Andrea Hinds

The Role of Controlled Exercise in Concussion Management

Concussion affects the autonomic nervous system and its control of cerebral blood flow, which may be why uncontrolled activity can exacerbate symptoms after concussion. Traditionally, patients have been advised to restrict physical and cognitive activity until all symptoms resolve. However, recent research suggests that prolonged rest beyond the first couple of days after a concussion might hinder rather than aid recovery. Humans do not respond well to removal from their social and physical environments, and sustained rest adversely affects the physiology of concussion and can lead to physical deconditioning and reactive depression. Some animal data show that early forced exercise is detrimental to recovery after concussion, but other animal data show that voluntary exercise is not detrimental to recovery. We developed the Buffalo Concussion Treadmill Test to systematically evaluate exercise tolerance in persons with prolonged symptoms after concussion (ie, more than 4‐6 weeks, which is called postconcussion syndrome [PCS]). Using a predetermined stopping criterion (symptom‐exacerbation threshold), akin to voluntary exercise in animals, the Buffalo Concussion Treadmill Test is the only functional test known to safely and reliably reveal exercise intolerance in humans with PCS. The test data are used to develop individualized subthreshold exercise treatment programs to restore the physiology to normal and enhance recovery. Return of normal exercise tolerance can then be used to establish physiological recovery from concussion. New research suggests that absolute rest beyond the first few days after concussion may be detrimental to concussion recovery. However, further research is required to determine the appropriate mode, duration, intensity, and frequency of exercise during the acute recovery phase of a concussion prior to making specific exercise recommendations. For patients with PCS, subsymptom threshold exercise improves activity tolerance and is an appropriate treatment option for this patient population.

The Effect of Exertion on Heart Rate and Rating of Perceived Exertion in Acutely Concussed Individuals

Objective Research suggests that one physiological effect of concussion is a disruption in regulation of autonomic nervous system control that affects the balance between parasympathetic and sympathetic output. While changes in heart rate after concussion have been observed, the nature of the heart rate change during progressive exercise has not been well evaluated in acutely symptomatic patients. Additionally, little is known about the relationship between HR and RPE in this population. Methods We compared changes in heart rate and perceived effort during graded treadmill exertion in recently concussed patients to elucidate the effect of brain injury on cardiovascular response to exercise. Resting HR, HR on exercise initiation, and changes in HR and RPE during the Buffalo Concussion Treadmill Test (BCTT) were compared on two test visits: When patients were symptomatic (acute) and after recovery. Results were compared with the test-retest results obtained from a control group consisting of healthy, non-concussed individuals. Results Patients had a significantly lower HR at onset of exercise when acutely concussed as compared to when recovered and reported greater perceived exertion at every exercise intensity level when symptomatic, despite exercising at lower workloads, than when recovered. Sympathetic response to increased exertion was not affected by concussion - HR increased in response to exercise at a comparable rate in both tests. These differences observed in response to exercise between the first BCTT and follow-up evaluation in initially concussed patients were not present in non-concussed individuals. Conclusion Our results suggest that during the acute phase after concussion, acutely concussed patients demonstrated an impaired ability to shift from parasympathetic to sympathetic control over heart rate at the onset of exercise. Changes in the autonomic nervous system after concussion may be more complex than previously reported. Continued evaluation of autonomic regulatory effects in the acute phase after concussion is warranted.

Behavioral Health Symptoms Associated With Chronic Traumatic Encephalopathy: A Critical Review of the Literature and Recommendations for Treatment and Research

Chronic traumatic encephalopathy (CTE) is a neurodegenerative syndrome that has been linked to serious psychiatric symptoms, including depression, aggression, and suicidal behavior. This review critically examines the extant research on the behavioral manifestations of CTE and concludes that the paucity of longitudinal prospective studies on CTE, combined with a lack of research-accepted diagnostic criteria for identifying individuals who are considered at risk for CTE, makes it difficult to reliably establish a causal relationship between CTE and the onset of behavioral health problems. Selection and reporting bias and inconsistency in data collection methods are other concerns. To advance the field, there is a critical need for more empirical research on the behavioral manifestations of CTE. Recommendations and intervention models are also discussed.

A Physiological Approach to Prolonged Recovery From Sport-Related Concussion

Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.

School attendance and symptoms in adolescents after sport-related concussion

A recent retrospective study reported that 45% of a sample of elementary school, high school, and college students returned to school too soon after concussion with a recurrence or worsening of symptoms. Another study found that 38% of high school student athletes reported symptoms and problems in school after concussion, although most students did not miss many days of school. Further studies suggest that excessive mental exertion can aggravate concussion symptoms and perhaps prolong recovery. The 2012 Zurich Consensus Statement highlights modification of school attendance and activities to avoid provocation of symptoms. A gradual return to cognitive activity and to school has been recommended with “pacing” to stay below the cognitive symptom threshold. One study showed that cognitive activity level reported by weekly recall was associated with duration of symptoms in adolescents sustaining sport-related concussion (SRC). While this study was prospective in nature, it relied on weekly recall by subjects and did not look at the specific number of school hours attended after injury. The hours spent in school may have a direct relationship with recovery time after SRC. This relationship requires further study. The purpose of this study was to prospectively evaluate the relationship of school attendance and symptoms after SRC. We specifically evaluated whether hours of school attended postconcussion was associated with increased concussion symptom severity scores and delayed recovery... Language: en

Sleep disturbance in patients with chronic concussive effects

Aim: Sleep disturbance is relatively overlooked in concussion treatment although sleep disorders may prolong or exacerbate symptoms after a concussion. We looked at the incidence of both sleep disturbance and postconcussion symptoms in a sample of recently concussed individuals. Methods & results: We evaluated scores on the insomnia severity index (ISI) and postconcussion symptom scale (PCSS) in 96 participants with persistent symptoms. Sleep disturbance significantly contributed to the severity of postconcussive symptoms and length of recovery; this effect was less pronounced in athletes. Conclusion: These results suggest a relationship between sleep problems and the time course of recovery from concussive injury. Clinicians who regularly treat concussion would benefit from a more thorough consideration of sleep function in the assessment of postconcussive symptoms.

Nutrition and Energy Expenditure of Retired Professional Contact Sport Athletes and Non Contact Sport Controls: 1287 Board #95 May 31 8

Methods Discussion and Conclusion Results Magnesium (p = 0.013) and Fiber (p = 0.02) are in grams Copper (p = 0.019), Potassium (p = 0.02), Phosphorous (p = 0.043), Manganese (p = 0.002), and Riboflavin (p = 0.047) are in milligrams Selenium (p = 0.037), Vitamin D (p = 0.035), and Folate (p = 0.02) are in micrograms Manesium Cpper Senium Vamin D Flate Poassium Phphorus Maganese Fiber Roflavin gr am s, gr am s) Non-contact Sport Athlete Contact Sport Athlete overweight (n = 21, 56.7 ± 9.5 years, 24.5 ± 2.6 kg/m2, p < neurologic function after suffering a TBI.11 Numerous studi 0.001). Calculated kilocalorie intake was not significantly activity they perform on a regular basis (Estimated Energy es ate to faster cognitive decline.12 Whereas the correlation between different; however, the total time spent doing common Expenditure, EEE), respectively: have shown that higher rates of folate intake correl 1. Food Frequency Questionnaire (FFQ) types of physical activities was significantly lower in retired contact sport athletes (22.5 ± 18.7 hrs/wk vs 51.1 ± 15.0 decreased cognition and decreased Vitamin D after traumatic 2. Yale Physical Activity Survey (YPAS)

Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial

Objective: To evaluate (1) systematic assessment of exercise tolerance in adolescents shortly after sport-related concussion (SRC) and (2) the prognostic utility of such assessment. Design: Prospective randomized controlled trial. Setting: University and community sports medicine centers. Participants: Adolescents with SRC (1–9 days from injury). Sixty-five were randomized and 54 completed the study (mean age 15 years, 4 days after injury). Interventions: Buffalo Concussion Treadmill Test (BCTT, n = 27) or not (controls, n = 27) on visit day #1. Heart rate threshold (HRt) at symptom exacerbation represented level of exercise tolerance. Participants reported symptoms daily for 14 days and then had follow-up BCTT (n = 54). Recovery was defined as returning to normal level of symptoms and exercise tolerance, verified by independent physician examination. Main Outcome Measures: Days to recovery and typical (⩽21 days) versus prolonged recovery (>21 days). Mixed effects linear models and linear regression techniques examined symptom reports and time to recovery. Linear regression assessed the association of HRt with recovery time. Results: Days to recovery (P = 0.7060) and typical versus prolonged recovery (P = 0.1195) were not significantly different between groups. Symptom severity scores decreased in both groups over 14 days (P < 0.0001), were similar (P = 0.2984), and did not significantly increase the day after the BCTT (P = 0.1960). Lower HRt on visit day #1 was strongly associated with prolonged recovery time (P = 0.0032). Conclusions: Systematic evaluation of exercise tolerance using the BCTT within 1 week after SRC did not affect recovery. The degree of early exercise intolerance after SRC was important for prognosis. This has implications for school academic and team preparation.

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

ABSTRACT 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.

Evaluation of physical examination elements in the diagnosis and prognosis of sports related concussion in adolescent athletes

Objective To evaluate a brief physical examination (PE) for diagnosis and prognosis of sport-related concussion (SRC) in adolescents. Design Prospective. Setting UniversityConcussion clinics. Subjects 53 adolescents with SRC (mean age 15.4; 70% male) and 30 uninjured controls (mean age 15.8; 73% male). Interventions Participants received a brief PE (11 PE elements in three systems: cervical, oculomotor and vestibular). Concussed adolescents were assessed acutely (mean 4.5 days post-injury) and at follow up (mean 18.5 days). Outcome measures Dependent variables 1: Concussion versus uninjured and 2: Standard versus slow recovery (>3 weeks). Recovery was defined as asymptomatic and exercise tolerant. Results Table 1 shows the significant PE variables that distinguished concussed from uninjured (via Fisher’s exact test; significance p<0.05). Abstract 136 Table 1 PE elements (Visit 1) with 95% CI for Odds ratio and p-value Element CI p Neck tenderness (1.92, Inf) 0.00321 Smooth Pursuits (5.70, 786.21) <0.00001 Convergence (1.10, 9.44) 0.03475 Abnormal saccades (3.34, 466.65) 0.00009 VOR (2.46, Inf) 0.00144 VOR Dizzy (3.67, Inf) 0.00015 Tandem gait (1.98, 291.60) 0.00191 Table 2 shows the significant PE variables distinguishing standard recovery from slow recovery at visit 2 (via Fisher’s exact test; significance p<0.05). Abstract 136 Table 2 PE variables (Visit 2) with 95% CI for Odds ratio and p-value Neck spasm (1.13, Inf) 0.04148 Smooth pursuits (2.26, 127.15) 0.00298 Convergence (2.08, 53.74) 0.00319 Tandem gait (2.91, 773.79) 0.00105 Conclusions Easily administered physical exam reveals clinical findings that are important and sensitive for diagnosing acute concussion. Prognosis was less precise due to the heterogeneity of aetiology of slow recovery. Competing interests No competing interests for any authors.