Anastasia Fischer

How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis

Abstract Background/aim: A standard definition of Post-concussion Syndrome (PCS) does not exist. The objective was to determine consensus regarding the definition of PCS among physician members of the American College of Sports Medicine (ACSM). Methods: Physician members of the ACSM were sent an electronic survey to determine opinions regarding the PCS diagnosis. Results: Five hundred and ninety-seven physicians completed the survey. When asked the minimum duration of symptoms required to diagnose PCS, respondents answered: <2 weeks (26.6%), 2 weeks to 1 month (20.4%), 1–3 months (33%) and >3 months (11.1%). Physicians who see ≥10% concussion patients in their practise, as well as physicians whose concussion population consists of >50% paediatric patients, were more likely to require >1 month of symptoms (p < 0.001). When asked the minimum number of symptoms required to diagnose PCS, responses varied: one symptom (55.9%), two symptoms (17.6%), three symptoms (14.6%) and four or more symptoms (3.2%). Respondents from the US were more likely than non-US respondents to require only one symptom for the PCS diagnosis (p = 0.01). Conclusions: There is a lack of consensus regarding the definition of PCS among physician members of the ACSM. A standard definition would improve consistency in concussion research and in clinical practise.

Orthostatic Intolerance and Autonomic Dysfunction in Youth With Persistent Postconcussion Symptoms: A Head-Upright Tilt Table Study.

Objective:To explore head-upright tilt table (HUT) signs of autonomic dysfunction in a cohort of youth with persistent postconcussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have postural tachycardia syndrome (POTS) on initial testing. Design:Prospective cohort design. Setting:Nationwide Childrens Hospital, Neurology Clinic. Participants:Thirty-four patients (13-18 years of age) with persistent PCSs. Main Outcome Measures:All patients underwent at least 1 tilt table test. The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden. Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted. Results:Twenty-four of the 34 (70.6%) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14). Patients with POTS had higher PCS-I scores than normal patients (P < 0.001) and higher ratings of light-headedness than both normal patients (P = 0.015) and syncope patients (P = 0.04). Twelve POTS patients underwent repeat tilt table testing, and 9 of 12 (75%) no longer met POTS diagnostic criteria. All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo. Conclusions:Our study demonstrates a high rate of tilt table abnormalities among youth with persistent PCSs. Several patients with POTS had normalization of tilt table testing when PCSs improved. These findings warrant further research of autonomic dysfunction related to concussion. Clinical Relevance:Our study is the first to prospectively characterize autonomic dysfunction in patients with persistent PCSs using HUT testing and to show that the tilt test abnormalities normalize in some patients as PCSs improve.

Post-traumatic headaches correlate with migraine symptoms in youth with concussion

Objective The term “post-traumatic migraine” (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion. Methods Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache. Results The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster. Conclusions PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients.

Utilization of conventional neuroimaging following youth concussion.

ABSTRACT Background/objective: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. Methods: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10–19 years, who presented to a sports concussion clinic within 30 days of injury. Results: The majority of CT scans (n = 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n = 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (all p < 0.001). Prior concussion (p = 0.002) and continued participation in activity after injury (p = 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p = 0.024, hazard ratio = 1.2) or MRI (p < 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. Conclusion: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield.

Timing of Physical Therapy Referral in Adolescent Athletes With Acute Spondylolysis: A Retrospective Chart Review.

Objectives: The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis. Study Design: Retrospective chart review. Setting: Hospital-based sports medicine clinic. Patients: The medical charts of 196 adolescent athletes (mean age = 14.3 ± 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed. Independent Variable: Patients were subgrouped based on physician referral to PT. Patterns: An aggressive referral group (<10 weeks) and a conservative referral group (>10 weeks). Main Outcome Measures: Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group. Results: Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509). Conclusions: Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups.

Physicians’ Management Practices and Perceived Health Risks When Postconcussion Symptoms Persist

Background: Concussion guidelines recommend physical and cognitive rest until all postconcussion symptoms resolve, in part because of potential health risks, including catastrophic injury related to a second impact. However, when postconcussion symptoms persist for weeks or months, these risks are poorly characterized. Hypothesis: Physicians’ perceived health risks and management strategies for patients with persistent postconcussion symptoms will vary. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: A survey of the physician members of the American College of Sports Medicine assessed the perceived health risks related to advancing activity, the indications for neuroimaging, and the referral patterns for patients with persistent postconcussion symptoms. Results: A total of 572 physicians completed the survey (response rate, 27.2%). The majority of physicians recommended physical rest (97.4%) and cognitive rest (93.8%) within the first week of injury. Perceived health risks related to advancing activity in the symptomatic patient differed at 2 weeks versus 3 months after injury (P < 0.001 for all comparisons). Respondents from the United States were more likely to list second impact syndrome as a potential health risk at 2 weeks compared with respondents from other countries (P = 0.04). The majority (56%) responded that the risk of second impact syndrome remains until all symptoms resolve. When postconcussion symptoms persist beyond 1 month, 61.9% of physicians responded that neuroimaging is indicated. Approximately 60% of respondents had access to a multidisciplinary concussion clinic within 60 miles of their practice. Conclusion: When postconcussion symptoms persist, the perceived health risks, management practices, and access to multidisciplinary care vary among physicians.