Rehabilitation of Concussion and Persistent Postconcussive Symptoms.

Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies.

Symptoms upon postural change and orthostatic hypotension in adolescents with concussion.

Objective: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls.Participants: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male).Methods: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury).Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p < .001) but did not differ in meeting standard OH criteria (3% vs 5%, p = .32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, p = .65).Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.

Long-Term Neurocognitive, Mental Health Consequences of Contact Sports.

This article presents a brief history and literature review of chronic traumatic encephalopathy (CTE) in professional athletes that played contact sports. The hypothesis that CTE results from concussion or sub-concussive blows is based largely on several case series investigations with considerable bias. Evidence of CTE in its clinical presentation has not been generally noted in studies of living retired athletes. However, these studies also demonstrated limitation in research methodology. This paper aims to present a balanced perspective amidst a politically charged subject matter.

Blunted Cardiac Parasympathetic Activation in Student Athletes With a Remote History of Concussion: A Pilot Study.

Introduction: Blunted cardiac autonomic nervous system (ANS) responses, quantified using heart rate variability (HRV), have been reported after sport-related concussion (SRC). Research suggests this persists beyond clinical recovery. This study compared cardiac parasympathetic responses in student athletes with a remote history of SRC (> 1-year ago, Concussion History: CH) with those who reported no lifetime history of SRC (Concussion Naïve: CN). Design: Retrospective nested case-control. Setting: University laboratory. Patients or Other Participants: CH (n = 9, 18.3 ± 2 years, 44% male, median 2 years since injury) were student athletes with a remote history of concussion(s) from more than 1 year ago. CN (n = 21, 16.7 ± 3 years, 67% male) were student athletes with no lifetime history of concussion. Exclusion criteria included taking medications that could affect ANS function, history of concussion within the past year, persistent concussion symptoms, lifetime history of moderate to severe brain injury, and lifetime history of more than 3 concussions. Material and Methods: Participants performed the Face Cooling (FC) test for 3-min after 10-min of supine rest while wearing a 3-lead electrocardiogram in a controlled environment. Outcome Measures: Heart rate (HR), R-R interval (RRI), root mean square of the successive differences (RMSSD) of RRI, high frequency (HF) and low frequency to HF (LF:HF) ratios. Results: At baseline, CH had a lower resting HR than CN (62.3 ± 11 bpm vs. 72.9 ± 12, p = 0.034). CH had a different HR response to FC than CN (+8.9% change from baseline in CH vs. -7.5% in CN, p = 0.010). CH also had a smaller RMSSD increase to FC than CN (+31.8% change from baseline in CH vs. +121.8% in CN, p = 0.048). There were no significant group differences over time in RRI (p = 0.106), HF (p = 0.550) or LF:HF ratio (p = 0.053). Conclusion: Asymptomatic student athletes with a remote history of concussion had a blunted cardiac parasympathetic response to FC when compared with athletes with no lifetime history of concussion. These data suggest that an impaired autonomic response to a physiological stressor persists after clinical recovery from SRC for longer than previously reported.

Postexercise Slowing on the King-Devick Test and Longer Recovery From Sport-Related Concussion in Adolescents: A Validation Study.

CONTEXT: The King-Devick (KD) test is a rapid number-reading test that has emerging use in the assessment of sport-related concussion (SRC). Previous research suggested that healthy individuals and patients with acute concussions who had shorter recovery times (<3 weeks) demonstrated a learning effect on the KD test after mild to moderate exertion, whereas patients with longer recovery times did not. OBJECTIVE: To assess if the absence of postexertional improvement on the KD test within 10 days of concussive head injury was associated with a longer duration of recovery. DESIGN: Prospective cohort study. SETTING: University concussion-management clinics. PATIENTS OR OTHER PARTICIPANTS: Male and female adolescent athletes (n = 99, aged 13-18 years) presenting within 10 days of SRC. MAIN OUTCOME MEASURE(S): The KD test was administered before and after the Buffalo Concussion Treadmill Test (BCTT). Days from injury to recovery, with recovery defined as being asymptomatic, confirmed by the assessment of a physician who was blinded to the treatment group, and the return of normal exercise tolerance on the BCTT were recorded. RESULTS: Participants with postexertional slowing (PES group, n = 33) had a longer duration of recovery (17 days versus 13.5 days, P = .033) than participants without PES (no-PES group, n = 66). At any clinic visit, PES was also associated with a relative risk of 2.36 (95% confidence interval = 1.55, 3.61; P < .001) of not recovering within the following week. CONCLUSIONS: The current study validates our prior work showing that acutely concussed adolescents who did not display the typical learning effect on the KD test after the BCTT took longer to recover from SRC than those who exhibited the typical learning effect.

Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents.

OBJECTIVE: To compare a sample of adolescents with sport-related concussion (SRC) who were prescribed rest with 2 arms of a randomized controlled trial comparing aerobic exercise with placebo-like stretching. We also compared sex differences across the 3 approaches to treatment. DESIGN: Quasi-experimental trial. SETTING: University concussion management clinics. PARTICIPANTS: Adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG], n=48, 15.4±1y, 25% female). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG], n=52, 15.3±2y, 46% female) or placebo-like stretching (placebo group [PG], n=51, 15.4±2y, 47% female) (N=151). MAIN OUTCOME MEASURES: The primary outcome was median days from injury to recovery. The secondary outcome was proportion classified as normal recovery (<30d) or delayed recovery (≥30d). RESULTS: The RG recovered in 16 days (interquartile range, 9.25-23.25d), which was significantly delayed (P=.020) compared with EG (13d; interquartile range, 10-18.5d). The PG recovered in 17 days (interquartile range, 13-23d). Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery (P=.190). There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups (P=.013). CONCLUSION: Relative rest and a placebo-like stretching program were very similar in days to recovery and symptom improvement pattern after SRC. Both conditions were less effective than subsymptom threshold aerobic exercise. Female adolescents appear to be susceptible to symptom increase when prescribed rest.

The Predictive Capacity of the Buffalo Concussion Treadmill Test After Sport-Related Concussion in Adolescents.

The Buffalo Concussion Treadmill Test (BCTT) identifies the heart rate threshold (HRt) of exercise tolerance in concussed patients. A previous study found that an absolute HRt of < 135 bpm was associated with prolonged recovery (>30 days) from sport-related concussion (SRC). In this study, we assessed the relationship of ΔHR (difference between resting HR and HRt) and recovery from SRC. Using a retrospective cohort design, we compared acutely (<10 days since injury) concussed adolescents who were prescribed either (1) relative rest (RG, n = 27, 15.2 ± 1 years, 33% female, median 17 days to recovery, ΔHR = 69.6 ± 28 bpm), (2) a placebo-stretching program (PG, n = 51, 15.4 ± 2 years, 49% female, median 17 days to recovery, ΔHR = 60.9 ± 22 bpm), or (3) sub-threshold aerobic exercise (AG, n = 52, 15.3 ± 2 years, 46% female, median 13 days to recovery, ΔHR = 62.4 ± 26 bpm). Linear regression showed that ΔHR significantly correlated with duration of clinical recovery for RG (p = 0.012, R 2 = 0.228) and PG (p = 0.011, R 2 = 0.126) but not for AG (p = 0.084, R 2 = 0.059). ΔHR values were significantly lower in participants with prolonged recovery (>30 days) in RG (p = 0.01) and PG (p = 0.04). A ΔHR of ≤50 bpm on the BCTT is 73% sensitive and 78% specific for predicting prolonged recovery in concussed adolescents who were prescribed the current standard of care (i.e., cognitive and physical rest).

Active recovery from concussion.

PURPOSE OF REVIEW: Recent studies are challenging the utility of prolonged rest as treatment for concussion and postconcussion syndrome (PCS). The purpose of this paper is to review the evidence for active recovery from concussion and PCS. RECENT FINDINGS: Emerging data identify the central role of autonomic nervous system (ANS) dysfunction in concussion pathophysiology. The exercise intolerance demonstrated by athletes after sport-related concussion may be related to abnormal ANS regulation of cerebral blood flow. As aerobic exercise training improves ANS function, sub-symptom threshold exercise treatment is potentially therapeutic for concussion. A systematic assessment of exercise tolerance using the Buffalo Concussion Treadmill Test has been safely employed to prescribe a progressive, individualized subthreshold aerobic exercise treatment program that can return patients to sport and work. Multiple studies are demonstrating the efficacy of an active approach to concussion management. SUMMARY: Sustained rest from all activities after concussion, so-called 'cocoon therapy', is not beneficial to recovery. Evidence supports the safety, tolerability, and efficacy of controlled sub-symptom threshold aerobic exercise treatment for PCS patients. Further study should determine the efficacy and optimal timing, dose, and duration of subthreshold aerobic exercise treatment acutely after concussion because early intervention has potential to prevent PCS.

Financial motivation to work among people with psychiatric disorders.

BACKGROUND: Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients' desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money. AIM: To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment. METHODS: We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics. RESULTS: Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not. CONCLUSION: Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

Brain potentials measured during a Go/NoGo task predict completion of substance abuse treatment.

BACKGROUND: U.S. nationwide estimates indicate that 50% to 80% of prisoners have a history of substance abuse or dependence. Tailoring substance abuse treatment to specific needs of incarcerated individuals could improve effectiveness of treating substance dependence and preventing drug abuse relapse. We tested whether pretreatment neural measures of a response inhibition (Go/NoGo) task would predict which individuals would or would not complete a 12-week cognitive behavioral substance abuse treatment program. METHODS: Adult incarcerated participants (n = 89; women n = 55) who volunteered for substance abuse treatment performed a Go/NoGo task while event-related potentials (ERPs) were recorded. Stimulus- and response-locked ERPs were compared between participants who completed (n = 68; women = 45) and discontinued (n = 21; women = 10) treatment. RESULTS: As predicted, stimulus-locked P2, response-locked error-related negativity (ERN/Ne), and response-locked error positivity (Pe), measured with windowed time-domain and principal component analysis, differed between groups. Using logistic regression and support-vector machine (i.e., pattern classifiers) models, P2 and Pe predicted treatment completion above and beyond other measures (i.e., N2, P300, ERN/Ne, age, sex, IQ, impulsivity, depression, anxiety, motivation for change, and years of drug abuse). CONCLUSIONS: Participants who discontinued treatment exhibited deficiencies in sensory gating, as indexed by smaller P2; error-monitoring, as indexed by smaller ERN/Ne; and adjusting response strategy posterror, as indexed by larger Pe. The combination of P2 and Pe reliably predicted 83.33% of individuals who discontinued treatment. These results may help in the development of individualized therapies, which could lead to more favorable, long-term outcomes.

Financial victimization of adults with severe mental illness.

OBJECTIVE: People with severe mental illness are vulnerable to having other people directly take or misappropriate their disability payments. This study investigated the prevalence of different types of financial victimization and the client characteristics associated with being financially victimized. METHODS: Adults (N=122) receiving inpatient or intensive outpatient psychiatric treatment who received Social Security disability payments completed assessments about money management and victimization. A path model was used to estimate the association of victimization with participant characteristics. RESULTS: Seventy percent of participants experienced at least one type of financial victimization in the preceding 28 days; 35% ran out of money because of victimization. Victimization was significantly associated with being younger, having had more psychiatric hospitalizations, having more recent alcohol use, and, most robustly, having problems managing money (ß=.52, p<.01). CONCLUSIONS: Financial victimization of disability recipients in acute care settings is common and more likely among people with recent substance use and difficulty managing their funds.

Recovery and money management.

OBJECTIVE: Social recovery and external money management are important approaches in contemporary mental health care, but little research has been done on the relationship between the two or on application of recovery principles to money management for people at risk of being assigned a representative payee or conservator. METHOD: Out of 49 total qualitative interviews, 25 transcripts with persons receiving Social Security insurance or Social Security disability insurance who were at risk of being assigned a money manager were analyzed to assess the presence of recognized recovery themes. RESULTS: The recovery principles of self-direction and responsibility were strong themes in participant comments related to money management. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Money management interventions should incorporate peoples' recovery-related motivations to acquire financial management skills as a means to direct and assume responsibility for one's finances. Staff involved in money management should receive training to support client's recovery-related goals.

In our own voice-family companion: reducing self-stigma of family members of persons with serious mental illness.

OBJECTIVE: This article reports preliminary findings from a novel, family peer-based intervention designed to reduce self-stigma among family members of people with serious mental illness. METHODS: A total of 158 primary caregivers of patients with schizophrenia were recruited from a large urban mental health facility (93 caregivers) or from a family and consumer advocacy organization (65 caregivers). Caregivers (N=122) who reported they perceived at least a moderate level of mental illness-related stigma were evaluated on measures of self-stigma, withdrawal, secrecy, anxiety, and social comparison and randomly assigned to receive one of two, one-session group interventions: a peer-led intervention (In Our Own Voice-Family Companion [IOOV-FC]) designed to stimulate group discussion or a clinician-led family education session, which delivered information about mental illness in a structured, didactic format. IOOV-FC consisted of playing a videotape of family members who describe their experiences coping with stigma, which was followed by a discussion led by two family peers who modeled sharing their own experiences and facilitated group sharing. RESULTS: Of 24 family members and ten consumers, 96% rated the videotape above a predetermined acceptability threshold on a 19-item scale assessing cultural sensitivity, respect for different stakeholders, relevance of content, and technical quality (α=.92). Caregivers receiving IOOV-FC with low to moderate pretreatment anxiety reported a substantial reduction in self-stigma (effect size=.50) relative to those receiving clinician-led family education (p=.017) as well as significant reductions in secrecy (p=.031). CONCLUSIONS: Peer-led group interventions may be more effective in reducing family self-stigma than clinician-led education, at least for persons reporting experiencing low to moderate anxiety levels on a standard questionnaire

Activin is a neuronal survival factor that is rapidly increased after transient cerebral ischemia and hypoxia in mice.

One approach for developing targeted stroke therapies is to identify the neuronal protective and destructive signaling pathways and gene expression that follow ischemic insult. In some neural injury models, the transforming growth factor-beta family member activin can provide neuroprotective effects in vivo and promote neuronal survival. This study tests if activin supports cortical neurons after ischemic challenge in vitro and if signals after cerebral ischemia involve activin in vivo. In a defined cell culture model that uses hydrogen peroxide (H(2)O(2))-free radical stress, activin addition maintained neuronal survival. H(2)O(2) treatment increased activin mRNA twofold in surviving cortical neurons, and inhibition of activin with neutralizing antibodies caused neuronal death. These data identify activin gene changes as a rapid response to oxidative stress, and indicate that endogenous activin acts as a protective factor for cortical neurons in vitro. Similarly, after transient focal cerebral ischemia in adult mice, activin mRNA increased at 1 and 4 h ipsilateral to the infarct but returned to control values at 24 h after reperfusion. Intracellular activated smad signals were detected in neurons adjacent to the infarct. Activin was also increased after 2 h of 11% hypoxia. Activin mRNA increased at 1 h but not 4 or 24 h after hypoxia, similar to the time course of erythropoietin and vascular endothelial growth factor induction. These findings identify activin as an early-regulated gene response to transient ischemia and hypoxia, and its function in cortical neuron survival during oxidative challenge provides a basis to test activin as a potential therapeutic in stroke injury.

Motivational interviewing techniques and the harm-reduction model in a short-term substance-abuse group for adolescents with psychiatric problems.

The authors describe techniques and practical examples for working with substance-abusing teens within a short-term psychiatric setting that derive from the Harm-Reduction model and the Motivational Interviewing approach.