Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury.

BACKGROUND: Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions. OBJECTIVE: To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice. LITERATURE SURVEY: A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process. METHODOLOGY: A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed. SYNTHESIS: There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity. CONCLUSIONS: The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.

Chronic exertional compartment syndrome in a patient with restrictive cardiomyopathy and portal hypertension.

Chronic exertional compartment syndrome (CECS) is a condition that produces exercise-induced pain and swelling due to a transient increase in compartment pressures. It is thought to be due to muscle hypertrophy and is classically associated with young athletes under 30, overtraining, anabolic steroid use, and aberrant running biomechanics. We present a unique case of CECS in a patient without the traditional risk factors but rather diagnosed with cardiac cirrhosis and portal hypertension. This patient's exercise-induced bilateral leg pain met the CECS criteria for leg compartment pressure testing and was attributed to fluid retention secondary to his comorbidities. His symptoms significantly improved after initiating diuretic pharmacotherapy. Based on our literature review, there is a dearth of literature associating CECS with specific chronic cardiac or hepatic conditions as well as describing its incidence in these conditions.

Analgesic benefit of niacin for shrapnel wound pain in war veteran.

We report a case of an 86-year-old male with a history of dyslipidemia, which had been treated with a medication regimen that included niacin. Upon discontinuation of niacin by his physician, he noticed recurrence of aching pain on the dorsal surface of the foot where he had a scar from a World War II shrapnel injury. With reinitation of niacin, his pain again abated.

Physical examination in radiculopathy.

History and physical examination is the cornerstone in the appropriate diagnosis and treatment of any patient. A comprehensive physical examination is necessary to aid in determining distributions of symptoms and to lead one to the site of pathology. The aim of this article is to aid the clinician in distinguishing radiculopathy from other causes of neck and low back pain. Physical examination of the patient with suspected radiculopathy needs to be thorough and complete to make the most accurate diagnosis. Thorough knowledge of the evidence-based literature is beneficial in maximizing patient care, particularly in the light of health care reform.

Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions.

Significant developments and changes in the use of interventions and treatments for the management of myofascial pain syndrome have occurred in the past 10 years. These emerging concepts have changed the approach for clinicians who manage these pain disorders. However, wide variations in practice patterns prevail, and no clear consensus exists regarding when and how to use these interventions; in addition, awareness of the evidence basis behind their use is limited. This review examines the most recent advances in the treatment of myofascial pain syndromes. Specifically, the evidence basis of various emerging interventions is reviewed and recommendations for routine clinical practice and their rationale are provided. The purpose of this review is to provide the clinician with a better understanding of emerging concepts in the interventions used for myofascial pain syndromes.