Effects of recent cannabis consumption on eye-tracking and pupillometry

Introduction

Cannabis consumption is known to immediately affect ocular and oculomotor function, however, cannabis consumption is also known to affect it for a prolonged period of time. The purpose of this study is to identify an eye tracking or pupillometry metric which is affected after recent cannabis consumption but is not confounded by cannabis consumption history or demographic variables.

Methods

Quasi-experimental design. Participants who would consume inhalable cannabis (n = 159, mean age 31.0 years, 54% male) performed baseline neurobehavioral testing and eye-function assessments when they were sober. Eye function assessments included eye-tracking [gaze (point of visual focus), saccades (smooth movement)] and pupillometry. Participants then inhaled cannabis until they self-reported to be high and performed the same assessment again. Controls who were cannabis naïve or infrequent users (n = 30, mean age 32.6 years, 57% male) performed the same assessments without consuming cannabis in between.

Results

Cannabis significantly affected several metrics of pupil dynamics and gaze. Pupil size variability was the most discriminant variable after cannabis consumption. This variable did not change in controls on repeat assessment (i.e., no learning effect), did not correlate with age, gender, race/ethnicity, or self-reported level of euphoria, but did correlate with THC concentration of cannabis inhaled.

Discussion

A novel eye-tracking metric was identified that is affected by recent cannabis consumption and is not different from non-users at baseline. A future study that assesses pupil size variability at multiple intervals over several hours and quantifies cannabis metabolites in biofluids should be performed to identify when this variable normalizes after consumption and if it correlates with blood THC levels.

Item-Specific Knee Injury and Osteoarthritis Outcome Score Characterization of Patients With Medial Meniscus Root Tear

Background

Most studies regarding medial meniscus posterior root tear (MMPRT) report total Knee injury and Osteoarthritis Outcome Score (KOOS) subscale values as important patient-reported outcomes, but there are few symptom-specific characterizations of patients with MMPRT.

Purpose/Hypothesis

The purpose of this study was to characterize the prevalence and severity of symptoms and functional limitations among patients with MMPRT based on item-level KOOS responses. It was hypothesized that patients with MMPRT would show similar symptoms to those of other meniscal tear types, with items from the KOOS pain subscale forming a majority of the most severe and prevalent symptoms.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The records of 1466 patients with medial meniscus root tear between January 2017 and December 2021 at a single institution were reviewed. KOOS subscale scores and item-specific responses from initial evaluation were collected for each patient. Each KOOS item was scored on a scale from 1 (none/least severe) to 5 (extreme/most severe). Median and mean item-level responses were calculated and ranked in order of most to least severe. For statistical analysis, item-level prevalence rates were calculated as the proportion of patients reporting at least mild symptoms and ranked from most to least prevalent.

Results

Included were 61 patients with MMPRT verified on magnetic resonance imaging (MRI). The most severe items according to item-level KOOS response were as follows: awareness of knee problem (mean, 4.62 [95% CI, 4.47-4.78]), difficulty jumping (mean, 4.06 [95% CI, 3.73-4.39]), difficulty twisting or pivoting (mean, 4.04 [95% CI, 3.76-4.32]), difficulty kneeling (mean, 3.98 [95% CI, 3.65-4.31]), and modification of lifestyle (mean, 3.94 [95% CI, 3.69-4.20]). The most prevalent items were knee stiffness later in the day, pain going up- or downstairs, difficulty ascending stairs, difficulty getting in and out of the car, difficulty twisting or pivoting, awareness of knee problem, and modification of lifestyle, with all patients reporting at least mild symptoms for each. Of the 11 most severe and prevalent symptoms, 8 came from the KOOS-Pain item-specific responses.

Conclusion

Pain-related items made up a majority of the most severe and most prevalent symptoms as identified by the item-specific KOOS responses. However, meniscal symptoms commonly seen in other tear types, such as clicking and knee stiffness, were still quite prevalent in patients with MMPRT.

An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion

OBJECTIVE

Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment.

DESIGN

Secondary analysis of a published cohort study and clinician consensus.

SETTING

Three university-affiliated sports medicine centers.

PARTICIPANTS

Two hundred seventy children (14.9 ± 1.9 years).

INDEPENDENT VARIABLES

Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm.

MAIN OUTCOME MEASURES

Correlations between independent variables were calculated, and network graphs were made. k-means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes.

RESULTS

Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait).

CONCLUSIONS

Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

Greater Mental Health Burden is Associated With Poor Postoperative Pain Control and Increased Opioid Utilization Following Total Shoulder Arthroplasty

Background

Prolonged opioid use is associated with higher complications and worse patient-reported outcomes following total shoulder arthroplasty (TSA). Identified risk factors for prolonged postoperative use are related to several medical comorbidities, gender, diagnoses of anxiety or depressive disorders, and preoperative opioid use. In this study, we hypothesized that patient-reported mental health characteristics can help to identify patients at risk of worse postoperative pain control, worse sleep, and higher opioid utilization following TSA.

Methods

Ninety-three consecutive patients were asked to fill out 2 mental health questionnaires prior to undergoing TSA. Following surgery, patients filled out a daily pain diary to track their daily pain, pain medication use, and quality and duration of their sleep for 30 days. Preoperative opioid use and postoperative refill were determined by the New York State Prescription Monitoring Program. Mixed-model linear regressions were conducted. Significance was defined as p < 0.05.

Results

Postoperative opioid refill was associated with female gender, preoperative opioid therapy, higher inpatient opioid use, worse anxiety, depression, somatization, and pain catastrophizing scores. The number of days using opioids postoperatively was associated with worse pain catastrophizing scale (PCS) and somatization scores (patient health questionnaire-15). Preoperative opioid therapy was associated with worse somatization scores, whereas no opioids used after surgery were associated with better somatization scores. Worse sleep quality and duration were associated with worse PCS scores.

Conclusion

A greater mental health burden is associated with worse postoperative pain control and higher opioid utilization during the acute postoperative period. This is especially evident in the pain catastrophizing and somatization domains.

Predictors of Postoperative Patient-Reported Outcome Measure Response Rates Among Patients With Rotator Cuff Repair

BACKGROUND

Patient-reported outcome measures (PROMs) contribute to evaluating and improving the quality of patient care. Patient outcomes after rotator cuff repair (RCR) have been researched; however, the relationship between PROM response rates and individual and health care correlates has not been thoroughly investigated.

PURPOSE

To examine differences in individual and health care factors among patients who had undergone RCR based on their PROM response rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Shoulder-specific and general PROMs were solicited via email and text message of all patients who underwent RCR between 2016 and 2020. Three subgroups were classified: (1) complete responders completed all 1-year postoperative PROMs, (2) partial responders answered enough questions to produce ≥1 usable score, and (3) nonresponders did not respond to a single measure. Correlates were assessed using analysis of variance and chi-square tests. Adjusted multinomial logistic regression models identified predictors of 1-year PROM response.

RESULTS

Of 2195 patients included at the 1-year follow-up, 34% were complete responders; 11%, partial responders; and 55%, nonresponders. Patients had a mean age of 61.8 years, 63% were men, and 90% were White. Pre- and postoperative PROM scores were similar across responder groups. In stepwise selection, 1-year responses (complete or partial) were associated with older age, later year of surgery, White race, and having workers' compensation insurance. The strongest predictor of PROM response was having workers' compensation insurance.

CONCLUSION

Patients with workers' compensation insurance compared with other insurance types responded to PROMs at disproportionately higher rates. This could distort postoperative PROM scores in the population studied because there are known differences among patients with this insurance status.

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.

Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center

Background

The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries.

Methods

This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation.

Results

A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline.

Conclusion

Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period.

Level of Evidence

Level IV, descriptive pilot study.

Does Physiologic Post-Concussion Disorder Cause Persistent Post-Traumatic Headache?

PURPOSE OF REVIEW

One system classifies patients with symptoms after concussion into physiologic, vestibulo-ocular, cervicogenic, and mood/cognition post-concussion disorders (PCD) based upon the preponderance of specific symptoms and physical impairments. This review discusses physiologic PCD and its potential relationship to the development of persistent post-traumatic headaches (PPTH).

RECENT FINDINGS

Headache is the most reported symptom after a concussion. Headaches in physiologic PCD are suspected to be due to abnormal cellular metabolism, subclinical neuroinflammation, and dysfunction of the autonomic nervous system (ANS). These abnormalities have been linked to the development of migraine-like and neuralgia-related PPTH. Physiologic PCD is a potential cause of PPTH after a concussion. Future research should focus on how to prevent PPTH in patients with physiologic PCD.

Delay to Surgical Treatment in Geriatric Hip Fracture Patients

Background

Hip fractures in the geriatric population are frequently encountered. There is increasing focus on minimizing the delay to surgery in these patients. This study was designed to evaluate factors responsible for a delay to surgery in a geriatric hip fracture population and how time to surgery affects mortality.

Methods

A retrospective cohort of patients sustaining low energy geriatric hip fractures in either an American College of Surgeons (ACS) verified Level 1 trauma center or a local university affiliated community teaching hospital were reviewed. The following variables were evaluated as independent risk factors for delay to surgery: demographic data, surgical details, use of cardiology resources, treatment center, and comorbidities. As a secondary objective, the effect of time to surgery on 1 year mortality was analyzed.

Results

1157 patients met inclusion criteria. The following factors increased the risk of delay to surgery greater than 48 hours: male sex, treatment in a community hospital (versus trauma center), older age, multiple comorbidities (eg, cardiovascular-related conditions or other fractures), cardiology consultation, and an American Society of Anesthesiologists physical status score of 3 or 4. Cardiology consultation was the strongest independent predictor of risk for delay to surgery of >48 hours (odds ratio, 6.68; 95% confidence interval, 4.40 to 10.14; P < .001). The 1-year mortality of patients did not differ when surgical treatment occurred before 48 hours or after 48 hours (Log-rank test P = .109).

Conclusion

The presence of cardiovascular comorbidities and cardiology consultations can delay surgical treatments for hip fractures in patients greater than 65 years old, but the delay did not influence 1-year all-cause mortality.

Level of Evidence

Level IV.

Adolescents With More Oculomotor and Vestibular Signs of Sport-Related Concussion Benefit from Aerobic Exercise: An Exploratory Analysis

Abstract Early targeted heart rate (HR) aerobic exercise has been shown to reduce the duration of recovery from sport-related concussion (SRC) as well as the incidence of persistent post-concussive symptoms (PPCS). It is not known, however, if more severe oculomotor and vestibular presentations of SRC benefit from a prescription of aerobic exercise. The current study is an exploratory analysis of two published randomized controlled trials that compared aerobic exercise within 10 days of injury with a placebo-like stretching intervention. Combining the two studies yielded a larger sample size to stratify severity of concussion based on the number of abnormal physical examination signs present at the initial office evaluation, which were confirmed with self-reported symptoms and recovery outcomes. The most discriminant cut-off was between those who had ≤3 oculomotor and vestibular signs and those who had >3 signs. Aerobic exercise (hazard ratio = 0.621 [0.412, 0.936], p = 0.023) reduced recovery times even when controlling for site (hazard ratio = 0.461 [0.303, 0.701], p < 0.001), severity (hazard ratio = 0.528 [0.325, 0.858], p = 0.010) and the interaction term of intervention and severity (hazard ratio = 0.972 [0.495, 1.909], p = 0.935). Adolescents who presented with >3 signs and were assigned to the placebo-like stretching group had a PPCS incidence of 38%, which was the highest of all subgroups (aerobic exercise and ≤3 findings: 8%; stretching and ≤3 findings: 11%; aerobic exercise and >3 findings: 21%). This exploratory study provides pilot evidence that prescribed sub-symptom threshold aerobic exercise treatment early after SRC may be effective for adolescents with more oculomotor and vestibular physical examination signs and should be validated in future adequately powered trials.

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

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

Factors Associated With Awareness, Adoption, and Implementation of Anterior Cruciate Ligament Injury Prevention in Youth Sports

BACKGROUND

Anterior cruciate ligament (ACL) injuries are among the most common injuries in adolescent athletes and result in significant financial and physical morbidity. Evidence-based programs designed to prevent ACL injury are effective. However, their adoption remains low. We sought to evaluate the awareness, evidence-based implementation, and barriers to implementation of ACL injury prevention programs (ACL-IPP) among youth athletic coaches.

HYPOTHESIS

Higher education level of the coach, higher level of training, number of teams coached, and coaching female teams would be associated with ACL-IPP implementation.

STUDY DESIGN

Cross-sectional survey.

LEVEL OF EVIDENCE

Level 4.

METHODS

We conducted an email survey sent to all 63 school districts within Section VI of the New York State Public High School Athletic Association. We employed descriptive statistics and tests of correlation to identify factors associated with ACL-IPP implementation.

RESULTS

A total of 73% of coaches said they were aware of ACL-IPP, and only 12% of coaches implemented ACL-IPP according to best evidence. Coaches of higher competitive levels were more likely to adopt ACL-IPP (P = 0.01), more likely to use them multiple times per week (P = 0.03), and for ≥1 seasons (P = 0.02). Coaches of multiple teams were more likely to adopt ACL-IPP (P = 0.01). There were no differences in evidence-based implementation of ACL-IPP with gender coached or level of education of the coach.

CONCLUSION

Overall awareness, adoption, and evidence-based implementation of ACL-IPP remain low. These results suggest that coaches at higher levels of play and multiple teams tend to use ACL-IPP more often. Gender coached and level of education do not appear to be associated with awareness or implementation.

CLINICAL RELEVANCE

Evidence-based ACL-IPP implementation remains low. Targeting coaches of younger athletes and fewer teams with local outreach programs and ACL-IPP may increase the implementation of ACL-IPP.

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

ABSTRACT

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

Exercise-Induced Vision Dysfunction Early After Sport-Related Concussion Is Associated With Persistent Postconcussive Symptoms

OBJECTIVE

The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS.

DESIGN

Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program.

SETTING

Three university-associated sports medicine clinical programs.

PARTICIPANTS

Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury.

INDEPENDENT VARIABLE

King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test.

MAIN OUTCOME MEASURE

Persistent post-concussive symptoms.

RESULTS

Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS.

CONCLUSIONS

Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction.

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.

Association of Concussion History and Prolonged Recovery in Youth

OBJECTIVE

To determine the number of prior concussions associated with increased incidence of persistent postconcussive symptoms (PPCS) in a cohort of acutely concussed pediatric patients.

DESIGN

Prospective observational cohort study.

SETTING

Three university-affiliated concussion clinics.

PARTICIPANTS

Two hundred seventy participants (14.9 ± 1.9 years, 62% male, 54% with prior concussion) were assessed within 14 days of concussion and followed to clinical recovery. Participants with a second head injury before clinical recovery were excluded.

MEASURES AND MAIN OUTCOME

Concussion history, current injury characteristics, recovery time, and risk for prolonged recovery from current concussion.

RESULTS

There was no statistically significant change in PPCS risk for participants with 0, 1 or 2 prior concussions; however, participants with 3 or more prior concussions had a significantly greater risk of PPCS. Twelve participants sustained a subsequent concussion after clinical recovery from their first injury and were treated as a separate cohort. Our secondary analysis found that these participants took longer to recover and had a greater incidence of PPCS during recovery from their latest concussion.

CONCLUSION

Pediatric patients with a history of 3 or more concussions are at greater risk of PPCS than those with fewer than 3 prior concussions.

Adolescents with Sport-Related Concussion Who Adhere to Aerobic Exercise Prescriptions Recover Faster

PURPOSE

There is growing evidence that subsymptom threshold aerobic exercise speeds recovery from sport-related concussion (SRC). It is not known whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden affects adherence to the prescription.

METHODS

This study was a planned secondary analysis of one arm of a randomized controlled trial. Male and female adolescent athletes (age 13-18 yr) presenting within 10 d of SRC were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test. Adherence was determined objectively with HR monitors and compared against time to recovery. Participants who completed at least two-thirds of their aerobic exercise prescription were considered to be adherent.

RESULTS

Sixty-one percent of adolescents met the adherence criterion. Those who were adherent were more symptomatic and were more exercise intolerant at their initial visit, yet they recovered faster than those who were not adherent (median recovery time, 12 (interquartile range, 9-22) d vs 21.5 (interquartile range, 13-29.8) d; P = 0.016). On linear regression, adherence during week 1 was inversely related to recovery time ( β = -0.002 (-0.003, 0.0), P = 0.046) and to initial exercise tolerance ( β = -0.886 (-1.385, -0.387), P < 0.001), but not to initial symptom severity ( β = 0.545 (-0.232, 1.323), P = 0.146). No adverse events or near misses were reported.

CONCLUSIONS

Adherence to individualized subsymptom threshold aerobic exercise within the first week of evaluation is associated with faster recovery from SRC. The data suggest that initial degree of exercise intolerance, but not initial symptom severity, affects adherence to aerobic exercise prescribed to adolescents within 10 d of SRC.

Norm-Based Cutoffs as Predictors of Prolonged Recovery After Adolescent Sport-Related Concussion

OBJECTIVES

To identify predictors of prolonged recovery (ie, >28 days) using patient demographic factors and healthy, norm-based cutoffs on a multimodal test battery in adolescents after sport-related concussions (SRCs).

DESIGN

Retrospective cohort. Patients were deemed recovered after successful completion of return-to-play/school protocols and received medical clearance.

SETTING

Community concussion clinic.

PATIENTS

Male and female adolescent student athletes diagnosed with a SRC and evaluated within 1 week of injury.

INDEPENDENT VARIABLES

Patient demographics, medical history, injury description, computerized neurocognitive testing, vestibular/ocular testing, and symptoms at initial clinical visit.

MAIN OUTCOME MEASURES

Performance on clinical testing to predict recovery duration, classified as normal (<28 days) or prolonged (>28 days).

RESULTS

A total of 201 adolescent student athletes (age = 15.3 ± 1.4 years) were included (female 35%). Average recovery duration for the entire cohort was 22.3 ± 13.3 days, with 22% (n = 45) of adolescent student athletes taking >28 days to recover. The final model was 88.3% accurate in classifying normal and prolonged recovery. Predictor variables included sex, loss of consciousness, history of ocular disorder, history of concussion, performance on visual motor speed composite, visual motion sensitivity symptom provocation and near point of convergence distance, number-naming total time, and symptom count.

CONCLUSIONS

These findings suggest that using norm-based cutoffs from cognitive, oculomotor, and vestibulo-ocular testing and symptom reporting, clinicians can accurately predict a prolonged recovery (sensitivity = 81%) and normal recovery (specificity = 83%) in an adolescent, SRC cohort.

COVID-19-induced surge in the severity of gender-based violence might increase the risk for acquired brain injuries

While initial reports have emphasized a global rise in the frequency of intimate partner violence following COVID-19, emerging data are now showing a concerning surge in the severity of COVID-19-induced physical intimate partner violence. One of the most dangerous, frequent, yet hidden consequences of severe physical intimate partner violence is acquired brain injury, including repetitive mild traumatic brain injury and hypoxic brain injury. Although the increase in high-risk physical abuse during COVID-19 is gaining recognition, what still remains absent is the urgent discussion on intimate partner violence-related acquired brain injury during these times. The potential analogous surge in intimate partner violence-related acquired brain injury may have implications for both healthcare providers and healthcare actions/policies as repeated brain injuries have been associated with residual functional deficits and chronic disability. In addition, even in the pre-pandemic times, intimate partner violence-related acquired brain injury is likely unrecognized and/or misclassified due to overlap in symptoms with other comorbid disorders. This review aimed to raise awareness about intimate partner violence-related acquired brain injury within the context of COVID-19. Health actions and policies that should be considered as part of the pandemic response to minimize adverse outcomes associated with intimate partner violence-related acquired brain injury have also been discussed.

Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial

BACKGROUND

Sport-related concussion is a public health problem, particularly in adolescents. Quality of life is reduced in adolescents with persistent post-concussive symptoms (symptoms >28 days). We replicated a previous randomised controlled trial to validate the safety, efficacy, and generalisability of, and objective adherence to, prescribed early targeted heart rate subsymptom threshold aerobic exercise compared with placebo-like stretching exercise for adolescent recovery from sport-related concussion and for reducing the risk of persistent post-concussive symptoms.

METHODS

This randomised controlled trial was done at three community and hospital-affiliated sports medicine concussion centres in the USA. Male and female adolescent athletes (aged 13-18 years) presenting within 10 days of sport-related concussion were randomly assigned to individualised subsymptom threshold aerobic or stretching exercise at least 20 min daily, for up to 4 weeks after injury. Exercise adherence and intensity were measured by heart rate monitors. The primary outcome was clinical recovery (ie, return to baseline symptoms, normal exercise tolerance, and a normal physical examination) within the 4-week intervention period, and development of persistent post-concussive symptoms beyond 28 days after injury. This study is registered with ClinicalTrials.gov, NCT02959216.

FINDINGS

Between Aug 1, 2018, and March 31, 2020, 118 adolescents were recruited (61 were randomly assigned to the aerobic exercise group and 57 to the stretching exercise group) and included in the intention-to-treat analysis. On survival analysis, controlling for sex, site, and mean daily exercise time, patients assigned to aerobic exercise were more likely to recover within 4 weeks after injury compared with those assigned to stretching exercise, with a 48% reduced risk of persistent post-concussive symptoms (hazard ratio for stretching vs aerobic exercise of 0·52 [95% CI 0·28-0·97], p=0·039). No adverse events were reported.

INTERPRETATION

This multicentre study found that early treatment with subsymptom threshold aerobic exercise safely speeds recovery from sport-related concussion and reduces the risk for persistent post-concussive symptoms, an important result given the impact of delayed recovery on adolescent quality of life. Adherence was good and there were no adverse events from this non-pharmacological treatment. These results suggest that physicians should not only permit, but consider prescribing, early subsymptom threshold physical activity to adolescents as treatment for sport-related concussion and to reduce the risk of persistent post-concussive symptoms.

FUNDING

American Medical Society for Sports Medicine.

Practical Management: Prescribing Subsymptom Threshold Aerobic Exercise for Sport-Related Concussion in the Outpatient Setting

ABSTRACT

Exercise intolerance is an objective biomarker of the physiological dysfunction after sport-related concussion (SRC). Several trials have established the safety and clinical efficacy of subsymptom threshold aerobic exercise prescribed within 1 week of injury as treatment for SRC. Clinicians, however, may not be comfortable prescribing aerobic exercise after SRC. This article presents 3 methods of exercise prescription for patients with SRC. The first requires a graded exertion test plus a home-based exercise program requiring a heart rate (HR) monitor. The second requires a graded exertion test but no HR monitor for home-based exercise. The third requires solely an HR monitor to safely progress through the home-based exercise prescription. Patients are encouraged to keep a symptom and exercise diary and return for re-evaluation every 1 to 2 weeks. Delayed recovery should prompt the clinician to evaluate for other potential symptom generators (eg, cervical, vestibular, oculomotor, mood, or migraine disorders).

Concussion reporting behaviors in student athletes across sexes and levels of contact

Context

Sport-related concussions (SRC) are common in student athletes. However, current literature suggests that many athletes do not accurately report their symptoms. The under-reporting of concussion symptoms can result in an increased risk of further injury and an underestimation of concussion prevalence.

Objective

This study aims to identify perspectives on concussion reporting behaviors in student athletes across levels of contact and by sex.

Design

Cross-sectional study.

Setting

Elementary and high school, college. Patients or other participants: 1126 female (52%) and male (48%) athletes, mean age 16.6 years. Main outcome measure(s): Standardized questionnaire on concussion reporting during a series of hypothetical scenarios.

Results

Student athletes participating in sports with higher levels of contact had more education about concussions, yet professed they were less likely to report a concussion. The most common reasons athletes chose not to report were ‘not wanting to miss the game’ and ‘not wanting to let the coach down.’ Minimal differences were found between sexes, with females being just as unlikely, or sometimes more unlikely, to report a concussion than males. Lastly, females playing contact and non-contact sports appear to be more concerned about not wanting to let their coach down than males.

Conclusions

Although perspective on concussion reporting behavior varied across sports of different levels of contact, we did not find any conclusive evidence of differences in willingness to report a concussion between sexes when compared within the same level of contact.

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

OBJECTIVES

The Buffalo Concussion Treadmill Test (BCTT) is a safe and validated tool to assess exercise tolerance after sport-related concussion (SRC). Sex differences may affect the interpretation of this systematic exertion test in the concussed population, which is important for clinicians. The purpose of this study was to examine sex differences in BCTT performance in adolescents with acute SRC.

DESIGN

Prospective cohort.

METHODS

Male (n = 103, 15.3 ± 2 years) and female (n = 87, 15.1 ± 2 years) adolescents with SRC performed the BCTT within 10 days of injury. Heart rate (HR), HR threshold (HRt), Delta HR (difference between resting HR and HRt), symptom severity on Visual Analog Scale (VAS) and symptoms exacerbated on the BCTT were collected and compared.

RESULTS

Males had lower resting HR (M: 70.9 ± 12 vs F: 75.7 ± 13 bpm, p < 0.01) and reached a lower HRt than females (M: 134.7 ± 23 vs F: 141.5 ± 25 bpm, p = 0.05). Sexes did not differ on Delta HR (M: 63.8 ± 26 vs F: 65.9 ± 24 bpm, p = 0.57), total treadmill time (M: 9.3 ± 5 vs F: 8.4 ± 4 min, p = 0.20), maximum VAS (M: 5.0 ± 2 vs F: 5.4 ± 2, p = 0.18) or incidence of a change in VAS (M: 91% vs F: 94%, p = 0.43) on the BCTT.

CONCLUSIONS

Although males may reach symptom exacerbation at a slightly lower mean HRt than females on the BCTT within 10 days of SRC, the BCTT provides comparable information and both sexes reach symptom exacerbation at similar Delta HR.

Rehabilitation of Concussion and Persistent Postconcussive Symptoms

Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies.

Derivation of a Focused, Brief Concussion Physical Examination for Adolescents With Sport-Related Concussion

OBJECTIVE

To describe the derivation of a brief but pertinent physical examination (PE) for adolescents who have sustained sport-related concussion (SRC).

DESIGN

Prospective cohort.

SETTING

University concussion management clinic.

PARTICIPANTS

Acutely concussed (AC, n = 52, 15.5 ± 1.4 years, 4.4 ± 2 days since injury, 26.2 ± 38 days to recovery, 71% males) and healthy control (HC) adolescents (n = 30, 15.8 ± 1.4 years, 73% males).

INTERVENTION

Acutely concussed had a PE on visit 1 and were retested at visit 2 (13.6 ± 1 day after visit 1). Acutely concussed were further characterized as normal recovery (NR, n = 41, 15.5 ± 1.5 years, recovery time 13.0 ± 7 days) and delayed recovery (DR, n = 11, 15.5 ± 1.2 years, recovery time 75.4 ± 63 days).

MAIN OUTCOME MEASURE

Physical examination findings, including cervical, vestibular, and oculomotor systems.

RESULTS

Visit 1 abnormal PE signs were significantly greater in AC versus HC (2.79 ± 2.13 vs 0.07 ± 0.37, P < 0.0001) but not in NR versus DR (2.61 ± 2.2 vs 3.45 ± 1.8, P = 0.246). Visit 2 abnormal PE signs differentiated NR versus DR (0.17 ± 0.7 vs 2.45 ± 2.1, P < 0.0001).

CONCLUSIONS

A brief focused PE can help to diagnose SRC, establish recovery, and may have prognostic value.

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.

Diagnosing mild traumatic brain injury using saliva RNA compared to cognitive and balance testing

BACKGROUND

Early, accurate diagnosis of mild traumatic brain injury (mTBI) can improve clinical outcomes for patients, but mTBI remains difficult to diagnose because of reliance on subjective symptom reports. An objective biomarker could increase diagnostic accuracy and improve clinical outcomes. The aim of this study was to assess the ability of salivary noncoding RNA (ncRNA) to serve as a diagnostic adjunct to current clinical tools. We hypothesized that saliva ncRNA levels would demonstrate comparable accuracy for identifying mTBI as measures of symptom burden, neurocognition, and balance.

METHODS

This case-control study involved 538 individuals. Participants included 251 individuals with mTBI, enrolled ≤14 days postinjury, from 11 clinical sites. Saliva samples (n = 679) were collected at five time points (≤3, 4-7, 8-14, 15-30, and 31-60 days post-mTBI). Levels of ncRNAs (microRNAs, small nucleolar RNAs, and piwi-interacting RNAs) were quantified within each sample using RNA sequencing. The first sample from each mTBI participant was compared to saliva samples from 287 controls. Samples were divided into testing (n = 430; mTBI = 201 and control = 239) and training sets (n = 108; mTBI = 50 and control = 58). The test set was used to identify ncRNA diagnostic candidates and create a diagnostic model. Model accuracy was assessed in the naïve test set.

RESULTS

A model utilizing seven ncRNA ratios, along with participant age and chronic headache status, differentiated mTBI and control participants with a cross-validated area under the curve (AUC) of .857 in the training set (95% CI, .816-.903) and .823 in the naïve test set. In a subset of participants (n = 321; mTBI = 176 and control = 145) assessed for symptom burden (Post-Concussion Symptom Scale), as well as neurocognition and balance (ClearEdge System), these clinical measures yielded cross-validated AUC of .835 (95% CI, .782-.880) and .853 (95% CI, .803-.899), respectively. A model employing symptom burden and four neurocognitive measures identified mTBI participants with similar AUC (.888; CI, .845-.925) as symptom burden and four ncRNAs (.932; 95% CI, .890-.965).

CONCLUSION

Salivary ncRNA levels represent a noninvasive, biologic measure that can aid objective, accurate diagnosis of mTBI.

Postexercise Slowing on the King-Devick Test and Longer Recovery From Sport-Related Concussion in Adolescents: A Validation Study

CONTEXT

The King-Devick (KD) test is a rapid number-reading test that has emerging use in the assessment of sport-related concussion (SRC). Previous research suggested that healthy individuals and patients with acute concussions who had shorter recovery times (<3 weeks) demonstrated a learning effect on the KD test after mild to moderate exertion, whereas patients with longer recovery times did not.

OBJECTIVE

To assess if the absence of postexertional improvement on the KD test within 10 days of concussive head injury was associated with a longer duration of recovery.

DESIGN

Prospective cohort study.

SETTING

University concussion-management clinics.

PATIENTS OR OTHER PARTICIPANTS

Male and female adolescent athletes (n = 99, aged 13-18 years) presenting within 10 days of SRC.

MAIN OUTCOME MEASURE(S)

The KD test was administered before and after the Buffalo Concussion Treadmill Test (BCTT). Days from injury to recovery, with recovery defined as being asymptomatic, confirmed by the assessment of a physician who was blinded to the treatment group, and the return of normal exercise tolerance on the BCTT were recorded.

RESULTS

Participants with postexertional slowing (PES group, n = 33) had a longer duration of recovery (17 days versus 13.5 days, P = .033) than participants without PES (no-PES group, n = 66). At any clinic visit, PES was also associated with a relative risk of 2.36 (95% confidence interval = 1.55, 3.61; P < .001) of not recovering within the following week.

CONCLUSIONS

The current study validates our prior work showing that acutely concussed adolescents who did not display the typical learning effect on the KD test after the BCTT took longer to recover from SRC than those who exhibited the typical learning effect.

Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents

OBJECTIVE

To compare a sample of adolescents with sport-related concussion (SRC) who were prescribed rest with 2 arms of a randomized controlled trial comparing aerobic exercise with placebo-like stretching. We also compared sex differences across the 3 approaches to treatment.

DESIGN

Quasi-experimental trial.

SETTING

University concussion management clinics.

PARTICIPANTS

Adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG], n=48, 15.4±1y, 25% female). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG], n=52, 15.3±2y, 46% female) or placebo-like stretching (placebo group [PG], n=51, 15.4±2y, 47% female) (N=151).

MAIN OUTCOME MEASURES

The primary outcome was median days from injury to recovery. The secondary outcome was proportion classified as normal recovery (<30d) or delayed recovery (≥30d).

RESULTS

The RG recovered in 16 days (interquartile range, 9.25-23.25d), which was significantly delayed (P=.020) compared with EG (13d; interquartile range, 10-18.5d). The PG recovered in 17 days (interquartile range, 13-23d). Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery (P=.190). There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups (P=.013).

CONCLUSION

Relative rest and a placebo-like stretching program were very similar in days to recovery and symptom improvement pattern after SRC. Both conditions were less effective than subsymptom threshold aerobic exercise. Female adolescents appear to be susceptible to symptom increase when prescribed rest.

A Preliminary Study of Early-Onset Dementia of Former Professional Football and Hockey Players

OBJECTIVE

To provide an overview of 3 studies of the same population of retired professional contact sport athletes compared with age-matched noncontact sport athlete controls on cognition, executive function, behavior, and advanced brain imaging.

SETTING

University Concussion Management Clinic.

PARTICIPANTS

Twenty-two retired professional hockey and football athletes (average age 56 years) and 21 age-matched noncontact sport athlete controls.

DESIGN

Case control.

MAIN MEASURES

Participants were assessed on a broad range of neuropsychological measures that are associated with identification of mild cognitive impairment and executive function. Athletes were also assessed using self-report measures of executive function and personality. Advanced structural and functional imaging techniques were utilized as well.

RESULTS

The former National Football League and National Hockey League athletes perceived themselves to have impaired executive function, but this was not confirmed by objective neurocognitive assessment. No significant differences were found when comparing contact-sport athletes with controls on the presence of mild cognitive impairment or brain structural and functional tissue injury. Contact sport athletes were more anxious and more likely to report unusual beliefs and experiences.

CONCLUSION

None of the retired contact sport athletes qualified as having early-onset dementia consistent with chronic traumatic encephalopathy. There were no remarkable differences in imaging, cognition, behavior, or executive function from noncontact sport athletes. The results underscore an apparent disconnect between public perceptions and evidence-based conclusions about the inevitability of chronic traumatic encephalopathy and the potential neurodegenerative effect on former athletes from contact sports.

The Buffalo Concussion Bike Test for Concussion Assessment in Adolescents

BACKGROUND

The Buffalo Concussion Treadmill Test (BCTT) is a graded exertion test for assessing exercise tolerance after concussion, but its utility is limited for certain populations.

HYPOTHESIS

We developed the Buffalo Concussion Bike Test (BCBT) and tested its comparability with the BCTT. We hypothesize that heart rate (HR) at symptom exacerbation on the BCBT will be equivalent to the BCTT.

STUDY DESIGN

Case-control study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Adolescents with acute concussion (AC) (n = 20; mean age, 15.9 ± 1.1 years; 60% male) presenting to a concussion clinic within 10 days of injury and age- and sex-matched healthy controls (n = 20; mean age, 15.9 ± 1.1 years; 60% male) performed the BCTT at first visit and returned within 3 days to perform the BCBT. Test duration, HR, symptom severity (measured using a visual analog scale), and exertion (measured using the Borg Rating of Perceived Exertion) were collected during each test.

RESULTS

Adolescents with AC who were exercise intolerant on the BCTT were also intolerant on the BCBT, with symptom exacerbation occurring at a mean 8.1 ± 2.8 minutes on the BCTT versus 14.6 ± 6.0 minutes on the BCBT (P < 0.01). Two 1-sided t tests showed that the HR at symptom exacerbation in AC patients (137 ± 28 bpm on BCTT vs 135 ± 25 bpm on BCBT; 95% CI, <0.01-0.03) and at voluntary exhaustion for controls (175 ± 13 bpm on BCTT vs 175 ± 13 bpm on BCBT; 95% CI, 0.03-0.03) on each test were statistically equivalent.

CONCLUSION

The HR at symptom exacerbation on BCBT is equivalent to the BCTT for the assessment of exercise tolerance after concussion in adolescents.

CLINICAL RELEVANCE

The BCBT can be used in patients with limited mobility or for research interventions that require limited participant motion.

A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males

OBJECTIVE

To study the effect of early prescribed aerobic exercise versus relative rest on rate of recovery in male adolescents acutely after sport-related concussion (SRC).

DESIGN

Quasi-experimental design.

SETTING

University sports medicine centers.

PARTICIPANTS

Exercise group (EG, n = 24, 15.13 ± 1.4 years, 4.75 ± 2.5 days from injury) and rest group (RG, n = 30, 15.33 ± 1.4 years, 4.50 ± 2.1 days from injury).

INTERVENTIONS

Exercise group performed a progressive program of at least 20 minutes of daily subthreshold aerobic exercise. Rest group was prescribed relative rest (no structured exercise). Both groups completed daily online symptom reports (Postconcussion Symptom Scale) for 14 days.

MAIN OUTCOME MEASURES

Days to recovery after treatment prescription. Recovery was defined as return to baseline symptoms, exercise tolerant, and judged recovered by physician examination.

RESULTS

Recovery time from initial visit was significantly shorter in EG (8.29 ± 3.9 days vs 23.93 ± 41.7 days, P = 0.048). Mixed-effects linear models showed that all symptom clusters decreased with time and that there was no significant interaction between treatment group and time. No EG participants experienced delayed recovery (>30 days), whereas 13% (4/30) of RG participants experienced delayed recovery.

CONCLUSIONS

These preliminary data suggest that early subthreshold aerobic exercise prescribed to symptomatic adolescent males within 1 week of SRC hastens recovery and has the potential to prevent delayed recovery.

The Predictive Capacity of the Buffalo Concussion Treadmill Test After Sport-Related Concussion in Adolescents

The Buffalo Concussion Treadmill Test (BCTT) identifies the heart rate threshold (HRt) of exercise tolerance in concussed patients. A previous study found that an absolute HRt of < 135 bpm was associated with prolonged recovery (>30 days) from sport-related concussion (SRC). In this study, we assessed the relationship of ΔHR (difference between resting HR and HRt) and recovery from SRC. Using a retrospective cohort design, we compared acutely (<10 days since injury) concussed adolescents who were prescribed either (1) relative rest (RG, n = 27, 15.2 ± 1 years, 33% female, median 17 days to recovery, ΔHR = 69.6 ± 28 bpm), (2) a placebo-stretching program (PG, n = 51, 15.4 ± 2 years, 49% female, median 17 days to recovery, ΔHR = 60.9 ± 22 bpm), or (3) sub-threshold aerobic exercise (AG, n = 52, 15.3 ± 2 years, 46% female, median 13 days to recovery, ΔHR = 62.4 ± 26 bpm). Linear regression showed that ΔHR significantly correlated with duration of clinical recovery for RG (p = 0.012, R ² = 0.228) and PG (p = 0.011, R ² = 0.126) but not for AG (p = 0.084, R ² = 0.059). ΔHR values were significantly lower in participants with prolonged recovery (>30 days) in RG (p = 0.01) and PG (p = 0.04). A ΔHR of ≤50 bpm on the BCTT is 73% sensitive and 78% specific for predicting prolonged recovery in concussed adolescents who were prescribed the current standard of care (i.e., cognitive and physical rest).

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial

IMPORTANCE

Sport-related concussion (SRC) is a significant public health problem without an effective treatment.

OBJECTIVE

To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen.

INTERVENTIONS

After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website.

MAIN OUTCOMES AND MEASURES

Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery.

RESULTS

A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08).

CONCLUSIONS AND RELEVANCE

This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02710123.

The King-Devick test in an outpatient concussion clinic: Assessing the diagnostic and prognostic value of a vision test in conjunction with exercise testing among acutely concussed adolescents

OBJECTIVE

This study investigated the diagnostic and prognostic value of the King-Devick (K-D) test in conjunction with treadmill testing in adolescents after sport-related concussion (SRC) in an outpatient concussion management clinic without baseline measures.

DESIGN

Prospective cohort.

METHODS

The K-D test was administered pre- and post-exercise on a graded treadmill test to acutely concussed (AC, <10 days from injury, n = 46, 15.4 ± 2.1 years) participants for 2 clinic visits (1 week apart) and to matched controls (MC, n = 30, 15.8 ± 1.4 years) for 2 visits (1 week apart). Initial K-D test times were compared between MC and AC. Changes in times from pre- to post- exercise during a treadmill test were compared for MC and AC and from Visit 1 to Visit 2. Smooth pursuits and repetitive saccades were compared with initial visit K-D test performance.

RESULTS

Comparison of pre-exercise K-D test times at Visit 1 distinguished MC from AC (46.1 ± 9.2 s vs. 53.7 ± 13.0 s, p = .007). Comparison of pre- and post-exercise K-D test times revealed significant improvements for MC (46.1 ± 9.2 s vs. 43.1 ± 8.5 s, p < .001) and AC who recovered by Visit 2 (Fast Recovery Group [FRG], n = 23, 50.4 ± 10.0 s vs. 47.3 ± 9.8 s, p = .002). No significant difference was seen in pre- and post-exercise K-D test times on Visit 1 for AC who took longer than 2 weeks to recover (Slow Recovery Group [SRG], n = 23, 57.0 ± 15.0 s vs. 56.0 ± 16.3 s, p = .478). At Visit 1, AC had more abnormal smooth pursuits than MC (17% vs. 3%, non-significant, p = .064). AC, however, had significantly more abnormal repetitive saccades than MC (37% vs. 3%, p = .001) and AC with abnormal repetitive saccades took significantly longer to complete the Visit 1 pre-exercise K-D test than AC with normal repetitive saccades (58.6 ± 16.0 s vs 50.8 ± 10.2 s, p = .049).

CONCLUSION

The study supports utility of the K-D test as part of outpatient concussion assessment. Lack of improvement in K-D test performance after an exercise test may be an indicator of delayed recovery from SRC.

Exercise is Medicine for Concussion

Sport-related concussion (SRC) is a physiological brain injury that produces cerebral and systemic effects, including exercise intolerance. Exercise intolerance after concussion is believed to be the result of autonomic nervous system (ANS) dysfunction. Ventilation is inappropriately low for the level of exercise intensity, raising arterial carbon dioxide (PaCO2) levels. Elevated PaCO2 increases cerebral blood flow (CBF) out of proportion to exercise intensity, which is associated with symptoms that limit exercise performance. Thus, elevated exercise PaCO2 may signal incomplete recovery from SRC. This article reviews recent observational and experimental data and presents the evidence that subthreshold aerobic exercise normalizes the cerebrovascular physiological dysfunction and is "medicine" for patients with concussion and persistent postconcussive symptoms (PPCS). It discusses the systematic evaluation of exercise tolerance after concussion using the Buffalo Concussion Treadmill Test (BCTT) and reviews the utility of the Buffalo Concussion Bike Test (BCBT), the data from which are used to establish an individualized heart rate "dose" of subthreshold exercise to safely speed recovery, which also may work in the acute recovery phase after SRC with the potential to reduce the incidence of PPCS. Evaluation and treatment approaches based on the physiology of concussion suggest that exercise is medicine for concussion, potentially adding a new dimension to concussion care to help safely speed recovery and prevent PPCS in some patients.

A systematic review of criteria used to define recovery from sport-related concussion in youth athletes

OBJECTIVE

The Concussion in Sport Group guidelines recommend a multifaceted approach to help clinicians make return to sport decisions. The purpose of this study was to identify the most common multifaceted measures used to define clinical recovery from sport-related concussion in young athletes (high school and/or college level) and to summarise existing knowledge of criteria used to make return to sport decisions.

DESIGN

Systematic review.

DATA SOURCES

The PubMed (MEDLINE), SPORTDiscus and Embase electronic databases were searched from 1 January 2000 to 1 March 2017 by three independent reviewers.

ELIGIBILITY CRITERIA

Inclusion criteria: elementary, high school and college age groups, and a specific definition of clinical recovery that required two or more measures.

EXCLUSION CRITERIA

review articles, articles using the same sample population, case studies, non-English language and those that used one measure only or did not specify the recovery measures used.

STUDY QUALITY

Study quality was assessed using the Downs and Black Criteria.

RESULTS

Of 2023 publications, 43 met inclusion criteria. Included articles reported the following measures of recovery: somatic symptom resolution or return to baseline (100%), cognitive recovery or return to baseline (86%), no exacerbation of symptoms on physical exertion (49%), normalisation of balance (30%), normal special physical examination (12%), successful return to school (5%), no exacerbation of symptoms with cognitive exertion (2%) and normalisation of cerebral blood flow (2%). Follow-up to validate the return to sport decision was reported in eight (19%) articles. Most studies were case-control or cohort (level of evidence 4) and had significant risk of bias.

CONCLUSION

All studies of sport-related concussion use symptom reports to define recovery. A minority of studies used multiple measures of outcome or had clearly defined recovery criteria, the most common being a combination of a self-reported symptom checklist and a computerised neurocognitive test. Future studies ideally should define recovery a priori using objective physiological measures in addition to symptom reports.

Intracranial pressure changes after mild traumatic brain injury: a systematic review

OBJECTIVE

Intracranial pressure (ICP) after mild traumatic brain injury (mTBI) is poorly studied due to lack of sensitive non-invasive methods. The purpose of this review was to summarize the existing knowledge of changes in ICP after mTBI. Literature selection: PubMed, Embase, CINAHL, and Scopus were searched by three reviewers independently up to December 2016.

INCLUSION CRITERIA

animal and human studies measuring ICP and brain oedema after an mTBI.

EXCLUSION CRITERIA

moderate and severe forms of traumatic brain injury, repeat samples, and studies that measured ICP at the time of impact but not after. Study quality was assessed using Downs and Black criteria.

RESULTS

Of 1067 papers, 9 studies were included. In human studies, one provided direct evidence on increased, one provided indirect evidence of increased, and two provided indirect evidence of decreased ICP. In animal studies, three studies provided direct evidence of increased, one provided indirect evidence of increased, and one provided indirect evidence of no change in ICP.

CONCLUSION

The existing research suggests that there may be increased ICP after mTBI and animal studies suggest an elevation for days which returns to baseline, which corresponds with functional and symptomatic recovery. Future human studies using sensitive indirect methods to measure ICP longitudinally after mTBI are needed.

Concussion management knowledge among residents and students and how to improve it

Aim:

Recognition and management of concussion is an area of growing importance. The objective was to measure concussion knowledge among residents and medical students (MS).

Methods:

Baseline knowledge was assessed by a standardized questionnaire. Control group (family medicine [FM], pediatric medicine [PM] and emergency medicine) residents were given reading material, and intervention group rotated in a clinic (sports medicine residents and MS). Subjects were retested after 36.82 (16.1) days. Pre- and post-intervention test scores were compared.

Results:

The average baseline knowledge scores were 79.2% for emergency medicine residents, 61.4% for FM, 68.5% for PM, 71.7% for sports medicine residents and 68.0% for MS. Knowledge increase for control group was 1.16% compared with 14.41% for the clinical rotation group (p < 0.0001).

Conclusion:

PM and FM residents can benefit from more focused education about concussion.

Comparative Study on Cryosurgery with Carbamazepine and Alcohol injection in Trigeminal Neuralgia

Objectives: To assess the efficacy of Cryosurgery for the treatment of Trigeminal neuralgia and to compare this procedure with Carbamazepine and alcohol block. Materials and method-A prospective study with 75       cases of Trigeminal neuralgia was carried out in the Department of Oral and Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University from January 2006 to December 2007. Out of 75 cases 25 treated with Carbamazepine only, starting dose 100 mg b.d. with incremental dose up to 800 mg, 25 received alcohol block with maintenance dose of Carbamazepine 200 mg b.d. over the study period and 25 received       Cryosurgery with initial maintenance dose of Carbamazepine 100 mg b.d. then tappered on 1st follow up visits and withdrawn on the 2nd follow up visits. Visual linear analogue scale (VAS) was used to measure pain intensity in different groups. Results: Out of different treatment modalities on follow up onwards pain control was better in Cryosurgery than Carbamazepine and alcohol block. Conclusion: This study reveals that the efficacy of Cryosurgery is better than Carbamazepine and alcohol block to eliminate the pain intensity in Trigeminal neuralgia.   DOI: http://dx.doi.org/10.3329/bjms.v11i3.11721   Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12