Kathryn Schneider

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps. A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …

Consensus statement on concussion in sport: the 4th international conference on concussion in sport, Zurich, november 2012

Paul McCrory, MBBS, PhD*; Willem H. Meeuwisse, MD, PhD†; Mark Aubry, MD‡; Robert C. Cantu, MD§; Jiři Dvořak, MD||; Ruben J. Echemendia, PhD¶; Lars Engebretsen, MD, PhD#; Karen Johnston, MD, PhD**; Jeffrey S. Kutcher, MD††; Martin Raftery, MBBS‡‡; Allen Sills, MD§§; Brian W. Benson, MD, PhD||||; Gavin A. Davis, MBBS¶¶; Richard Ellenbogen, MD##; Kevin M. Guskiewicz, PhD***; Stanley A. Herring, MD†††; Grant L. Iverson, PhD‡‡‡; Barry D. Jordan, MD§§§; James Kissick, MD||||||; Michael McCrea, PhD¶¶¶; Andrew S. McIntosh, PhD###; David Maddocks, LLB, PhD****; Michael Makdissi, MBBS, PhD††††; Laura Purcell, MD‡‡‡‡; Margot Putukian, MD§§§§; Kathryn Schneider, PhD||||||||; Charles H. Tator, MD, PhD¶¶¶¶; Michael Turner, MD####

Are Joint Injury, Sport Activity, Physical Activity, Obesity, or Occupational Activities Predictors for Osteoarthritis? A Systematic Review

STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To identify risk factors for osteoarthritis (OA) of the knee, hip, and ankle, including joint injury, sport, physical activity, overweight/obesity, and occupational activity, in all age groups. BACKGROUND OA is a significant health problem worldwide, affecting up to 10% of men and 18% of women over 60 years of age. There has not been a comprehensive review examining modifiable physical risk factors associated with the onset of OA. This evidence is important to inform the physiotherapy management of individuals following onset of OA. METHODS Twelve electronic databases were systematically reviewed. The studies selected met the following criteria: (1) original data; (2) joint injury, sport activity, physical activity, overweight/obesity, and/or occupational activity investigated as risk factors; (3) outcomes included OA (hip, knee, and/or ankle); and (4) analytic component of study design. The data extracted included study design, years of follow-up, study population, OA definition, risk factors, and results (effect estimates reported or calculated where available). The quality of evidence was assessed based on a modified version of the Downs and Black checklist. RESULTS Joint injury, obesity, and occupational activity were associated with an increased risk of OA of the knee and hip. Sport and physical activity produced inconsistent findings. Joint injury was identified as a significant risk factor for knee OA (combined odds ratio = 3.8; 95% confidence interval: 2.0, 7.2) and hip OA (combined odds ratio = 5.0; 95% confidence interval: 1.4, 18.2), as was previous meniscectomy with or without anterior cruciate ligament injury for knee OA (combined odds ratio = 7.4; 95% confidence interval: 4.0, 13.7). There is a paucity of research examining risk factors associated with ankle OA; this review identified only 2 studies with this outcome. CONCLUSION Joint injury, obesity, and occupational activity are associated with an increased risk of knee and hip OA. Some findings remain inconclusive, including levels of physical activity and sport specificity in individuals who do not suffer an injury. Early identification of individuals at risk for OA provides an opportunity for physiotherapy management or other interventions to modify risk-related behavior. There is a need in the literature for additional high-quality studies, such as prospective cohort studies, that minimize potential bias in examining the relationship between physical risk factors and OA. LEVEL OF EVIDENCE Prognosis, level 2a-.

The effects of rest and treatment following sport-related concussion: a systematic review of the literature

Objective To evaluate the evidence for rest, treatment, and rehabilitation following sport-related concussion (SRC). Data sources PubMed, CINAHL, PsychInfo, Cochrane Controlled Trials Registers, Health STAR, Sport Discus, EMBASE, Web of Science, and ProQuest. Study selection Articles were included if they met the following criteria: original research, reported SRC as a source of injury, and evaluated the effect of rest or treatment. Data extraction Study design, participants, treatment, outcome measures, and key findings. Data synthesis Three studies met the inclusion criteria for evaluating the effects of rest and twelve for treatment. Low-intensity aerobic exercise may be of benefit. Conclusions The current evidence evaluating the effect of rest and treatment following SRC is sparse. An initial period of rest may be of benefit. Low-level exercise and multimodal physiotherapy may be of benefit for those who are slow to recover. There is a strong need for high level studies evaluating the effects of rest and treatment following SRC.

Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial

Background/aim Concussion is a common injury in sport. Most individuals recover in 7–10 days but some have persistent symptoms. The objective of this study was to determine if a combination of vestibular rehabilitation and cervical spine physiotherapy decreased the time until medical clearance in individuals with prolonged postconcussion symptoms. Methods This study was a randomised controlled trial. Consecutive patients with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion (12–30 years, 18 male and 13 female) were randomised to the control or intervention group. Both groups received weekly sessions with a physiotherapist for 8 weeks or until the time of medical clearance. Both groups received postural education, range of motion exercises and cognitive and physical rest until asymptomatic followed by a protocol of graded exertion. The intervention group also received cervical spine and vestibular rehabilitation. The primary outcome of interest was medical clearance to return to sport, which was evaluated by a study sport medicine physician who was blinded to the treatment group. Results In the treatment group, 73% (11/15) of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% (1/14) in the control group. Using an intention to treat analysis, individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared by 8 weeks. Conclusions A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion. Trial registration number NCT01860755.

Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012.

the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Paul McCrory, Willem H Meeuwisse, Mark Aubry, Bob Cantu, Jiří Dvořák, Ruben J Echemendia, Lars Engebretsen, Karen Johnston, Jeffrey S Kutcher, Martin Raftery, Allen Sills, Brian W Benson, Gavin A Davis, Richard G Ellenbogen, Kevin Guskiewicz, Stanley A Herring, Grant L Iverson, Barry D Jordan, James Kissick, Michael McCrea, Andrew S McIntosh, David Maddocks, Michael Makdissi, Laura Purcell, Margot Putukian, Kathryn Schneider, Charles H Tator, Michael Turner

Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion

Background Concussion is one of the most commonly occurring injuries in sport today. The Sport Concussion Assessment Tool (SCAT) is a commonly used paper neurocognitive tool. To date, little is known about SCAT baseline normative values in youth athletes. Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players. Methods This is a secondary data analysis of pooled data from three prospective cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years. A preseason baseline demographic and injury history questionnaire was completed by each player. Results A total of 4193 players completed SCATs at baseline and were included in the analysis. 781 players (18.6%) reported a previous history of concussion. Fatigue and low energy followed by headache were the most commonly reported symptoms in all players. The majority of youth players could recite all five words immediately but only three words when delayed. A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age. The median number of digits recited in reverse order was 4. Conclusions Youth ratings varied between age groups, gender and from previously reported ratings of varsity athletes, possibly reflecting developmental and gender differences. An understanding of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion.

Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients.

BackgroundThe cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine.MethodsMeasures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPTs) and cold pain thresholds (CPTs). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD.ResultsAt baseline, PPTs were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPTs at all sites (p < 0.05), and significant decreases in CPTs at the cervical spine (p < 0.001).ConclusionsThe patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.

What is the difference in concussion management in children as compared with adults? A systematic review

Aim To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp). Design Systematic review. Data sources MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID). Eligibility criteria for selecting studies Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC. Results A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5–12 years. Summary/conclusions This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate. Systematic review registration PROSPERO 2016:CRD42016039184