Early Exercise is Associated with Faster Concussion Recovery Among Collegiate Athletes: Findings from the NCAA-DoD CARE Consortium.

BACKGROUND: Growing evidence indicates early exercise may improve symptoms and reduce clinical recovery time after concussion, but research examining collegiate student-athletes is scarce. OBJECTIVE: The aim of this study was to compare symptom recovery time, clinical recovery time, and persisting post-concussion symptom (i.e., symptoms ≥ 28 days) prevalence by the timing of light exercise initiation before the graded return to play (RTP) protocol among concussed participants. METHODS: Collegiate student-athletes (n = 1228; age 18.4 ± 0.9 years; 56.5% male, 76.3% division I; 33.7% ≥ 1 prior concussion) across 30 institutions enrolled in the CARE Consortium completed post-concussion assessments and were monitored over time. Symptom recovery (days from injury to symptom resolution) and clinical recovery (days from injury to return to play protocol completion) was determined by the student-athletes' clinicians. Student-athletes were categorized by timing of light exercise initiation. Early (< 2 days post-concussion; n = 161), typical (3-7 days post-concussion; n = 281), and late exercise (≥ 8 days post-concussion; n = 169) groups were compared with the no-exercise group (n = 617; i.e., did not exercise prior to beginning the RTP protocol) for all analyses. Multivariable Cox regression models with hazard ratios (HR) and survival curves and a multivariable binomial regression model with prevalence ratios (PR) compared recovery outcomes between exercise groups while accounting for covariates. RESULTS: Compared to the no-exercise group, the early exercise group was 92% more probable to experience symptom recovery (HR 1.92; 95% CI 1.57-2.36), 88% more probable to reach clinical recovery (HR 1.88; 95% CI 1.55-2.28) and took a median of 2.4 and 3.2 days less to recover, respectively. The late exercise group relative to the no-exercise group was 57% less probable to reach symptom recovery (HR 0.43; 95% CI 0.35-0.53), 46% less probable to achieve clinical recovery (HR 0.54; 95% CI 0.45-0.66) and took 5.3 days and 5.7 days more to recover, respectively. The typical exercise group did not differ in hazard for symptom or clinical recovery (p ≥ 0.329) compared with the no-exercise group. The prevalence of persisting post-concussion symptoms in the combined sample was 6.6%. Early exercise had 4% lower prevalence (PR 0.96, 95% CI 0.94-0.99) and typical exercise had 3% lower prevalence (PR 0.97, 95% CI 0.94-0.99) of persisting post-concussion symptoms, while the late exercise group had an elevated prevalence (PR 1.11, 95% CI 1.04-1.18) compared with the no-exercise group. CONCLUSION: Exercise < 2 days post-concussion was associated with more probable and faster symptom and clinical recovery, and lower persisting post-concussion symptom prevalence. When considering our findings and existing literature, qualified clinicians may implement early exercise into their clinical practice to provide therapeutic treatment and improve student-athlete recovery.

Slowed driving-reaction time following concussion-symptom resolution.

BACKGROUND: Concussed patients have impaired reaction time (RT) and cognition following injury that may linger and impair driving performance. Limited research has used direct methods to assess driving-RT post-concussion. Our study compared driving RT during simulated scenarios between concussed and control individuals and examined driving-RT's relationship with traditional computerized neurocognitive testing (CNT) domains. METHODS: We employed a cross-sectional study among 14 concussed (15.9 ± 9.8 days post-concussion, mean ± SD) individuals and 14 healthy controls matched for age, sex, and driving experience. Participants completed a driving simulator and CNT (CNS Vital Signs) assessment within 48 h of symptom resolution. A driving-RT composite (ms) was derived from 3 simulated driving scenarios: stoplight (green to yellow), evasion (avoiding approaching vehicle), and pedestrian (person running in front of vehicle). The CNT domains included verbal and visual memory; CNT-RT (simple-, complex-, Stroop-RT individually); simple and complex attention; motor, psychomotor, and processing speed; executive function; and cognitive flexibility. Independent t tests and Hedge d effect sizes assessed driving-RT differences between groups, Pearson correlations (r) examined driving RT and CNT domain relationships among cohorts separately, and p values were controlled for false discovery rate via Benjamini-Hochberg procedures (α = 0.05). RESULTS: Concussed participants demonstrated slower driving-RT composite scores than controls (mean difference = 292.86 ms; 95% confidence interval (95%CI): 70.18-515.54; p = 0.023; d = 0.992). Evasion-RT (p = 0.054; d = 0.806), pedestrian-RT (p = 0.258; d = 0.312), and stoplight-RT (p = 0.292; d = 0.585) outcomes were not statistically significant after false-discovery rate corrections but demonstrated medium to large effect sizes for concussed deficits. Among concussed individuals, driving-RT outcomes did not significantly correlate with CNT domains (r-range: -0.51 to 0.55; p > 0.05). No correlations existed between driving-RT outcomes and CNT domains among control participants either (r-range: -0.52 to 0.72; p > 0.05). CONCLUSION: Slowed driving-RT composite scores and large effect sizes among concussed individuals when asymptomatic signify lingering impairment and raise driving-safety concerns. Driving-RT and CNT-RT measures correlated moderately but not statistically, which indicates that CNT-RT is not an optimal surrogate for driving RT.

Dry Cupping Therapy for Improving Nonspecific Neck Pain and Subcutaneous Hemodynamics.

CONTEXT: Dry cupping therapy is a noninvasive treatment commonly used to reduce pain and promote the healing process in various populations, including those with nonspecific neck pain; however, no data are available to support most of this method's true physiological benefits. OBJECTIVE: To determine if dry cupping therapy decreased pain and increased subcutaneous blood flow compared with sham cupping and control conditions. DESIGN: Controlled laboratory study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 32 participants (age = 22.5 ± 2.8 years, height = 173.3 ± 10.1 cm, mass = 76.6 ± 18.7 kg) with self-reported nonspecific neck pain. INTERVENTION(S): We used dry cupping and sham cupping interventions and a control condition. For the dry cupping intervention, 1 stationary cup was placed directly over the most painful area for 8 minutes. The sham cupping intervention followed the same procedures as the dry cupping intervention except a sham cup was applied. For the control condition, participants received no treatment. MAIN OUTCOME MEASURE(S): Subjective pain intensity (visual analog scale); pain-pressure threshold; subcutaneous hemodynamics, including superficial and deep oxygenated, deoxygenated, and total hemoglobin levels; and tissue saturation index. RESULTS: We observed differences in the visual analog scale score and the superficial and deep oxygenated and total hemoglobin levels (P values ≤ .002) immediately postintervention compared with baseline. Post hoc tests revealed that the dry cupping group had less pain than the sham cupping and control groups and higher superficial and deep oxygenated and total hemoglobin levels (P values ≤ .008). No differences were found between baseline and 24 hours postintervention. CONCLUSIONS: A single session of dry cupping therapy may be an effective short-term treatment method for immediately reducing pain and increasing oxygenated and total hemoglobin levels in patients with nonspecific neck pain.

Influence of Postconcussion Sleep Duration on Concussion Recovery in Collegiate Athletes.

OBJECTIVE: To determine whether decreased sleep duration postconcussion influences days to asymptomatic and assessment of performance throughout recovery. DESIGN: Prospective. SETTING: Institutional Clinical Research Laboratory. PATIENTS: Four hundred twenty-three collegiate athletes were diagnosed with concussion. INTERVENTIONS: Multidimensional concussion assessment battery was conducted at baseline, within 24 to 48 hours, daily [2-4 days postinjury (PI); symptoms only], once asymptomatic, and after return-to-play. The battery included the following: 22-item symptom checklist, Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and computerized neurocognitive test [Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)]. MAIN OUTCOME MEASURES: We subtracted baseline sleep duration from 24 to 48 hours postconcussion sleep duration and categorized athletes into the following groups: shorter sleep (≤-1 hour), no change (>-1 hour, <+1 hour), and longer sleep (≥+1 hour). A 1-way analysis of variance (ANOVA) was conducted to compare days to asymptomatic and separate mixed-model ANOVAs to compare total symptom scores, SAC total scores, BESS total error scores, and ImPACT composite scores between sleep categories across time points (α = 0.05). RESULTS: Sleep groups did not differ in days to asymptomatic. The shorter sleep group had greater symptom severity than no sleep change and longer sleep groups at 24 to 48 hours (shorter: 39.1 ± 20.7; no change: 25.1 ± 18.4, P = 0.007; longer: 25.7 ± 21.8, P = 0.004), and at 2 to 4 days PI (shorter: 21.8 ± 21.8; no change: 10.5 ± 10.8, P = 0.013; longer: 11.9 ± 14.2, P = 0.007), but did not differ at other time points (ie, asymptomatic and return-to-play). Participants with shorter sleep exhibited slower ImPACT reaction times at 24 to 48 hours (shorter: 0.68 ± 0.14; no change: 0.61 ± 0.09, P = 0.016; and longer: 0.62 ± 0.12, P = 0.028) and asymptomatic time points (shorter: 0.62 ± 0.11; no change: 0.56 ± 0.05; P = 0.015). CONCLUSION: Postinjury sleep declines may be associated with symptom severity and worsened reaction time during initial stages of recovery or may be the result of the concussion itself. Clinicians should be aware of alterations in sleep duration and manage appropriately to mitigate initial symptom burden postconcussion.

King-Devick Test Time Varies by Testing Modality.

OBJECTIVE: To explore differences in baseline King-Devick Test (KD) completion time between 2 testing modalities: (1) spiral-bound paper cards (cards) and (2) iPad application (iPad). DESIGN: Cross-sectional cohort analysis. SETTING: National Collegiate Athlete Association (NCAA) institutions. PARTICIPANTS: Student athletes from 13 women's and 11 men's collegiate sports who completed KD baseline testing as part of their first year in the Concussion Assessment, Research and Education (CARE) Consortium from 2014 to 2016 (n = 2003, 52.2% male). INDEPENDENT VARIABLES: King-Devick Test modalities; cards or iPad. MAIN OUTCOME MEASURE: Baseline KD completion time (seconds). RESULTS: Mean baseline KD completion time of the iPad modality group [42.8 seconds, 95% confidence interval (CI), 42.1-43.3] was 2.8 seconds (95% CI, 2.1-3.4) greater than the cards group (40.0 seconds, 95% CI, 39.7-40.3) (t(1, 1010.7) = -8.0, P < 0.001, Cohen's d = 0.41). CONCLUSIONS: Baseline KD performance is slower when tested on an iPad than when tested on spiral-bound paper cards. The 2 KD modalities should not be used interchangeably in concussion assessments because differences in the modalities can lead to time differences similar in magnitude to those used to indicate concussion. From a research perspective, modality may influence interpretation and/or synthesis of findings across studies.

Relationships between Post-Concussion Sleep and Symptom Recovery: A Preliminary Study.

Post-concussion sleep disturbances can be debilitating and may influence days to symptom recovery; however, evidence is minimal. The purpose of this study was to explore relationships between days to symptom recovery and aspects of sleep, as measured by actigraphy and subjective sleep questionnaires in a concussed sample. Thirty-one college students were physician-diagnosed with a concussion and asked to complete a daily sleep symptom checklist. Participants (n = 14) were excluded based on lack of compliance/early termination (22.6%), recorded <5 nights of data (12.9%), and protracted recoveries (3.2%). Final concussed sample included 17 college-aged students (varsity student-athletes, n = 5; university students, n = 12). A wrist-worn ActiGraph GT9X Link was provided during initial evaluation (within 72 h post-injury) and worn continuously until symptom recovery (follow-up evaluation; 14.3 ± 5.9 days post-injury). The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) also were completed at follow-up. Pearson's correlations were conducted to determine relationships between days to symptom recovery and actigraphy sleep outcomes (sleep onset latency, wake after sleep onset (WASOnorm), total sleep time, sleep efficiency (SE), and number of awakenings) across recovery stages (2-3 days post-injury, mid-point, and end). Spearman's rho correlations were used to determine relationships between subjective sleep (PSQI global), sleepiness (ESS total), and sleep cluster symptom severity and days to symptom recovery. At recovery mid-point, individuals who were awake longer throughout the night (24.1 ± 9.0%) and/or were less efficient at sleeping (73.7 ± 9.7%) took longer to recover (WASOnorm: r = 0.58, p = 0.015; SE: r = -0.51, p = 0.035). Poorer post-concussion sleep quality (based on PSQI) was correlated with longer recovery (rs = 0.70, p = 0.001). Post-concussion sleep-wake disturbances at recovery mid-point and overall poorer sleep quality may be associated with longer symptom recovery. Our findings provide preliminary guidance on identifying those who may be at risk for longer recoveries based on poorer sleep post-injury.

Relationship Between the King-Devick Test and Commonly Used Concussion Tests at Baseline.

CONTEXT: Comprehensive assessments are recommended to evaluate sport-related concussion (SRC). The degree to which the King-Devick (KD) test adds novel information to an SRC evaluation is unknown. OBJECTIVE: To describe relationships at baseline among the KD and other SRC assessments and explore whether the KD provides unique information to a multimodal baseline concussion assessment. DESIGN: Cross-sectional study. SETTING: Five National Collegiate Athletic Association institutions participating in the Concussion Assessment, Research and Education (CARE) Consortium. PATIENTS OR OTHER PARTICIPANTS: National Collegiate Athletic Association student-athletes (N = 2258, age = 20 ± 1.5 years, 53.0% male, 68.9% white) in 11 men's and 13 women's sports. MAIN OUTCOME MEASURE(S): Participants completed baseline assessments on the KD and (1) the Symptom Inventory of the Sport Concussion Assessment Tool-3rd edition, (2) the Brief Symptom Inventory-18, (3) the Balance Error Scoring System, (4) the Standardized Assessment of Concussion (SAC), (5) the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test battery, and (6) the Vestibular/Ocular Motor Screening tool during their first year in CARE. Correlation coefficients between the KD and the 6 other concussion assessments in isolation were determined. Assessments with ρ magnitude >0.1 were included in a multivariate linear regression analysis to evaluate their relative association with the KD. RESULTS: Scores for SAC concentration, ImPACT visual motor speed, and ImPACT reaction time were correlated with the KD (ρ = -0.216, -0.276, and 0.164, respectively) and were thus included in the regression model, which explained 16.8% of the variance in baseline KD time (P < .001, Cohen f2 = 0.20). Better SAC concentration score (ß = -.174, P < .001), ImPACT visual motor speed (ß = -.205, P < .001), and ImPACT reaction time (ß = .056, P = .020) were associated with faster baseline KD performance, but the effect sizes were small. CONCLUSIONS: Better performance on cognitive measures involving concentration, visual motor speed, and reaction time was weakly associated with better baseline KD performance. Symptoms, psychological distress, balance, and vestibular-oculomotor provocation were unrelated to KD performance at baseline. The findings indicate limited overlap at baseline among the CARE SRC assessments and the KD.

Differences in sleep between concussed and nonconcussed college students: a matched case-control study.

Study Objectives: To describe sleep 2-3 days postconcussion through symptom recovery and make comparison to well-matched nonconcussed controls. Methods: Twenty college students were physician diagnosed with a concussion and compared with 20 nonconcussed controls matched on age, sex, physical activity, and sleep quality. A wrist-worn ActiGraph GT9X Link was provided during initial evaluation (within 72 hr postinjury for concussed) and worn continuously until symptom resolution (duration matched for nonconcussed). All participants completed a sleep symptom severity checklist, the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS). Separate 2(group) × 3(time points) mixed model ANOVAs were conducted to compare actigraphy sleep outcomes (sleep onset latency [SOL], normalized wake after sleep onset [WASOnorm], total sleep time [TST], sleep efficiency, and number of awakenings) across recovery stages (2-3 days postinjury, mid-point, and end of recovery). Intraindividual coefficient of variation was calculated for each sleep outcome. Mann-Whitney U tests compared PSQI global score, ESS total score, and sleep symptom severity between groups (α = 0.05). Results: At 2-3 days postinjury, concussed individuals took longer to fall asleep compared with controls (p = 0.002). Greater intraindividual variability in WASOnorm (p = 0.017) and TST (p = 0.044) existed in concussed individuals across recovery. Poorer sleep quality (p < 0.001), excessive daytime sleepiness (p = 0.014), and worse sleep symptoms (p < 0.001) existed in concussed compared with controls. Conclusions: Concussed individuals took longer to fall asleep 2-3 days postconcussion, experienced greater variation in sleep fragmentation and sleep time until symptom resolution, and reported worse sleep quality. Our preliminary findings may guide researchers interested in better understanding sleep postconcussion.

Influences of Mental Illness, Current Psychological State, and Concussion History on Baseline Concussion Assessment Performance.

BACKGROUND: A student-athlete's mental state, including history of trait anxiety and depression, or current psychological state may affect baseline concussion assessment performance. PURPOSE: (1) To determine if mental illness (anxiety, depression, anxiety with depression) influences baseline scores, (2) to determine if psychological state correlates with baseline performance, and (3) to determine if history of concussion affects Brief Symptom Inventory-18 (BSI-18) subscores of state anxiety, depression, and somatization. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A sample of 8652 collegiate student-athletes (54.5% males, 45.5% females) participated in the Concussion Assessment, Research and Education (CARE) Consortium. Baseline assessments included a demographic form, a symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, a psychological state assessment (BSI-18), and Immediate Post-concussion Assessment and Cognitive Test. Baseline scores were compared between individuals with a history of anxiety (n = 59), depression (n = 283), and anxiety with depression (n = 68) and individuals without a history of those conditions (n = 8242). Spearman's rho correlations were conducted to assess the relationship between baseline and psychological state subscores (anxiety, depression, somatization) (α = .05). Psychological state subscores were compared between individuals with a self-reported history of concussions (0, 1, 2, 3, 4+) using Kruskal-Wallis tests (α = .05). RESULTS: Student-athletes with anxiety, depression, and anxiety with depression demonstrated higher scores in number of symptoms reported (anxiety, 4.3 ± 4.2; depression, 5.2 ± 4.8; anxiety with depression, 5.4 ± 3.9; no anxiety/depression, 2.5 ± 3.4), symptom severity (anxiety, 8.1 ± 9.8; depression, 10.4 ± 12.4; anxiety with depression, 12.4 ± 10.7; no anxiety/depression, 4.1 ± 6.9), and psychological distress in state anxiety (anxiety, 3.7 ± 4.7; depression, 2.5 ± 3.6; anxiety with depression, 3.8 ± 4.2; no anxiety/depression, 0.8 ± 1.8), depression (anxiety, 2.4 ± 4.0; depression, 3.2 ± 4.5; anxiety with depression, 3.8 ± 4.8; no anxiety/depression, 0.8 ± 1.8), and somatization (anxiety, 2.3 ± 2.9; depression, 1.8 ± 2.8; anxiety with depression, 2.2 ± 2.4; no anxiety/depression, 0.9 ± 1.7). A moderate positive relationship existed between all BSI-18 subscores and total symptom number (n = 8377; anxiety: rs = 0.43, P < .001; depression: rs = 0.42, P < .001; somatization: rs = 0.45, P < .001), as well as total symptom severity (anxiety: rs = 0.43, P < .001; depression: rs = 0.41, P < .001; somatization: rs = 0.45, P < .001). Anxiety, depression, and somatization subscores were greater among student-athletes that self-reported more concussions. CONCLUSION: Clinicians should be cognizant that student-athletes with a history of trait anxiety, depression, and anxiety with depression may report higher symptom score and severity at baseline. Individuals with extensive concussion history may experience greater state anxiety, depression, and somatization.

Age at First Concussion Influences the Number of Subsequent Concussions.

BACKGROUND: Individuals who sustain their first concussion during childhood may be at greater risk of sustaining multiple concussions throughout their lifetime because of a longer window of vulnerability. This article aims to estimate the association between age at first concussion and number of subsequent concussions. PATIENTS AND METHODS: A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age 19.9 ± 1.4 years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n = 3,647, 15.5%) were categorized as having sustained their first concussion during childhood (less than ten years old) or adolescence (≥10 and ≤18 years old). Poisson regression was used to model age group (childhood, adolescence) predicting the number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted the number of subsequent concussions. RESULTS: Participants self-reporting their first concussion during childhood had an increased risk of subsequent concussions (rate ratio = 2.19, 95% confidence interval: 1.82, 2.64) compared with participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (rate ratio = 0.84, 95% confidence interval: 0.82, 0.86). CONCLUSIONS: Individuals self-reporting a concussion at a young age sustained a higher number of concussions before age 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level.

Driving after Concussion: Is It Safe To Drive after Symptoms Resolve?

Post-concussion impairments may result in unsafe driving performance, but little research is available to guide consensus on when concussed individuals should return to driving. The purpose of this study was to compare driving performance between individuals with and without a concussion and to explore relationships between neuropsychological and driving performance. Fourteen participants with concussion (age 20.2 ± 0.9 years old) and 14 non-concussed age- and driving experience-matched controls (age 20.4 ± 1.1 years old) completed a graded symptom checklist, a brief neuropsychological exam, and a 20.5 km driving simulation task. Participants with a concussion completed driving simulation within 48 h of becoming asymptomatic (15.9 ± 9.0 days post-concussion). One-way analyses of variance were used to compare total number of crashes, tickets, and lane excursions, as well as standard deviation of lateral position (SDLP) and standard deviation of speed. Pearson's correlations were conducted to explore the relationship between the neuropsychological and driving performance separately by group (α = 0.05). Participants with a concussion committed more frequent lane excursions (concussed 10.9 ± 4.5; controls 7.4 ± 2.4; p = 0.017) and exhibited greater SDLP, compared with controls, during the first curve (concussed 45.7 ± 21.3 cm, controls 27.4 ± 6.1 cm; p = 0.030) and final curve (concussed 39.6 ± 24.4 cm; controls 33.5 ± 21.3 cm; p = 0.036). Poorer performance on symbol digit modalities (r = -0.54), Rey Osterrieth Complex Figure (r = -0.53), verbal memory (r = -0.77), and motor speed (r = -0.54) were correlated with more frequent lane excursions in the concussed group, but not in the control group. Despite being asymptomatic, concussed participants exhibited poorer vehicle control, especially when navigating curves. Driving impairments may persist beyond when individuals with a concussion have returned to driving. Our study provides preliminary guidance regarding which neuropsychological functions may best indicate driving impairment following concussion.