The Difficult Concussion Patient: What Is the Best Approach to Investigation and Management of Persistent (>10 Days) Postconcussive Symptoms?

The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms?

Br J Sports Med. 2013 Apr; 47(5): 308-13
Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH

Concussion in sport typically recovers clinically within 10 days of injury. In some cases, however, symptoms may be prolonged or complications may develop. The objectives of the current paper are to review the literature regarding the difficult concussion and to provide recommendations for an approach to the investigation and management of patients with persistent symptoms.A qualitative review of the literature on concussion in sport was conducted with a focus on prolonged recovery, long-term complications and management including investigation and treatment strategies. MEDLINE and Sports Discus databases were reviewed.Persistent symptoms (>10 days) are generally reported in 10-15% of concussions. This figure may be higher in certain sports (eg, ice hockey) and populations (eg, children). In general, symptoms are not specific to concussion and it is important to consider and manage coexistent pathologies. Investigations may include formal neuropsychological testing and conventional neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or genetics markers. Preliminary studies demonstrate the potential benefit of subsymptom threshold activity as part of a comprehensive rehabilitation programme. Limited research is available on pharmacological interventions.Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. Important components of management, after the initial period of physical and cognitive rest, include associated therapies such as cognitive, vestibular, physical and psychological therapy, assessment for other causes of prolonged symptoms and consideration of a graded exercise programme at a level that does not exacerbate symptoms. HubMed – rehab


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

Br J Sports Med. 2013 Apr; 47(5): 304-7
Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH

To evaluate the evidence for rest, treatment, and rehabilitation following sport-related concussion (SRC).PubMed, CINAHL, PsychInfo, Cochrane Controlled Trials Registers, Health STAR, Sport Discus, EMBASE, Web of Science, and ProQuest.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.Study design, participants, treatment, outcome measures, and key findings.Three studies met the inclusion criteria for evaluating the effects of rest and twelve for treatment. Low-intensity aerobic exercise may be of benefit.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. HubMed – rehab


Recovery and Adaptation from Repeated Intermittent Sprint Exercise.

Int J Sports Physiol Perform. 2013 Mar 8;
Leeder J DC, van Someren KA, Gaze D, Jewell A, Deshmukh N IK, Shah I, Barker J, Howatson G

PURPOSE: This investigation aimed to 1) ascertain a detailed physiological profile of recovery from intermittent sprint exercise on athletes familiar with the exercise, and 2) investigate if athletes receive a protective effect on markers of exercise-induced muscle damage (EIMD), inflammation and oxidative stress following a repeated exposure to an identical bout of intermittent sprint exercise. METHODS: Eight well trained male team sport athletes of National League or English University Premier Division standard (mean ± SD age 23 ± 3 years; VO2max 54.8 ± 4.6 ml·kg-1·min-1) completed the Loughborough Intermittent Shuttle Test (LIST) on two occasions, separated by 14 days. Maximal isometric voluntary contraction (MIVC), counter-movement jump (CMJ), creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), F2-isoprostanes and muscle soreness (DOMS) were measured before, and up to 72 h following the initial, and repeated LIST. RESULTS: MIVC, CMJ, CK, IL-6 and DOMS all showed main effects for time (P < 0.05) following the LIST indicating EIMD was present. DOMS peaked at 24 h following LIST 1 (110±53 mm) and was attenuated following LIST 2 (56±39 mm), and was the only dependent variable to demonstrate a reduction in the second bout (P = 0.008). All other markers indicated EIMD were not different between bouts. CONCLUSION: Well-trained games players experienced EIMD following exposure to both exercise tests, despite being accustomed to the exercise type. This suggests well-trained athletes receive a very limited protective effect from the first bout. HubMed – rehab


Part-time Work or Social Benefits as Predictors for Disability Pension: a Prospective Study of Swedish Twins.

Int J Behav Med. 2013 Mar 13;
Ropponen A, Alexanderson K, Svedberg P

BACKGROUND: To a large extent, it is unknown whether work absences other than sickness absence (SA) covered by social benefits such as parental leave, rehabilitation, or unemployment would predict disability pension (DP). PURPOSE: We investigated whether part-time work or having received social benefits for sick leave, rehabilitation, or parental leave would be predictors for DP taking into account familial confounding (genetics and shared environment, e.g., social background) in these associations. METHOD: A sample of 17,640 complete same-sex Swedish twin pairs was followed from 2000 to 2008 via national registries for their receipt of social benefits and DP including additional baseline questionnaire data. Cox proportional hazard ratios were estimated. RESULTS: Full-time work was less common (47 %) among those being granted DP during the follow-up compared to those without DP (69 %). Self-reported full-time work, part-time work (?50 %), and self-employment and registry data of caring for a child were the direct protective factors, whereas self-reported part-time work (<50 %) and long-term SA and registry data on SA, compensation for rehabilitation, and benefits during return to work were the direct risk factors for DP, i.e., independent of familial confounding. CONCLUSION: Part-time work and social benefits play different roles in predicting DP. Thus, full-time work, part-time work (?50 %), self-employment, and benefits for parental leave seem to protect from DP. In contrast, SA and part-time work (<50 %) carry a highly increased risk for DP. Although these associations were mainly independent from several mediating factors, some of the associations seem to be influenced by family situation, social benefits, or severity of diseases. HubMed – rehab