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Archives of Physical Medicine and... Feb 2020At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have...
At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.
Topics: Athletes; Biomarkers; Brain Concussion; Humans; Military Personnel; Patient Education as Topic; Pediatrics; Practice Guidelines as Topic; Primary Health Care; Prognosis; Referral and Consultation; Return to Sport; United States
PubMed: 31654620
DOI: 10.1016/j.apmr.2019.10.179 -
Current Opinion in Neurology Dec 2018Recent studies are challenging the utility of prolonged rest as treatment for concussion and postconcussion syndrome (PCS). The purpose of this paper is to review the... (Review)
Review
PURPOSE OF REVIEW
Recent studies are challenging the utility of prolonged rest as treatment for concussion and postconcussion syndrome (PCS). The purpose of this paper is to review the evidence for active recovery from concussion and PCS.
RECENT FINDINGS
Emerging data identify the central role of autonomic nervous system (ANS) dysfunction in concussion pathophysiology. The exercise intolerance demonstrated by athletes after sport-related concussion may be related to abnormal ANS regulation of cerebral blood flow. As aerobic exercise training improves ANS function, sub-symptom threshold exercise treatment is potentially therapeutic for concussion. A systematic assessment of exercise tolerance using the Buffalo Concussion Treadmill Test has been safely employed to prescribe a progressive, individualized subthreshold aerobic exercise treatment program that can return patients to sport and work. Multiple studies are demonstrating the efficacy of an active approach to concussion management.
SUMMARY
Sustained rest from all activities after concussion, so-called 'cocoon therapy', is not beneficial to recovery. Evidence supports the safety, tolerability, and efficacy of controlled sub-symptom threshold aerobic exercise treatment for PCS patients. Further study should determine the efficacy and optimal timing, dose, and duration of subthreshold aerobic exercise treatment acutely after concussion because early intervention has potential to prevent PCS.
Topics: Athletic Injuries; Brain Concussion; Exercise; Exercise Therapy; Humans; Post-Concussion Syndrome; Recovery of Function; Rest
PubMed: 30382949
DOI: 10.1097/WCO.0000000000000611 -
Tidsskrift For Den Norske Laegeforening... Sep 2022Concussion is common and usually resolves without complications. However, persistent symptoms occur in 10-15 % of patients. These post-concussion symptoms are... (Review)
Review
Concussion is common and usually resolves without complications. However, persistent symptoms occur in 10-15 % of patients. These post-concussion symptoms are predominantly somatic, cognitive and emotional. The condition is most common in those with previous somatic and mental health issues. The causes underlying long-term post-concussion symptoms are unclear, but a biopsychosocial explanatory model is currently regarded as the most appropriate basis for diagnosis and treatment. This clinical review article is based on key literature and our own clinical experiences with patients who have these long-term post-concussion symptoms.
Topics: Brain Concussion; Humans; Post-Concussion Syndrome
PubMed: 36066235
DOI: 10.4045/tidsskr.21.0713 -
Current Sports Medicine Reports Aug 2018Sport-related concussion (SRC) is a physiological brain injury that produces cerebral and systemic effects, including exercise intolerance. Exercise intolerance after... (Review)
Review
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.
Topics: Animals; Athletic Injuries; Brain Concussion; Carbon Dioxide; Clinical Trials as Topic; Diagnosis, Differential; Exercise Test; Exercise Therapy; Exercise Tolerance; Humans; Post-Concussion Syndrome; Rest
PubMed: 30095546
DOI: 10.1249/JSR.0000000000000505 -
Neurosurgery Oct 2014Since the original descriptions of postconcussive pathophysiology, there has been a significant increase in interest and ongoing research to study the biological... (Review)
Review
Since the original descriptions of postconcussive pathophysiology, there has been a significant increase in interest and ongoing research to study the biological underpinnings of concussion. The initial ionic flux and glutamate release result in significant energy demands and a period of metabolic crisis for the injured brain. These physiological perturbations can now be linked to clinical characteristics of concussion, including migrainous symptoms, vulnerability to repeat injury, and cognitive impairment. Furthermore, advanced neuroimaging now allows a research window to monitor postconcussion pathophysiology in humans noninvasively. There is also increasing concern about the risk for chronic or even progressive neurobehavioral impairment after concussion/mild traumatic brain injury. Critical studies are underway to better link the acute pathobiology of concussion with potential mechanisms of chronic cell death, dysfunction, and neurodegeneration. This "new and improved" article summarizes in a translational fashion and updates what is known about the acute neurometabolic changes after concussive brain injury. Furthermore, new connections are proposed between this neurobiology and early clinical symptoms as well as to cellular processes that may underlie long-term impairment.
Topics: Athletic Injuries; Brain Concussion; Female; Humans; Male; Neuroimaging
PubMed: 25232881
DOI: 10.1227/NEU.0000000000000505 -
American Family Physician Apr 2019Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external... (Review)
Review
Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.
Topics: Athletic Injuries; Brain Concussion; Disease Management; Humans; Neurologic Examination; Sports Medicine
PubMed: 30932451
DOI: No ID Found -
Biomedicine & Pharmacotherapy =... Sep 2020The growing number of concussions and mild traumatic brain injuries (mTBI) with the lack of evidence-based treatment options is a continuous health concern. This creates... (Review)
Review
The growing number of concussions and mild traumatic brain injuries (mTBI) with the lack of evidence-based treatment options is a continuous health concern. This creates problems when evaluating and providing efficacious symptom management to patients suffering from post-concussion syndrome (PCS). Numerous pharmacological and non-pharmacological agents have been utilized in an attempt to treat PCS. Some of these approaches include physical therapy, analgesics, antidepressants, and nutraceuticals. Although these treatments have had some success, there has been inconsistent outcomes, with some examples of patients' symptoms worsening. Among pharmaceutical agents, fluoxetine has been a popular choice for the symptom management of PCS. Although some patients have had symptom resolution with the use of fluoxetine, there is still a lack of conclusive data. Of the several biochemical changes that occur in a patient's brain following a concussion, an increase in reactive oxygen species (ROS) is of particular concern. In order to counteract the responses of the brain, antioxidants, such as ascorbic acid, have been utilized to reverse the damaging cellular effects. However, this may inadvertently cause an increase in ROS, rather than a reduction. Although there is a lack of consistency in exactly when each treatment was used in the post-injury interval, it is important that we analyze the strengths and weaknesses of the most commonly used agents due to the lack of a set protocol. The studies were chosen in a non-exhaustive manner and were not consistent in patients' post-injury intervals, in addition to other baseline characteristics. However, over-arching claims that some treatments may benefit more than others can be made. This review evaluates both the pharmaceutical and non-pharmaceutical protocols that are most commonly utilized in post-concussive patients for their efficacy in treatment of post-concussive syndrome (PCS).
Topics: Brain; Brain Concussion; Clinical Protocols; Evidence-Based Medicine; Humans; Post-Concussion Syndrome; Treatment Outcome
PubMed: 32768934
DOI: 10.1016/j.biopha.2020.110406 -
Journal of Athletic Training Mar 2017Vestibular and oculomotor impairment and symptoms may be associated with worse outcomes after sport-related concussion (SRC), including prolonged recovery. In this... (Review)
Review
Vestibular and oculomotor impairment and symptoms may be associated with worse outcomes after sport-related concussion (SRC), including prolonged recovery. In this review, we evaluate current findings on vestibular and oculomotor impairments as well as treatment approaches after SRC, and we highlight areas in which investigation is needed. Clinical researchers have intimated that recovery from SRC may follow certain clinical profiles that affect the vestibular and oculomotor pathways. Identifying clinical profiles may help to inform better treatment and earlier intervention to reduce recovery time after SRC. As such, screening for and subsequent monitoring of vestibular and oculomotor impairment and symptoms are critical to assessing and informing subsequent referral, treatment, and return to play. However, until recently, no brief-screening vestibular and oculomotor tools were available to evaluate this injury. In response, researchers and clinicians partnered to develop the Vestibular/Ocular-Motor Screening, which assesses pursuits, saccades, vestibular ocular reflex, visual motion sensitivity, and convergence via symptom provocation and measurement of near-point convergence. Other specialized tools, such as the King-Devick test for saccadic eye movements and the Dizziness Handicap Inventory for dizziness, may provide additional information regarding specific impairments and symptoms. Tools such as the Vestibular/Ocular-Motor Screening provide information to guide specialized referrals for additional assessment and targeted rehabilitation. Vestibular rehabilitation and visual-oculomotor therapies involve an active, expose-recover approach to reduce impairment and symptoms. Initial results support the effectiveness of both vestibular and visual-oculomotor therapies, especially those that target specific impairments. However, the evidence supporting rehabilitation strategies for both vestibular and oculomotor impairment and symptoms is limited and involves small sample sizes, combined therapies, nonrandomized treatment groups, and lack of controls. Additional studies on the effectiveness of screening tools and rehabilitation strategies for both vestibular and oculomotor impairment and symptoms after SRC are warranted.
Topics: Athletic Injuries; Brain Concussion; Early Diagnosis; Female; Humans; Male; Oculomotor Nerve Diseases; Post-Concussion Syndrome; Return to Sport; Sports; Vestibular Diseases
PubMed: 28387548
DOI: 10.4085/1062-6050-51.11.05 -
PloS One 2017Mild traumatic brain injury (mTBI), or concussion, is the most common type of traumatic brain injury. With mTBI comes symptoms that include headaches, fatigue,... (Review)
Review
Mild traumatic brain injury (mTBI), or concussion, is the most common type of traumatic brain injury. With mTBI comes symptoms that include headaches, fatigue, depression, anxiety and irritability, as well as impaired cognitive function. Symptom resolution is thought to occur within 3 months post-injury, with the exception of a small percentage of individuals who are said to experience persistent post-concussion syndrome. The number of individuals who experience persistent symptoms appears to be low despite clear evidence of longer-term pathophysiological changes resulting from mTBI. In light of the incongruency between these longer-term changes in brain pathology and the number of individuals with longer-term mTBI-related symptoms, particularly impaired cognitive function, we performed a scoping review of the literature that behaviourally assessed short- and long-term cognitive function in individuals with a single mTBI, with the goal of identifying the impact of a single concussion on cognitive function in the chronic stage post-injury. CINAHL, Embase, and Medline/Ovid were searched July 2015 for studies related to concussion and cognitive impairment. Data relating to the presence/absence of cognitive impairment were extracted from 45 studies meeting our inclusion criteria. Results indicate that, in contrast to the prevailing view that most symptoms of concussion are resolved within 3 months post-injury, approximately half of individuals with a single mTBI demonstrate long-term cognitive impairment. Study limitations notwithstanding, these findings highlight the need to carefully examine the long-term implications of a single mTBI.
Topics: Brain Concussion; Chronic Disease; Cognitive Dysfunction; Humans
PubMed: 28399158
DOI: 10.1371/journal.pone.0174847 -
Neurobiology of Disease Feb 2020Sleep and circadian rhythms are among the most powerful but least understood contributors to cognitive performance and brain health. Here we capitalize on the circadian... (Randomized Controlled Trial)
Randomized Controlled Trial
A randomized, double-blind, placebo-controlled trial of blue wavelength light exposure on sleep and recovery of brain structure, function, and cognition following mild traumatic brain injury.
Sleep and circadian rhythms are among the most powerful but least understood contributors to cognitive performance and brain health. Here we capitalize on the circadian resetting effect of blue-wavelength light to phase shift the sleep patterns of adult patients (aged 18-48 years) recovering from mild traumatic brain injury (mTBI), with the aim of facilitating recovery of brain structure, connectivity, and cognitive performance. During a randomized, double-blind, placebo-controlled trial of 32 adults with a recent mTBI, we compared 6-weeks of daily 30-min pulses of blue light (peak λ = 469 nm) each morning versus amber placebo light (peak λ = 578 nm) on neurocognitive and neuroimaging outcomes, including gray matter volume (GMV), resting-state functional connectivity, directed connectivity using Granger causality, and white matter integrity using diffusion tensor imaging (DTI). Relative to placebo, morning blue light led to phase-advanced sleep timing, reduced daytime sleepiness, and improved executive functioning, and was associated with increased volume of the posterior thalamus (i.e., pulvinar), greater thalamo-cortical functional connectivity, and increased axonal integrity of these pathways. These findings provide insight into the contributions of the circadian and sleep systems in brain repair and lay the groundwork for interventions targeting the retinohypothalamic system to facilitate injury recovery.
Topics: Actigraphy; Adolescent; Adult; Brain; Brain Concussion; Brain Mapping; Cognition; Double-Blind Method; Female; Humans; Light; Magnetic Resonance Imaging; Male; Middle Aged; Neuropsychological Tests; Phototherapy; Sleep; Treatment Outcome; Young Adult
PubMed: 31751607
DOI: 10.1016/j.nbd.2019.104679