provide relief.

DESIGN

  Cross-sectional study.

SETTING

  Rehabilitation clinic.

PATIENTS OR OTHER PARTICIPANTS

  Fifty-one patients being treated after concussion.

INTERVENTION(S)

  We assessed postconcussion patients for visual symptoms including photophobia and photosensitivity. Off-the-shelf glasses were used to determine whether specific colors provided relief from photophobia. Screening was done using a penlight and multiple pairs of colored glasses.

MAIN OUTCOME MEASURE(S)

  Self-reported mitigation of photophobia symptoms and the specific color frequency that reduced symptoms in each individual.

RESULTS

  Of the 39 patients studied who had visual symptoms, 76% complained of photophobia. Using glasses of 1 or more colors, symptoms were relieved in 85% of patients reporting photophobia. The colors that provided the most relief were blue, green, red, and purple. No adverse events were reported.

CONCLUSIONS

  An empirical assessment of frequency-specific photophobia is easy to perform. A traditional penlight is used to elicit photophobia and then the colored glasses are tested for optimal relief. Frequency-specific photophobia can be reduced with a strategy of light-mitigation therapy, including colored glasses, sunglasses, hats, and light avoidance. This, we believe, helps to improve the patient's quality of life and may aid in the recovery process. More work is needed to identify the best colors and methods of mitigating frequency-specific photophobia.

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.