Cervical Injury Assessments for Concussion Evaluation: A Review

The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium

BACKGROUND

Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes.

HYPOTHESIS

New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018.

RESULTS

A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592).

CONCLUSION

This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

The role of the physiotherapist in concussion

In the last decade, concussion research has exploded in multiple fields of scientific research. This has helped to clarify what causes, influences, and perpetuates human concussion, and displays the integral role physiotherapists play in concussion management. In this article we discuss the latest research relevant to the key role of physiotherapy in concussion management. A narrative review of the literature on concussion was conducted. The current review analyses how concussion has influenced physiotherapy in several categories: assessment, treatment, management, research rigour and building the profile of the profession. Scientific concussion research has largely converged in support of the role of physiotherapists utilising specific components including: (1) autonomic, (2) cervicogenic, (3) vestibulo-ocular and (4) psychological approaches to management. Latest research supports the critical role of physiotherapy in concussion care in the assessment, management, and prevention of concussion with scope for further interdisciplinary collaborations.

Clinical implications

Concussion is complex. A basic mental health, Vestibular Ocular Motor Screening (VOMS) and four key components relating to concussion management (autonomic, cervicogenic, vestibular oculomotor, and psychological approaches to management) should be included in the undergraduate and postgraduate curriculum. This will aid clinical physiotherapists to support their patients. A call to advance more intradisciplinary physiotherapy teamwork should be encouraged as valuable knowledge sharing is potentially lost within the framework of 'specialisation'. If needed, the skills of a greater interdisciplinary team are imperative to facilitate patient management and recovery from this multi-faceted injury.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Early Identification and Management of Cervical Impairments in Pediatric Patients With Concussion May Reduce Risk of Delayed Recovery

OBJECTIVE

Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury.

DESIGN

Prospective cohort study.

SETTING

Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019.

PATIENTS

One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion).

INDEPENDENT VARIABLES

Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness).

MAIN OUTCOME MEASURES

Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS.

RESULTS

Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340).

CONCLUSIONS

We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery.

Research Letter: Prevalence of Spine Injuries Among US Military Personnel With Combat-Related Concussion

OBJECTIVE

To describe the prevalence of spine injuries among US service members with combat-related concussion.

DESIGN AND PARTICIPANTS

A retrospective review of medical records for US service members injured during combat operations in Iraq and Afghanistan between 2002 and 2020. The study sample included 27 897 service members categorized into 3 groups: concussion with loss of consciousness (LOC, n = 4631), concussion non-LOC ( n = 5533), and non-concussion ( n = 17 333).

MAIN MEASURES

Spine injuries were identified by International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes and classified by body region and nature of injury using the Barell injury diagnosis matrix. Differences in prevalence of spine injuries by concussion group were evaluated using χ 2 tests.

RESULTS

Spine injuries were most prevalent among service members with concussion LOC (31.1%), followed by concussion non-LOC (18.3%), and non-concussion (10.0%, P < .001). Sprains and strains were the most prevalent spine injury category, with injuries to the cervical, thoracic, and lumbar regions significantly more prevalent in the concussion groups ( P values < .001), particularly individuals with LOC compared with non-concussion.

CONCLUSION

The US military personnel with combat-related concussion, especially individuals with LOC, may also have spine injuries. Routine assessment for spine injury is recommended during concussion screening because this may impact clinical management and rehabilitation.

Pupillometric parameters of alertness during unpredictable but not predictable smooth pursuit neck torsion test are altered in patients with neck pain disorders: a cross-sectional study

Despite commonly investigated predictable smooth-pursuit neck-torsion tasks (SPNT) in neck pain patients, unpredictable conditions have been seldom investigated but are indicative of preserved oculomotor functions during neck torsion. Although not previously studied, some speculations about compensatory cognitive mechanisms such as increased phasic alertness during unpredictable tasks were suggested. The aim of this study was to investigate eye movement accuracy and pupillometric responses during predictable and unpredictable SPNT test in neck pain patients and asymptomatic controls. Eye movements (gain and SPNT-difference) and pupillometry indicative of tonic (average and relative pupil diameter) and phasic (index of cognitive activity-ICA) alertness were measured in 28 idiopathic neck pain patients and 30 asymptomatic individuals using infrared video-oculography during predictable and unpredictable SPNT test. Gain in unpredictable SPNT test was lower as compared to predictable tasks and presented with similar levels in neutral and neck torsion positions, but not in the predictable SPNT test. ICA was lower during neutral position in all tasks in patients as compared to control group but increased during neck torsion positions in unpredictable tasks. Relative pupil diameters presented with no differences between the groups or neck positions, but the opposite was observed for average pupil diameter. Higher ICA indicates an increase in phasic alertness in neck pain patients despite no alterations in oculomotor control during SPNT test. This is the first study to indicate cognitive deficits in oculomotor task in neck pain patients. The latter could negatively affect other tasks where additional cognitive resources must be involved.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms

OBJECTIVE

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups.

METHODS

Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults.

RESULTS

All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings.

CONCLUSION

Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

How well can we detect cervical driven sensorimotor dysfunction in concussion patients? An observational study comparing patients with idiopathic neck pain, whiplash associated disorders and concussion

BACKGROUND

Patients with mild traumatic brain injury (mTBI) suffer from sensorimotor impairments. Evidence is emerging that cervical spine plays an important role in mTBI, but it is not known how cervicocephalic kinaesthetic sensibility measured during dynamic unpredictable head movements and measures of position sense, cervical induced postural balance and eye movement control differ between mTBI, whiplash associated disorders (WAD) patients, idiopathic neck pain patients and healthy controls.

RESEARCH QUESTION

Are cervical sensorimotor deficits present in mTBI patients and do they differ from sensorimotor deficits found in traumatic and nontraumatic neck pain patients and whether they differ from healthy controls.

METHODS

Twenty idiopathic neck pain patients, 18 WAD, 17 mTBI and 20 healthy controls were enroled in the study. Frequency and velocity of centre of pressure movements were measured during parallel stance in the neutral and neck torsion positions, gain and smooth pursuit neck torsion difference of eye movements during smooth pursuit neck torsion test (SPNTT) and cervicocephalic kinaesthesia using Butterfly and head-to-neutral relocation test.

RESULTS

Statistically significant differences in postural balance, both tests of cervicocephalic kinaesthesia and SPNTT were observed between healthy controls and all patient groups. No differences were observed between patient groups for SPNTT, Butterfly and head-to-neutral relocation test, but differences were present in postural balance between mTBI and both groups of patients with neck pain disorders. Differences were found in the ML direction for mTBI, but not differences were found for AP direction.

SIGNIFICANCE

Results of our study show that mTBI present with similar impairment in cervical driven sensorimotor deficits as patients with neck pain disorders, but they differ from healthy individuals. Clinical practice would benefit from identifying cervical spine related sensorimotor impairments in patients with mTBI. This could enable to design more targeted prevention and rehabilitation programs to minimise cervical spine related disorders in concussion patients.

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Eye tracking for classification of concussion in adults and pediatrics

Introduction

In order to obtain FDA Marketing Authorization for aid in the diagnosis of concussion, an eye tracking study in an intended use population was conducted.

Methods

Potentially concussed subjects recruited in emergency department and concussion clinic settings prospectively underwent eye tracking and a subset of the Sport Concussion Assessment Tool 3 at 6 sites. The results of an eye tracking-based classifier model were then validated against a pre-specified algorithm with a cutoff for concussed vs. non-concussed. The sensitivity and specificity of eye tracking were calculated after plotting of the receiver operating characteristic curve and calculation of the AUC (area under curve).

Results

When concussion is defined by SCAT3 subsets, the sensitivity and specificity of an eye tracking algorithm was 80.4 and 66.1%, The AUC was 0.718. The misclassification rate (n = 282) was 31.6%.

Conclusion

A pre-specified algorithm and cutoff for diagnosis of concussion vs. non-concussion has a sensitivity and specificity that is useful as a baseline-free aid in diagnosis of concussion. Eye tracking has potential to serve as an objective “gold-standard” for detection of neurophysiologic disruption due to brain injury.

Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes

OBJECTIVES

To explore the prevalence of acute neck pain in high school athletes following sports-related concussion (SRC) and to examine the role of acute neck pain in modifying or amplifying concurrent concussive symptoms.

DESIGN

Retrospective observational.

SETTING

High school sporting events.

PARTICIPANTS

High school athletes who suffered a sports-related concussion between the 2011 and 2019 academic years academic years from the National Athletic Treatment, Injury and Outcomes Network (NATION) Study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence of neck pain (yes/no) along with 33 other commonly reported concussion symptoms, number of symptoms reported, mechanism of injury (contact with person/surface or object), sport type (contact/noncontact), and injury history (first time/repeated injury).

RESULTS

One hundred thirty-eight of 401 athletes (33.9%) indicated acute neck pain following SRC. Those with neck pain reported significantly more symptoms overall (M = 13.53, SD = 6.89) relative to their non-neck pain counterparts (M = 8.46, SD = 5.68; t [191.35] = 7.11, P < 0.001). Athletes with SRC due to contact with a surface were significantly less likely to report neck pain than those reported contact with a person. Neck pain, repeated injury, and female sex were significantly associated with a greater number of concussion symptoms in the acute phase.

CONCLUSIONS

Our data suggest that acute neck pain is a frequent acute symptom following SRC and signals the necessity for additional screening to seek and identify comorbid cervical pathology. Prospective studies should seek to access the benefit of cervical therapy in the early stages in SRC patients with neck pain to reduce the risk of persistent postconcussion symptoms.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion

OBJECTIVE

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.

DESIGN

Cross sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients ≤14 days post concussion.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.

RESULTS

We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).

CONCLUSIONS

In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Cervical spine characteristics differ in competitive combat athletes compared with active control participants

BACKGROUND

Injury to the head and neck are common in combat sport athletes. Impairments of the cervical spine have been found in some athletes who participate in sports with high forces and collisions. There is a lack of research on the effects of combat sports on the cervical spine.

OBJECTIVE

The primary study aim was to investigate differences in cervical spine characteristics between combat athletes and a similarly aged active control group. The secondary aim was to investigate the relationship between symptom-based outcome measures and characteristics of the cervical spine.

DESIGN

Cross-sectional.

METHOD

40 male adult combat sport athletes and 40 male adult control participants were recruited from 4 combat sport clubs and a university campus, Australia. Cervical spine assessments were conducted at a private physiotherapy clinic. The Neck Disability Index and the Post-Concussion Symptom Scale were used as symptom-based outcome measures.

RESULTS

Combat sport athletes had a reduced range of cervical motion, but greater isometric strength and endurance compared with a control group (p < 0.05). The Neck Disability Index and Post-Concussion Symptom Scale were negatively correlated with cervical spine range of motion and isometric strength, meaning that higher scores correlated with a reduction in function.

CONCLUSIONS

Differences were observed in characteristics of the cervical spine in combat sport athletes compared with a control group. Higher symptom-based outcome scores correlated with reduced range of motion and strength of cervical spine muscles. Further investigation to establish clinical cut-off scores for functional impairment may be warranted.

A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools

BACKGROUND

It can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear.

OBJECTIVE

To identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event.

DESIGN

Scoping review.

METHOD

A structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described.

RESULTS

The structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination.

CONCLUSION

Few standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.

Practical Management: Telehealth Examination for Sport-Related Concussion in the Outpatient Setting

ABSTRACT

This article presents the telehealth version of the Buffalo Concussion Physical Examination (BCPE) (Tele-BCPE). It is a brief, focused telehealth PE for use in the outpatient setting by sports medicine physicians, pediatricians, neurologists, and primary care physicians. It is derived from the BCPE and includes general considerations for providers performing telehealth services and instructions for adapting traditional clinical tests for virtual use. The Tele-BCPE includes an orthostatic intolerance screen, examination of the cranial nerves, and tests of the oculomotor, vestibular, and cervical systems. It is meant to be used at initial and follow-up outpatient visits for patients acutely after concussion and in those with prolonged symptoms. This telehealth PE, when combined with other assessments, can help provide direct treatment to patients at any stage after concussion and reduce barriers to healthcare access posed by the COVID-19 pandemic and for patients living in rural or underserved areas.

Cervical Fracture During COVID-19 Pandemic Era: A Case Series

Background

Cervical fractures are potentially serious and can have fatal consequences if not treated properly. Correct diagnosis and classification of injury is the first step in determining the most appropriate treatment. Cervical fractures will have an impact on the patient’s work, and COVID-19 is a challenge in the hospital to treat a cervical fracture. This study aims to discuss the case of patients with cervical fractures that have undergone surgical treatment in the COVID-19 pandemic.

Case Presentation

Two cases of emergency patients with cervical injury treated at the hospital in the acute setting of the COVID-19 pandemic. All these patients experienced delayed timing to arrive in the emergency department of Prof. Dr. R. Soeharso Orthopedic Hospital. Neurological outcome was assessed before being discharged after surgery and a 3-month follow-up post-surgery.

Results

Laminectomy and posterior stabilization and fusion (PSF) were performed immediately after diagnosis was established in both patients. Physical rehabilitation was performed. In a 3-month follow-up, both patients’ neurological functions improved.

Conclusion

Clinical outcomes of cervical injury patients can be affected by some factors, for example, timing to diagnosis, timing to traction application, timing to surgery, and timing to rehabilitation. Depending on the institution, weekend days can also affect the delay of the COVID-19 PCR swab. MRI schedule and patient optimal condition can also affect the timing to surgery. The immediate diagnosis and prompt treatment are needed to make a better outcome, especially better neurological status.

Clinical Assessment of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion produces a variety of signs and symptoms. Most patients recover within 2-4 weeks, but a significant minority experiences persistent post-concussive symptoms (PPCS), some of which may be from associated cervical or persistent neurologic sub-system (e.g., vestibular) dysfunction. This review provides evidence-based information for a pertinent history and physical examination of patients with concussion.

RECENT FINDINGS

The differential diagnosis of PPCS is based on the mechanism of injury, a thorough medical history and concussion-pertinent neurological and cervical physical examinations. The concussion physical examination focuses on elements of autonomic function, oculomotor and vestibular function, and the cervical spine. Abnormalities identified on physical examination can inform specific forms of rehabilitation to help speed recovery. Emerging data show that there are specific symptom generators after concussion that can be identified by a thorough history, a pertinent physical examination, and adjunct tests when indicated.

Evaluation of the Effect of Atorvastatin Administration on the Outcomes of Patients with Traumatic Brain Injury: A Double-blinded Randomized Clinical Trial

Background

Traumatic brain injury (TBI) is one of the common causes of long-term disabilities and mortality. This study aimed to evaluate the effect of atorvastatin administration on the Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), and Disability Rating Scale (DRS) in patients with TBI.

Methods

This double-blinded randomized clinical trial included 60 patients with TBI in Golestan Hospital of Ahvaz, Iran. After obtaining an informed consent from all patients, the patients were randomly assigned into two groups. For the intervention group, atorvastatin with a daily dose of 20 mg was used. The control group was administered the same amount of placebo for 10 days. Changes in the level of consciousness were measured using the GCS, and functional recovery rate in patients was measured by GOS and DRS in the third follow-up month.

Results

According to the obtained results, compared with the control group, the atorvastatin administration significantly increased the level of GCS and DRS within 2 - 3 months post-intervention and improved GOS since the tenth day after the study (P < 0.05).

Conclusions

The results revealed the positive effect of atorvastatin on the improvement of outcomes measurements such as GCS, DRS, and GOS in patients after moderate and severe TBI.

Can the neck contribute to persistent symptoms post concussion? Long-term follow up from a prospective descriptive case series

OBJECTIVE

To describe individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment as part of multidisciplinary concussion care. A secondary objective is to report on how participants describe the outcomes of neck treatmentMethods: Long-term follow-up for a subgroup of participants in a prospective case series (n = 11). Data were collected at initial assessment, completion of neck treatment, 6 and 12 months including standard questionnaires (Rivermead post-concussion symptoms questionnaire, neck disability index, dizziness handicap inventory); patient-reported measures of headache, dizziness and neck pain and participant descriptions of the effects of neck treatmentResults: Grouped measures of post-concussion symptoms were further improved or sustained at 6 and 12 months. Ten of the 11 participants reported neck treatment as a beneficial part of their care and described the effects on the neck, multiple symptoms and their overall recovery. However, seven participants experienced recurrent headache, neck pain or dizziness at 6- or 12-month follow-up.

CONCLUSION

Long-term follow-up of individuals receiving neck treatment shows improvement across a range of patient reported outcomes, yet highlights frequent recurrence of symptoms. Neck treatment can play a valuable role in people's recovery that extends beyond local effects on the neck.

Changes in White Matter of the Cervical Spinal Cord after a Single Season of Collegiate Football

The involvement of the central nervous system (CNS), specifically the white matter tracts in the cervical spinal cord, was examined with diffusion tensor imaging (DTI) following exposure to repetitive head acceleration events (HAEs) after a single season of collegiate football. Fifteen National Collegiate Athletic Association (NCAA) Division 1 football players underwent DTI of the cervical spinal cord (vertebral level C1–4) at pre-season (before any contact practices began) and post-season (within 1 week of the last regular season game) intervals. Helmet accelerometer data were also collected in parallel throughout the season. From pre-season to post-season, a significant decrease (p < 0.05) of axial diffusivity was seen within the right spino-olivary tract. In addition, a significant decrease (p < 0.05) in global white matter fractional anisotropy (FA) along with increases (p < 0.05) in global white matter mean diffusivity (MD) and radial diffusivity (RD) were found. These changes in FA from pre-season to post-season were significantly moderated by previous concussion history (p < 0.05) and number of HAEs over 80 g (p < 0.05). Despite the absence of sports-related concussion (SRC), we present measurable changes in the white matter integrity of the cervical spinal cord suggesting injury from repetitive HAEs, or SRC, may include the entirety of the CNS, not just the brain.

The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review

BACKGROUND

Patients with cervicogenic symptoms following a concussion have shown a disproportionate rate of delayed symptom resolution. However, the prevalence of cervicogenic symptoms in the acute stages following a concussion and the percentage of those patients who continue on to suffer delayed symptom resolution is poorly described in the literature.

OBJECTIVES

To provide a comprehensive report on the clinical prevalence, diagnostic methods, and potential treatment options for cervicogenic symptoms that are elicited during acute and chronic phases following a concussion.

METHODS

Electronic searches were conducted in PubMed, SPORTDiscus, ICL, CINAHL and PEDro, from inception to May 2020, to identify original research articles on concussion involving cervicogenic symptoms. We assessed each included article for risk of bias, methodological quality, level of evidence and evidence quality. The articles were categorized into three topics: (1) prevalence of post-concussion cervicogenic symptoms; (2) diagnostic testing for cervicogenic symptoms, and (3) treatment techniques for cervicogenic symptoms.

RESULTS

The initial review resulted in 1443 abstracts, of which 103 abstracts met the inclusion criteria of our research. After the review of full text, 80 articles were excluded, which resulted in a total of 23 articles for this systematic review. Prevalence of cervicogenic symptoms in the acute stages ranged from 7 to 69% and increased to 90% in patients experiencing persistent post-concussive symptoms. Neck pain at initial evaluation increased risk of developing persistent post-concussive symptoms (PPCS) by 2.58-6.38 times. Patient-reported outcome measures (e.g., Neck Disability Index, Dizziness Handicap Inventory, and Rivermead Post-Concussion Questionnaire) can identify patients with cervicogenic symptoms that should be further differentiated by clinical testing. Lastly, treatment using graded cervical manual therapy has shown to reduce time to symptom resolution and medical clearance.

CONCLUSIONS

Cervicogenic symptoms are prevalent in the acute and chronic stages following concussion, which if not diagnosed appropriately increase the likelihood of PPCS. Several clinical tests are available to help differentiate cervicogenic symptoms; however, lack of awareness and hesitation by practitioners limits their use. More randomized controlled trials are necessary to evaluate the effectiveness of cervical specific treatment programs for PPCS.

Inter-Visit Reliability of Smooth Pursuit Neck Torsion Test in Patients with Chronic Neck Pain and Healthy Individuals

Visual disturbances are commonly reported in patients with neck pain. Smooth pursuit neck torsion (SPNT) test performed in neutral position and with trunk rotated under the stationary head has been used to discriminate between those with cervical component and those without. However, no studies investigated the reliability of the SPNT-test in patients with chronic neck pain and healthy controls. The aim of this study was to assess inter-visit reliability of the SPNT-test while applying different amplitudes and velocities of target movement. Thirty-two controls and thirty-one patients were enrolled in the study. The SPNT-test was performed in neutral position and through 45° torsion positions. The test was performed at 20°/s, 30°/s and 40°/s velocities and at 30°, 40° and 50° amplitudes of cyclic sinusoidal target movements. Interclass correlation coefficient and smallest detectable change were calculated for parameters of gain and SPNT-differences. In patients, moderate to good reliability was observed for gain at 40° and 50° amplitudes and for 20°/s and 30°/s velocities, while moderate to excellent reliability for gain was observed in controls. Both groups presented with moderate to good reliability for SPNT-difference. Our findings imply that amplitudes of 40° and 50° and velocities of 20°/s and 30°/s are the most reliable and should be applied in future studies assessing oculomotor functions during the SPNT test.

Certified Athletic Trainers' Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion

CONTEXT

Despite evidence implicating cervicogenic symptoms in the development of persistent postconcussion symptoms, factors that influence utilization of cervical clinical tests to identify cervicogenic symptoms following concussion are poorly understood.

OBJECTIVE

Explore barriers to the utilization of cervical clinical testing in multifaceted concussion evaluation.

DESIGN

Cross-sectional.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 122 athletic trainers (AT) (age = 42.6 [6.4] y; female = 51.6%; 52% >10 y of clinical practice; 68% master's degree or greater; 35% treated a minimum of 15 concussions/y).

MAIN OUTCOME MEASURE(S)

Perceived importance, clinical experience, number of concussions treated, utilization of cervical clinical tests following nonspecific cervical pathology and following concussion, comfort with cervical treatment modalities following a concussion, and recommendation for cervical-specific therapy to treat persistent postconcussion symptoms.

RESULTS

Ordinal logistic regression revealed perceived importance had the strongest positive impact on AT's likelihood of high utilization of cervical clinical testing following concussion (95% CI, .17 to .99; P = .005), while clinical experience (95% CI, -.43 to .29; P = .71) and number of concussions treated/y (95% CI, -.21 to .31; P = .71) had no bearing. Moreover, low comfort with cervical treatments following a concussion (95% CI, -2.86 to -.26; P = .018) and low utilization of cervical clinical testing following nonspecific cervical pathology (95% CI, -7.01 to -3.39; P ≤ .001) had a strong positive impact on high utilization of cervical clinical testing following concussion. Two logistic regression models demonstrated how recommendations for cervical-specific therapy in persistent post-concussion symptom patients could be predicted based on (1) cervical test utilization and (2) perceptions and clinical experience with 79% and 78%, respectively.

CONCLUSIONS

Perceived importance played a major role in utilization of cervical clinical test following concussion. ATs who utilized common cervical treatments when dealing with non-concussive injuries were more likely to utilize those same treatments to treat comorbid cervical pathology following a concussion.

Diagnostic Utility of New SCAT5 Neurological Screen Sub-tests

Background

The Sports Concussion Assessment Tool (SCAT) is recommended to screen for concussion following head impact events in elite sport. The most recent 5th edition (SCAT5) included a ‘rapid neurological screen’ which introduced new subtests examining comprehension, passive neck movement, and diplopia. This study evaluated the additional diagnostic value of these new subtests.

Methods

A prospective cohort study was performed in the Pro14 elite Rugby Union competition between September 2018 and January 2020. The SCAT5 was administered by the team doctor to players undergoing off-field screening for concussion during a medical room assessment. Sensitivity, specificity, false negatives, and positives were examined for SCAT5 comprehension, passive neck movement, and diplopia subtests. The reference standard was a final diagnosis of concussion, established by serial standardised clinical assessments over 48 h.

Results

Ninety-three players undergoing off-field screening for concussion were included. Sensitivity and specificity of the comprehension, passive neck movement, and diplopia subtests were 0, 8, 5% and 0, 91, 97%, respectively (concussion prevalence 63%). No players had any abnormality in comprehension. No players had abnormal passive neck movement or diplopia in the absence of abnormalities in other SCAT5 sub-components.

Conclusions

The new SCAT5 neurological screen subtests are normal in the majority of players undergoing off-field concussion screening and appear to lack diagnostic utility over and above other SCAT5 subtests.

Differences in cervical kinesthesia between amateur athletes with and without a history of contact sport participation

Objective: Identify cervical sensorimotor function differences between amateur athletes with and without a history of contact sport participation. A secondary aim of the study was to explore the association between neck reposition error and previously identified injury risk factors.Design: Cross-sectional.Participants: 27 amateur campus recreation sport athletes with a history of contact sport participation and 20 amateur campus recreation sport athletes with no history of contact sport.Main Outcome Measures: Baseline signs and symptoms (S/S) number and severity, Neck Disability Index, total neck reposition error, maximum reposition error, cervical range of motion, and cervical isometric strength were then compared between independent factor groups (contact vs. non-contact).Results: Amateur sport athletes with a history of contact sport exposure exhibited 25.2% more total neck reposition error and 24.6% more maximum neck reposition error than athletes with no history of contact sport participation. S/S number (r2 = .12, F(2,44) = 6.2, p = .017) and S/S severity (r2 = .14, F(2,44) = 5.6, p = .02) were significantly correlated with total neck reposition error.Conclusions: Athletes with a history of contact sport participation exhibited greater cervical spine reposition error. The degree to which these sensory position-sense deficits increase risk of injury and long-term quality of life is unknown, but should be explored in future studies.

The association of concussion history and symptom presentation in combat sport athletes

OBJECTIVE

The purpose of this study was to describe the concussion-related symptoms reported among combat sport athletes with and without a history of concussion, and a history of neck injury.

DESIGN

Cross-sectional survey.

SETTING

Data were collected using an online survey instrument.

PARTICIPANTS

Three hundred and nine adult combat sport athletes.

MAIN OUTCOME MEASURES

Self-reported 12-month concussion history and neck injury history and a 22-item symptom checklist.

RESULTS

A history of concussion was reported by 19.1% of athletes, a history of neck injury was reported by 23.0%, and 13.6% reported both injuries. Neck pain was the most frequently reported symptom. Athletes with a history of injury had significantly greater proportions of 'high' total symptoms and symptom severity scores compared with athletes with no history of injury. Athletes with a history of concussion had 2.35 times higher odds of reporting 'high' total symptoms and symptoms severity scores.

CONCLUSION

Athletes with a history of concussion or neck injury have greater odds of presenting with higher symptom scores. The presence of high total symptom scores and high symptom severity scores may indicate a need for further investigation into domains commonly associated with concussion.

Diagnosis clinical criteria of sport related concussion: Toward an operational criteria definition in France

OBJECTIVE

An expert working group was set up at the initiative of the French Ministry of Sports with the objective of harmonising the management of sport related concussion (SRC) in France, starting with its definition and diagnosis criteria.

RESULTS

Definition: A clinical definition in 4 points have been established as follows: Concussion is a brain injury: 1) caused by a direct or indirect transmission of kinetic energy to the head; 2) resulting in an immediate and transient dysfunction of the brain characterised by at least one of the following disorders: a) Loss of consciousness, b) loss of memory, c) altered mental status, d) neurological signs; 3) possibly followed by one or more functional complaints (concussion syndrome); 4) the signs and symptoms are not explained by another cause. Diagnosis criteria: In the context of the direct or indirect transmission of kinetic energy to the head, the diagnosis of concussion may be asserted if at least one of the following signs or symptoms, observed or reported, is present within the first 24hours and not explained by another cause: 1) loss of consciousness; 2) convulsions, tonic posturing; 3) ataxia; 4) visual trouble; 5) neurological deficit; 6) confusion; 7) disorientation; 8) unusual behaviour; 9) amnesia; 10) headaches; 11) dizziness; 12) fatigue, low energy; 13) feeling slowed down, drowsiness; 14) nausea; 15) sensitivity to light/noise; 16) not feeling right, in a fog; 17) difficulty concentrating.

CONCLUSION

Sharing the same definition and the same clinical diagnostic criteria for concussion is the prerequisite for common rules of management for all sports and should allow the pooling of results to improve our knowledge of this pathology.

Rehabilitation of Sport-Related Concussion

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.

Does interprofessional concussion management improve recovery in varsity athletes? A year to year effectiveness-implementation hybrid study

OBJECTIVES

The main purpose of this study was to explore the effectiveness of an integrated interprofessional management (IPM) concussion care approach in varsity athletes.

SETTING

The study was completed in a university environment with varsity athletes.

DESIGN

Data analysis was quantitative, as compared between seasons, in this observational cohort study.

MAIN OUTCOME MEASURES

The metrics for the effectiveness of the IPM team were: time spent in treatment and post-concussion symptom severity scores. These measures were compared for each season year and both sexes for the primary concussive domain they were initially diagnosed with.

PARTICIPANTS

University varsity athletes from various in-season teams.

RESULTS

A Kruskal-Wallis revealed that 2017/18 athletes spent a significantly shorter amount of time in treatment between the two seasons, median 29 days in the 2016/17 season year (IQR = 29) versus 13 days in the 2017/18 season year (IQR = 11), for both sexes (p = 0.009). It appears women tended to recover more quickly than men, particularly in the 2016/2017 season first year.

CONCLUSIONS

A highly communicative interprofessional management (IPM) strategy was shown to lead to reduced return to play (RTP) and return to learn (RTL) times. Increased experience as an IPM team may be a factor contributing to the effectiveness in IPM strategies as well as overall concussion treatment.

Physician Medical Assessment in a Multidisciplinary Concussion Clinic

Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.

Presence of Neck or Shoulder Pain Following Sport-Related Concussion Negatively Influences Recovery

Our objective was to examine the effect of current neck or shoulder pain on concussion outcomes. Variables included symptom resolution and return-to-sport time, symptom severity, amount of school missed, and sleep disturbances. Three hundred twelve patients (37% female; median age = 15.0 years; evaluated median = 9 days postinjury) reported experiencing current neck or shoulder pain at initial evaluation, and 268 did not (31% female; median age = 14.7 years; evaluated median = 8 days postinjury). Neck or shoulder pain was associated with longer symptom resolution time (β = 6.38, 95% confidence interval [CI] = 2.44, 10.31; P = .002), more severe symptoms (β = 7.06, 95% CI = 4.91, 9.21; P < .001), and greater odds of missing >5 days of school (adjusted odds ratio [aOR] = 1.89, 95% CI = 1.23, 2.93; P = .004), and postinjury sleep problems (aOR = 2.20, 95% CI = 1.51, 3.21; P < .001). Experiencing neck or shoulder pain during the initial postinjury clinical evaluation was associated with worsened clinical outcomes. Clinicians may consider referral to early rehabilitation following concussion among those who report neck or shoulder pain.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

Evaluation of a pilot paediatric concussion telemedicine programme for northern communities in Manitoba

Pediatric concussion patients living in northern communities in Canada can face unique challenges accessing primary and specialized healthcare. In this study we report the clinical characteristics, healthcare utilization, outcomes and estimated cost avoidance associated with a pilot pediatric concussion telemedicine program established between a multi-disciplinary pediatric concussion program in Winnipeg, Manitoba and a hospital in Thompson, Manitoba. From October 1^st- July 1^st, 2018, 20 patients were evaluated; mean age 13.1 years, 15 (75%) males and 14 (70%) self-identified as Indigenous. Injury mechanisms included hockey (50%), falls (35%) and assaults (15%). Median time from referral to initial consultation was 2.0 days. After screening by the neurosurgeon, 90% of patients underwent initial consultation via real-time videoconferencing with 80% managed exclusively through telemedicine. At the end of the study, 90% met the criteria for clinical recovery, one remained in treatment and one was discharged to a headache neurologist. Sixty-six telemedicine encounters were completed including 57 videoconferencing appointments and 9 telephone follow-ups representing an estimated cost avoidance of $40,972.94. This study suggests telemedicine may be a useful approach to assist pediatric concussion programs with delivering timely, safe and cost-effective care to patients living in medically underserviced remote and northern communities in Canada.

Normative Responses to Clinical Tests for Cervicogenic Dizziness: Clinical Cervical Torsion Test and Head-Neck Differentiation Test

BACKGROUND

The clinical diagnosis of cervicogenic dizziness (CGD) is challenging because of a lack of sensitive and specific diagnostic tests. It is vital for clinicians to know normative responses to suggested clinical tests to help them develop the method and interpretation of these tests and maximize their diagnostic value for CGD.

OBJECTIVE

The purpose of the study was to determine normative responses to the clinical application of the cervical torsion test and the head-neck differentiation test, with consideration of different age groups and sex.

DESIGN

This was an observational study.

METHODS

One hundred forty-seven people who were healthy and asymptomatic served as controls and performed both tests, which involved 3 components: cervical torsion, cervical rotation, and en bloc rotation (head and trunk rotation together).

RESULTS

Thirty-five (23.81%) of the 147 participants reported some symptoms (mild dizziness, visual disturbances, unusual eye movements on opening eyes after the test, motion sickness, or nausea) on 1 or more of the 3 test components in either test. The specificity when using a positive response to torsion alone (ie, a negative response to the rotation or en bloc component) was high (for the cervical torsion test, 98.64%; for the head-neck differentiation test, 89.8%), as participants with likely global sensorimotor sensitivity were eliminated. The combined specificity was 100%, as no participants presented with exclusive positive torsion results in both tests. Age and sex did not influence the results.

LIMITATIONS

There were several examiners who were not blinded.

CONCLUSIONS

Confirmation of the high specificity of these clinical tests with the method used in this study to conduct and interpret the results will allow future research to determine the sensitivity of these clinical measures in a population with CGD and specificity in those with dizziness of other origins.

Concussion Guidelines Step 2: Evidence for Subtype Classification

BACKGROUND

Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments.

OBJECTIVE

To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury.

METHODS

A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD).

RESULTS

The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P < .05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD = 0.66 and 0.24; P < .001). Furthermore, ocular-motor in adult patients (SMD = 0.72; P < .001) and vestibular symptoms in both pediatric and adult patients (SMD = 0.18 and 0.36; P < .05) were significantly worse in concussion patients than in controls.

CONCLUSION

Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.

Use of information modelling techniques to understand research trends in eye gaze estimation methods: An automated review

Eye gaze tracking has been used to study the influence of visual stimuli on consumer behavior and attentional processes. Eye gaze tracking techniques have made substantial contributions in advertisement design, human computer interaction, virtual reality and disease diagnosis. Eye gaze estimation is considered critical for prediction of human attention, and hence indispensable for better understanding human activities. In this paper, Latent Semantic Analysis is used to develop an information model for identifying emerging research trends within eye gaze estimation techniques. An exhaustive collection of 423 titles and abstracts of research papers published during 2005-2018 were used. Five major research areas and ten research trends were classified based upon this study.

Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series

BACKGROUND

Persistent symptoms post concussion can arise from a range of sources, including the neck. There is little description of neck assessment findings in people with persistent symptoms post concussion.

OBJECTIVES

To assess people with persistent symptoms following a concussion and determine whether the neck has also been injured, and to evaluate the potential of the neck to contribute to their symptoms.

METHODS

A consecutive series of participants (n = 20) referred for neck assessment were prospectively recruited by 2 providers of a multidisciplinary concussion service for people with persistent symptoms. Data were collected at initial assessment and on completion of neck treatment, which included standard questionnaires (Rivermead Post Concussion Symptoms Questionnaire, Neck Disability Index, Dizziness Handicap Inventory); patient-reported measures of headache, dizziness, and neck pain; physical examination findings; and details of comorbidities.

RESULTS

Participants were evaluated at a mean of 7.5 weeks post concussion (median, 5 weeks). On neck assessment, 90% were considered by the clinician to have a neck problem contributing to their current symptoms. Multiple findings were consistent with this view, including moderate-to-severe Neck Disability Index scores (mean ± SD, 33.4 ± 9.5 points), frequent neck pain (85%), frequent moderate-to-severe pain on occiput-C4 segmental assessment (85%), a positive flexion-rotation test (45%), and muscle tenderness (50%-55%).

CONCLUSION

Multiple findings were indicative of concurrent neck injury, particularly involving the upper cervical spine. These neck-related findings are important to recognize, as they have the potential to contribute to persistent symptoms post concussion and may respond to neck treatment. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001183471). J Orthop Sports Phys Ther 2019;49(11):845-854. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8547.

Re-conceptualizing postural control assessment in sport-related concussion: Transitioning from the reflex/hierarchical model to the systems model

Background: While postural control impairment is common following sport-related concussion, few investigations have studied the physiological basis for this impairment. Both the Reflex/Hierarchical Model and the Systems Model are commonly used to characterize the physiological basis of postural control.Purpose: To discuss the physiological basis of postural control impairment resulting from sport-related concussion based on these models and suggest directions for future research.Methods: Narrative literature review.Findings: Postural control impairment seen with sport-related concussion is a multifaceted construct that can result from deficits in numerous systems that underlie postural control as described by the Systems Model, rather than a unidimensional construct that stems from the central nervous systems' inability to integrate sensory input to control posture as per the Reflex/Hierarchical Model.Conclusion: We recommend a transition away from the Hierarchical/Reflex Model of postural control towards the Systems Model in the conceptualization of sport-related concussion. Future research on postural control following sport-related concussion should account for the multifaceted nature of the resulting postural control impairment based on the Systems Model. Clinically, there is a need for a clinical postural control test that allows examination across the affected systems under single-task, dual-task, and sport-specific paradigms.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BACKGROUND

Concussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important.

OBJECTIVES

To determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery.

DESIGN

Longitudinal observational study.

METHODS

Pre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments.

RESULTS

There was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation.

CONCLUSIONS

While no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.

Concussion - Part I: The need for a multifaceted assessment

INTRODUCTION

Concussion is among the most commonly occurring sport and recreation injuries in today's society. An understanding of the heterogenous nature of concussion will assist in directing a multifaceted and comprehensive interdisciplinary assessment following injury.

PURPOSE

The purpose of this masterclass article is to summarize the current state of the evidence in the area of concussion, describe typical symptom presentations and assessment techniques that may assist in directing appropriate management following concussion.

IMPLICATIONS

A comprehensive assessment including a thoughtful differential diagnosis will assist the clinician to direct care appropriately and efficiently in individuals who have suffered a concussion.

Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis

BACKGROUND

Clinical management of sport-related concussion typically involves a symptom checklist, clinical examination of mental status, and neurocognitive testing. However, recent studies have identified unresolved, impaired sensorimotor function after athletes return to sport. A review and meta-analysis of all current literature regarding risk of subsequent musculoskeletal (MSK) injury after concussion has yet to be published in the medical literature.

PURPOSE/HYPOTHESIS

To determine the odds that athletes will sustain MSK injury after concussion. It was hypothesized a priori that concussion would increase the risk for MSK injury.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed and Google Scholar were searched from January 2000 to November 2017. Reference lists of the included studies were manually searched. Two reviewers independently searched the literature for studies published in English that reported MSK injury after athletes returned to play following a concussion. Two independent reviewers completed data extraction using PRISMA guidelines and assessed study quality using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institutes of Health. Random effects meta-analyses were used to calculate odds ratio (OR) and incidence rate ratio (IRR) of MSK injury after concussion. The primary study outcome of interest was the number of athletes who sustained MSK injury after concussion.

RESULTS

Eight studies met inclusion criteria for meta-analysis. Meta-analysis results indicated that athletes who had a concussion had 2 times greater odds of sustaining a MSK injury than athletes without concussion (OR, 2.11; 95% CI, 1.46-3.06). In addition, athletes with concussion demonstrated a higher incidence of MSK injury after return to sport compared with nonconcussed athletes (IRR, 1.67; 95% CI, 1.42-1.96). Further analysis showed that both male and female athletes with concussion were at an increased risk of MSK injury compared with their respective same-sex, nonconcussed controls (OR > 1.56, P < .01).

CONCLUSION

Based on the evidence of higher risk of MSK injuries after concussion, standard clinical assessments for athletes with concussion should include not only physical symptoms and cognitive function before return to sport but also neuromuscular risk factors associated with increased risk for MSK injuries.

EPIDEMIOLOGY of NECK INJURIES ACCOMPANYING SPORT CONCUSSIONS in YOUTH OVER a 13-YEAR PERIOD IN a COMMUNITY-BASED HEALTHCARE SYSTEM

Background

The same trauma that produces concussion may also produce neck injury. The signs of concussion and neck injury are similar, and symptoms after acceleration-deceleration trauma to the head-neck complex do not accurately discriminate between them. Research on the epidemiology of neck injury among sport-concussed youth is sparse.

Purpose

The purpose of this study was to investigate the epidemiology of diagnosed neck injury in non-sport-related concussion (Non-SRC) versus sport-related concussion (SRC) in youth by age, sex, and sport.

Study design

Cross-sectional epidemiologic study.

Methods

De-identified data from community-based electronic health records over 13 years were extracted to analyze rates and characteristics of neck injuries among non-SRCs and SRCs in youth aged five to 21. Neck injury diagnosis prevalence rates and odds ratios were calculated to estimate risk of neck injury among concussed youth, comparing non-SRCs to SRCs by age and sex.

Results

Sixteen thousand, eight hundred eighty-five concussion records were extracted, of which 3,040 SRCs and 2,775 non-SRCs in youth aged five to 21 were identified by cross-filtering sport-related keywords (e.g., football, basketball, soccer, running, swimming, batting, horseback riding, skiing, etc.) with all ICD-9 and ICD-10 concussion codes. The prevalence of neck injuries diagnosed among SRCs (7.2%) was significantly different than the prevalence of neck injuries diagnosed among non-SRCs (12.1%, p < 0.000). Neck injury diagnoses were significantly more prevalent in females overall (p < 0.000) and among non-SRCs (p < 0.000). The prevalence of neck injury diagnoses was not significantly higher in concussed females versus concussed males with SRC (p = 0.164).Among youth aged five to 21 exposed to concussions, non-SRCs were more likely to be accompanied by a neck injury diagnosis than SRCs (OR 1.66; 95% CI 1.39 to 1.98; p < 0.000). Similarly, female-to-male neck injury proportion ratios were significantly higher in females in non-SRCs compared to SRCs (IPR 1.90, 95% CI 1.60 to 2.25, p < 0.000).Sports with highest prevalence of concussion differ from sports with highest prevalence of concussion-related neck injury in both sexes.

Conclusions

The overall prevalence of diagnosed neck injuries in youth was higher in non-SRCs compared to SRCs (12.1 vs. 7.2%, p < 0.001), with the highest prevalence at age 14 in both sexes. The risk of neck injury diagnosis accompanying concussion was significantly higher in females compared to males (6.1% difference; p < 0.000).

CHARACTERIZATION OF CERVICAL SPINE IMPAIRMENTS IN CHILDREN AND ADOLESCENTS POST-CONCUSSION

BACKGROUND

Patients with concussion may present with cervical spine impairments, therefore accurate characterization of cervical post-concussion impairments is needed to develop targeted physical therapy interventions.

PURPOSE

To characterize the type, frequency and severity of cervical impairments in children and adolescents referred for physical therapy after concussion.Study design: Retrospective, descriptive study.

METHODS

A retrospective analysis was conducted for 73 consecutive children and adolescents who received cervical physical therapy following a concussion. Data was classified into six broad categories. The frequency and intensity of cervical impairments within and across the categories was reported.

RESULTS

Ninety percent of patients demonstrated impairments in at least three out of five assessment categories whereas 55% demonstrated impairments in at least four out five assessment categories. Of the five assessment categories, posture (99%) and myofascial impairment (98%) demonstrated highest impairment frequency followed by joint mobility (86%) and muscle strength (62%). Cervical joint proprioception was the least commonly evaluated assessment category.

CONCLUSION

High prevalence of cervical spine impairments was observed in the subjects included in this study with muscle tension, joint mobility, and muscle strength being most commonly affected. The categories of impairments examined in this cohort were consistent with the recommendations of the most recent clinical practice guidelines for neck pain. This study provides preliminary data to support the framework for a cervical spine evaluation tool in children and adolescents following concussion.

LEVEL OF EVIDENCE

Level 4.

Blood and cerebrospinal fluid biomarkers

Sports-related traumatic brain injuries (TBIs) range in severity from severe to subconcussive. Although technologies exist for clinical diagnosis of more severe injuries, methods for diagnosis of milder forms of brain injury are limited. Developing objective measures to indicate pathogenic processes after a suspected mild TBI is challenging for multiple reasons. The field of biomarker discovery for diagnosing TBI continues to expand, with newly identified candidate biomarkers being reported regularly. Brain-specific biomarkers include proteins derived from neurons and glia, and are often measured to assess neural injury and repair, and to predict outcomes. Ideally, changes in biomarker levels should indicate pathologic events and answer critical questions for accurate diagnosis and prognosis. For example, does the presence or a change in the biomarker level suggest greater vulnerability for sustaining a second concussion or show that the window of increased vulnerability has passed? Likewise, do changes in biomarker levels predict postconcussion syndrome or recovery/repair? Although there are numerous promising candidates for fluid biomarkers that may diagnose mild TBI or concussion, none has reached the clinic to date. In this chapter, we will define biomarkers, discuss the importance of understanding their normal and pathologic functions, and outline some considerations for interpreting detection assay results in TBI. We will then review five proposed blood and cerebrospinal fluid biomarkers (tau, neurofilament, ubiquitin carboxyl-terminal hydrolase L1, S100β, and glial fibrillary acidic protein) used currently to address TBI. Lastly, we will discuss a future trajectory for developing new, clinically useful fluid biomarkers.

How often is neck and vestibulo-ocular physiotherapy treatment recommended in people with persistent post-concussion symptoms? A retrospective analysis

BACKGROUND

Persistent post-concussion symptoms (PPCS) are complex, and typically involve multidisciplinary assessment and management. The neck and vestibulo-ocular systems are recognised as potential contributors to PPCS, yet it is not clear how often treatment for these systems is warranted.

OBJECTIVES

To explore how often neck and vestibulo-ocular treatment is received or recommended in people with PPCS.

DESIGN

Retrospective chart review.

METHOD

De-identified clinical service data for the calendar year of 2017 were extracted from a single concussion service provider in Dunedin, New Zealand. A summary of the individual assessments and treatments received were extracted and used to determine how often cases were considered to require physician or neuropsychological assessment; and how often cases received or were recommended neck and/or vestibulo-ocular physiotherapy treatment.

RESULTS/FINDINGS

147 cases were included in this study. Physician assessment was considered required in 25 cases (17%), and neuropsychological assessment in 90 cases (61%). For physiotherapy, neck treatment was received or recommended in 80 cases (54%), and vestibulo-ocular treatment in 106 cases (72%). Notably, this included 59 cases (40%) where both neck and vestibulo-ocular treatment were received or recommended.

CONCLUSIONS

The high proportion of cases receiving or recommended neck and vestibulo-ocular treatment strongly suggests both these systems often contribute to PPCS, often in overlap. While based on retrospective data, these findings highlight the value of routine neck and vestibulo-ocular examination in the assessment and management of PPCS. Further prospective study would be beneficial to explore these proportions in more detail and in other regions.