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A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes.

ABSTRACT: Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

SUBMITTER: Ellis MJ

PROVIDER: S-EPMC6306465 | biostudies-other | 2018

REPOSITORIES: biostudies-other

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A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes.

Ellis Michael J MJ Leddy John J Cordingley Dean D Willer Barry B

Frontiers in neurology 20181220

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on t ...[more]

PMID: 30619068

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Project description:CONTEXT:? Without a true criterion standard assessment, the sport-related concussion (SRC) diagnosis remains subjective. Inertial balance sensors have been proposed to improve acute SRC assessment, but few researchers have studied their clinical utility. OBJECTIVE:? To determine if group differences exist when using objective measures of balance in a sample of collegiate athletes with recent SRCs and participants serving as the control group and to calculate sensitivity and specificity to determine the diagnostic utility of the inertial balance sensor for acute SRC injuries. DESIGN:? Cross-sectional cohort study. SETTING:? Multicenter clinical trial. PATIENTS OR OTHER PARTICIPANTS:? We enrolled 48 participants with SRC (age = 20.62 ± 1.52 years, height = 179.76 ± 10.00 cm, mass = 83.92 ± 23.22 kg) and 45 control participants (age = 20.85 ± 1.42 years, height = 177.02 ± 9.59 cm, mass = 74.61 ± 14.92 kg) at 7 clinical sites in the United States. All were varsity or club collegiate athletes, and all participants with SRC were tested within 72 hours of SRC. MAIN OUTCOME MEASURE(S):? Balance performance was assessed using an inertial balance sensor. Two measures (root mean square sway and 95% ellipse sway area) were analyzed to represent a range of general balance measures. Balance assessments were conducted in double-legged, single-legged, and tandem stances. RESULTS:? A main effect for group was associated with the root mean square sway measure ( F1,91 = 11.75, P = .001), with the SRC group demonstrating balance deficits compared with the control group. We observed group differences in the 95% ellipse sway area measure for the double-legged ( F1,91 = 11.59, P = .001), single-legged ( F1,91 = 6.91, P = .01), and tandem ( F1,91 = 7.54, P = .007) stances. Sensitivity was greatest using a cutoff value of 0.5 standard deviations (54% [specificity = 71%]), whereas specificity was greatest using a cutoff value of 2 standard deviations (98% [sensitivity = 33%]). CONCLUSIONS:? Inertial balance sensors may be useful tools for objectively measuring balance during acute SRC evaluation. However, low sensitivity suggests that they may be best used in conjunction with other assessments to form a comprehensive screening that may improve sensitivity.

Project description:ContextMandated concussion education has aimed to improve student-athlete knowledge; however, some collegiate student-athletes continue to not disclose concussion. Concussion knowledge may not be the only factor influencing reporting, as student-athlete sex, sport, and pressure from external stakeholders (eg, coaches, teammates, fans, parents or family) have all been documented as influencing collegiate concussion-reporting behavior.ObjectiveTo examine factors associated with concussion nondisclosure in collegiate student-athletes.DesignCross-sectional study.SettingFour National Collegiate Athletic Association Division I and two Division II universities.Patients or other participantsA total of 1125 collegiate student-athletes completed the survey, and 741 provided viable responses and were included for data analysis.Main outcome measure(s)We used a 10- to 15-minute electronic or paper-and-pencil survey that asked about personal and sport demographics, diagnosed concussions and nondisclosed concussion history, concussion knowledge, and level of agreement regarding pressure to play after a head impact experienced during collegiate sport participation. Significant univariable factors were entered into a multivariable logistic regression analysis.ResultsSex (P = .005), sport-risk type (P < .001), diagnosed concussion history (P < .001), concussion knowledge (P = .017), and pressure from coaches (P < .001), teammates (P < .001), fans (P = .024), and parents or family (P = .003) were factors associated with concussion nondisclosure in individual univariable logistic regressions. After we conducted multivariable analyses, male sex (P = .001), high concussion-risk sport participation (P = .048), diagnosed concussion history (P < .001), increased concussion knowledge (P = .013), and experiencing pressure from coaches to continue playing after sustaining a hit to the head (P = .002) were factors associated with concussion nondisclosure in collegiate student-athletes.ConclusionsOur results suggest that concussion-education programs should go beyond the identification of signs and symptoms to include the dangers of continuing to play, long-term consequences, and transparency about concussion protocols. Comprehensive concussion-education programs should involve coaches and athletes to improve the reporting culture.

Project description:ContextConcussions are a global public health concern, and education on the importance of self-reporting may not reach all athletes to the same degree around the world.ObjectiveTo determine if differences were present in the concussion awareness, understanding, and -reporting behaviors of collegiate athletes' in 3 countries with varied degrees of concussion publicity.DesignCross-sectional survey.SettingCollegiate sports medicine clinics.Patients or other participantsCollegiate athletes in the United States (n = 964; high publicity), Ireland (n = 302; moderate publicity), and Jordan (n = 129; low publicity). The degree of concussion publicity was categorized based on the extent of national public health awareness initiatives, care guidelines, research publications, and mass media coverage.Main outcome measure(s)Participants completed a 10- to 15-minute survey on concussion awareness, understanding, and -reporting behaviors. The main outcome measures were concussion education (awareness; 21 options; select all sources of concussion information), concussion knowledge (understanding; maximum score of 49), and diagnosed/nondisclosed concussion history (reporting behaviors; self-report yes/no items).ResultsA higher proportion of Jordanian athletes reported never having received concussion information previously (73.6%) than Irish (24.2%) or US athletes (9.4%). Knowledge differed among countries (P < .0001, η2 = .28), with US athletes displaying higher total knowledge scores (40.9 ± 4.5) than Jordanian (35.1 ± 5.6) and Irish (32.1 ± 3.5) athletes. Greater percentages of Irish and US athletes reported a history of a diagnosed concussion (31.8% and 29.6%, respectively) and history of concussion nondisclosure (25.2% and 15.5%, respectively) than Jordanian athletes (2.3% and 0.0% for history of a diagnosed concussion and history of concussion nondisclosure, respectively).ConclusionsIn the United States, where concussion publicity is high, formal legislation exists, and sports medicine resources and concussion awareness and understanding were increased. More culturally appropriate concussion initiatives are needed globally to ensure that athletes around the world can identify concussive injuries and understand the dangers of continued sport participation while concussed.

Project description:ObjectiveTo describe variability in concussion biomarker concentrations collected from serum in a sample of healthy collegiate athletes, as well as report reliability metrics in a subsample of female athletes.MethodsIn this observational cohort study, β-amyloid peptide 42 (Aβ42), total tau, S100 calcium binding protein B (S100B), ubiquitin carboxy-terminal hydrolyzing enzyme L1 (UCH-L1), glial fibrillary acidic protein, microtubule associated protein 2, and 2',3'-cyclic-nucleotide 3'-phosphodiesterase (CNPase) serum concentrations were measured in 415 (61% male, 40% white, aged 19.0 ± 1.2 years) nonconcussed collegiate athletes without recent exposure to head impacts. Standardized normative distributions are reported for each biomarker. We evaluated main effects (analyses of variance) of sex and race, reporting demographic-specific normative metrics when appropriate. In a subset of 31 female participants, test-retest reliability (Pearson r) and reliable change indices (80%, 90%, and 95% confidence intervals) across a 6- to 12-month interval are reported for Aβ42, total tau, S100B, and UCH-L1.ResultsMales exhibited higher UCH-L1 (p < 0.001, Cohen d = 0.75) and S100B (p < 0.001, d = 0.56) than females, while females had higher CNPase (p < 0.001, d = 0.43). Regarding race, black participants had higher baseline levels of UCH-L1 (p < 0.001, d = 0.61) and S100B (p < 0.001, d = 1.1) than white participants. Conversely, white participants had higher baseline levels of Aβ42 (p = 0.005, d = 0.28) and CNPase (p < 0.001, d = 0.46). Test-retest reliability was generally poor, ranging from -0.02 to 0.40, and Aβ42 significantly increased from time 1 to time 2.ConclusionHealthy collegiate athletes express concussion-related serum biomarkers in variable concentrations. Accounting for demographic factors such as sex and race is essential. Evidence suggested poor reliability for serum biomarkers; however, understanding how other factors influence biomarker expression, as well as knowledge of reliable change metrics, may improve clinical interpretation and future study designs.

Project description:ImportanceIdentifying plasma biomarkers associated with the amount of time an athlete may need before they return to sport (RTS) following a sport-related concussion (SRC) is important because it may help to improve the health and safety of athletes.ObjectiveTo examine whether plasma biomarkers can differentiate collegiate athletes who RTS in less than 14 days or 14 days or more following SRC.Design, setting, and participantsThis multicenter prospective diagnostic study, conducted by the National Collegiate Athletics Association-Department of Defense Concussion Assessment, Research, and Education Consortium, included 127 male and female athletes who had sustained an SRC while enrolled at 6 Concussion Assessment, Research, and Education Consortium Advanced Research Core sites as well as 2 partial-Advanced Research Core military service academies. Data were collected between February 2015 and May 2018. Athletes with SRC completed clinical testing and blood collection at preseason (baseline), postinjury (0-21 hours), 24 to 48 hours postinjury, time of symptom resolution, and 7 days after unrestricted RTS.Main outcomes and measuresA total of 3 plasma biomarkers (ie, total tau protein, glial fibrillary acidic protein [GFAP], and neurofilament light chain protein [Nf-L]) were measured using an ultrasensitive single molecule array technology and were included in the final analysis. RTS was examined between athletes who took less than 14 days vs those who took 14 days or more to RTS following SRC. Linear mixed models were used to identify significant interactions between period by RTS group. Area under the receiver operating characteristic curve analyses were conducted to examine whether these plasma biomarkers could discriminate between RTS groups.ResultsThe 127 participants had a mean (SD) age of 18.9 (1.3) years, and 97 (76.4%) were men; 65 (51.2%) took less than 14 days to RTS, and 62 (48.8%) took 14 days or more to RTS. Linear mixed models identified significant associations for both mean (SE) plasma total tau (24-48 hours postinjury, <14 days RTS vs ≥14 days RTS: -0.65 [0.12] pg/mL vs -0.14 [0.14] pg/mL; P = .008) and GFAP (postinjury, 14 days RTS vs ≥14 days RTS: 4.72 [0.12] pg/mL vs 4.39 [0.11] pg/mL; P = .04). Total tau at the time of symptom resolution had acceptable discrimination power (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.63-0.86; P < .001). We also examined a combined plasma biomarker panel that incorporated Nf-L, GFAP, and total tau at each period to discriminate RTS groups. Although the analyses did reach significance at each time period when combined, results indicated that they were poor at distinguishing the groups (area under the receiver operating characteristic curve, <0.7).Conclusions and relevanceThe findings of this study suggest that measures of total tau and GFAP may identify athletes who will require more time to RTS. However, further research is needed to improve our ability to determine recovery following an SRC.

Dataset Information

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes.

Publications

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes.

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