Treatments and rehabilitation in the acute and chronic state of traumatic brain injury.

Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.

Do post-concussion-like symptom responses change following exercise or sports participation in a non-concussed cohort?

The purposes of this study were (a) to determine the reliable change in post-concussion-like symptoms reported following self-selected exercise or sports activities and (b) to explore the potential influence of gender and exercise parameters on post-concussion-like symptoms reported by a non-concussed cohort following exercise/training. A pre-to-post observational design was used. A convenience sample of students aged 18-30 years who visited a university recreation center to engage in their chosen exercise activity and a purposeful sample of men's and women's rugby union players engaged in their regular training sessions were included in the study. All participants reported their symptoms using the symptom scale of the Sport Concussion Assessment Tool 2. The reliable change index was used to determine the change in symptom scores reported from pre-to post-exercise/training. Multiple linear regression analysis was used to model the exercise variables to explain the impact on the reporting of symptoms. A total of 260 participants (146 males and 114 females) completed their self-selected exercise activity or rugby union training. Approximately two-thirds of all participants did not demonstrate a change (increase or decrease) in total symptom score (201/260, 77.9%) and/or symptom severity score (212/260, 81.9%) from pre-to post-exercise/training. The symptom response following exercise or sports training did not change in the majority of participants. Clinicians need to be aware of these findings to make informed decisions on return-to-play following a concussive brain injury.

Prediction of winning amateur boxers using pretournament reaction times.

AIM: Boxing requires agility and manual dexterity, which is associated with fast reflexes and reaction time. This study evaluated the relation between reaction times on cognitive tasks and competition outcomes in boxers. METHODS: The design was a prospective cohort study. Participants were collegiate amateur boxers who won at least one bout in a single elimination tournament. Optimal pre-participation performance using a computerized cognitive assessment tool (CCAT, Axon Sports) and no significant deterioration in cognitive performance within 24 hours post-bout was required to compete in future bouts. Winners were assumed to be motivated to perform optimally on testing. Performance on speed and accuracy measures were compared in winning and non-winning boxers. Pre-competition minutes of sparring and tournament seedings were recorded. RESULTS: There were 96 eligible boxers who won at least one of 160 bouts. The mean age was 21.3 (SD 1.9) years (range 18.5-29.7). A significant improvement in mean reaction times as a function of advancement in the boxing tournament was observed. The 18 winning boxers who advanced to the finals had significantly faster mean reaction times at the baseline assessment before the competition began (speed composite z-score F(1,94)=4.14, P<0.05, effect size 0.54). Winners also had more sparring experience (Mann-Whitney U=302.5, P<0.001) and higher pre-competition rankings (Mann-Whitney U=288.5, P<0.001). CONCLUSION: In highly motivated amateur boxers, finalists performed significantly faster than those who failed to reach the finals on measures of pre-competition reaction time. These findings suggest that winners of boxing tournaments might be predicted using pre-competition measures of processing speed.

The diagnostic accuracy of selected neurological tests.

The diagnostic value and reliability of selected neurological clinical tests was studied in control subjects with normal neuroimaging (n=42), and subjects with a focal brain lesion (n=38). The items were studied by two examiners blinded to group membership and using standardized protocols, and subsequently by a neurologist who was not blinded to diagnosis. The positive likelihood ratios ranged from 1.06 (pronator drift) to 22.11 (single leg stance with eyes open, while the negative likelihood ratios ranged from 0.47 (tandem gait) to 0.97 (pupil symmetry). Three items (single leg stance - eyes closed - firm surface; single leg stance - eyes open - foam surface; and tandem gait) successfully distinguished between the two groups (odds ratio p<0.05). The inter-rater reliability was generally poor, with only tandem gait showing excellent agreement (kappa [K]=0.92). Tandem gait was the only item to show noteworthy agreement (K=0.93) between the examiners and the neurologist. The tests varied considerably in their ability to detect radiologically demonstrated structural brain lesions, and several items were poorly reproducible, questioning their value as part of a routine neurological examination.

Sports concussion assessment: the effect of exercise on dynamic and static balance.

This study determined the effect of exercise on measures of static and dynamic balance used in the assessment of sports-related concussion (SRC). A balanced three-group cross-over randomized design was used with three levels of exercise verified by blood-lactate, heart rate and "perceived-exertion": no exercise/rest (NE), moderate-intensity exercise (ME), and high-intensity exercise (HE). Participants performed two timed balance tasks: tandem gait (TG) and single-leg stance (SLS); pre- and post-exercise and 15 min after exercise. Linear mixed-models with adjusted means and contrasts compared exercise effects. Ninety asymptomatic participants (45♂:45♀) were recruited. When times were contrasted with NE; HE resulted in a significant decrease in SLS (P<0.001) and TG (P<0.001) performance immediately following exercise. Fifteen minutes of recovery improved SLS (P<0.001) and TG (P=0.011) from post-exercise performance. ME caused a significant decrease in performance in SLS (P=0.038) but not TG (P=0.428). No statistically significant change occurred following ME in any tasks after 15-min recovery (SLS P=0.064; TG P=0.495). Test-retest reliability was considerably higher for the dynamic task compared with the static task. The reliability of static and dynamic balance tasks, and the change in performance following exercise, have implications for the immediate assessment of SRC, as these measures are utilized in concussion assessment instruments.

Iliotibial band syndrome: an examination of the evidence behind a number of treatment options.

Iliotibial band (ITB) syndrome (ITBS) is a common cause of distal lateral thigh pain in athletes. Treatment often focuses on stretching the ITB and treating local inflammation at the lateral femoral condyle (LFC). We examine the area's anatomical and biomechanical properties. Anatomical studies of the ITB of 20 embalmed cadavers. The strain generated in the ITB by three typical stretching maneuvers (Ober test; Hip flexion, adduction and external rotation, with added knee flexion and straight leg raise to 30 degrees ) was measured in five unembalmed cadavers using strain gauges. Displacement of the Tensae Fasciae Latae (TFL)/ITB junction was measured on 20 subjects during isometric hip abduction. The ITB was uniformly a lateral thickening of the circumferential fascia lata, firmly attached along the linea aspera (femur) from greater trochanter up to and including the LFC. The microstrain values [median (IQR)] for the OBER [15.4(5.1-23.3)me], HIP [21.1(15.6-44.6)me] and SLR [9.4(5.1-10.7)me] showed marked disparity in the optimal inter-limb stretching protocol. HIP stretch invoked significantly (Z=2.10, P=0.036) greater strain than the SLR. TFL/ITB junction displacement was 2.0+/-1.6 mm and mean ITB lengthening was <0.5% (effect size=0.04). Our results challenge the reasoning behind a number of accepted means of treating ITBS. Future research must focus on stretching and lengthening the muscular component of the ITB/TFL complex.

Head, face and neck injury in youth rugby: incidence and risk factors.

OBJECTIVES: In this study, the incidence of head, neck and facial injuries in youth rugby was determined, and the associated risk factors were assessed. DESIGN: Data were extracted from a cluster randomised controlled trial of headgear with the football teams as the unit of randomisation. No effect was observed for headgear use on injury rates, and the data were pooled. SETTING: General school and club-based community competitive youth rugby in the 2002 and 2003 seasons. PARTICIPANTS: Young male rugby union football players participating in under-13, under 15, under 18 and under 21 years competitions. Eighty-two teams participated in year 1 and 87 in year 2. MAIN OUTCOME MEASURES: Injury rates for all body regions combined, head, neck and face calculated for game and missed game injuries. RESULTS: 554 head, face and neck injuries were recorded within a total of 28 902 h of rugby game exposure. Level of play and player position were related to injury risk. Younger players had the lowest rates of injury; forwards, especially the front row had the highest rate of neck injury; and inside backs had the highest rate of injuries causing the player to miss a game. Contact events, including the scrum and tackle, were the main events leading to injury. CONCLUSION: Injury prevention must focus on the tackle and scrum elements of a youth rugby game.

Patient-based not problem-based learning: an Oslerian approach to clinical skills, looking back to move forward.

CONTEXT: There have been significant changes in the past decade in both the curriculum and its delivery, in undergraduate medical education. Many of these changes have been made simultaneously, preventing clear assessment of outcome measures. The move away from a pre-clinical science grounding, to an integrated 'problem-based learning (PBL) approach' has been widespread in many countries across the world. PURPOSE: One effect of these changes has been the way in which clinical skills, in particular history and examination are taught. By integrating clinical scenarios earlier in the undergraduate course, clinical skills are increasingly taught in tutorials. This approach, when used in the pre-clinical setting may have shortcomings in the development of the ability to construct a differential diagnosis. There has been little evidence that PBL improves problem-solving ability and this is critical to the differential diagnostic process. The concurrent decline in anatomical teaching and understanding contributes to this difficulty. DISCUSSION: The authors outline a model which clinicians can re-emphasize to students and juniors based on the fundamentals of clinical practice. The apprenticeship is more important than ever in the days of small group learning. The relinquishing of the traditional model of undergraduate medicine is of concern. The effects of educational reform should be examined by further research into the competencies of graduates entering higher professional training, before it is accepted that this change has been for the better.

Return to play after sports concussion in elite and non-elite athletes?

OBJECTIVE: To examine the published literature relating to the difference in concussion management strategies between elite and non-elite athletes. DESIGN: Systematic literature review of concussion management. INTERVENTION: Pubmed, Medline, Psych Info, Cochrane Library and Sport Discus databases were reviewed using the MeSH keywords brain concussion and mild traumatic brain injury, combined with athletic injuries. Each were then refined by adding the keyword "return to play" (RTP). English language and human studies only were assessed. RESULTS: For the Medline search, using "brain concussion" as a keyword, 4319 articles were found; this was decreased to 111 when RTP was used to refine the search. When "mild traumatic brain injury" was used, 2509 articles were found; this decreased to 39 when RTP was used to refine the search. Following initial review, these articles form the basis of the discussion below. CONCLUSIONS: The non-elite athlete may not have the same resources available as the elite athlete (such as the presence of trained medical staff during practice and competition, a concussion programme as part of sideline preparedness, the benefit of neuropsychological or postural testing, as well as consultants with expertise in concussion readily available) and as a result will generally be managed more conservatively. Younger athletes often have a greater incidence of concussion with longer recovery time frames; however, they are often managed with less expertise and with limited resources.

Self-report scales/checklists for the measurement of concussion symptoms: a systematic review.

OBJECTIVE: To identify self-reported sport concussion symptom scales and to describe the psychometric properties of these identified scales. DESIGN: Systematic review. INTERVENTION: PubMed, Medline, CINAHL, Scopus, Web of Science, Sport Discus, PsycINFO and AMED were searched from their establishment until December 2008. The medical subject heading terms "brain concussion", "signs or symptoms" and "athletic injuries". The search was limited to articles published in English. An additional search of the reference lists of the retrieved articles was conducted. Only full-text articles were considered for this study and these were retrieved to determine whether they met the inclusion criteria. RESULTS: The initial search resulted in 421 articles, which were reduced to 290 articles after removing duplicates. The hand search resulted in 17 articles, thus giving a total of 307 articles. Full text was available for 295 articles of which 60 met the criteria for inclusion. The excluded 235 articles were case reports, reviews and guidelines on concussion management or studies that had not used a symptom scale or checklist. CONCLUSIONS: Six core scales were identified with a broad range of symptom items but with limited information on their psychometric properties. There were numerous derivative scales reported, most of which have not been methodically developed or subjected to scientific scrutiny. Despite this, they do make a contribution to the detection, assessment and return to play decisions but there is a need for the clinical user to be aware that many of these scales have "evolved" rather than being scientifically developed.