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.

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.

The gluteal triangle: a clinical patho-anatomical approach to the diagnosis of gluteal pain in athletes.

Gluteal pain is a common presentation in sports medicine. The aetiology of gluteal pain is varied, it may be referred from the lower back, mimic other pathology and refer to the hip or the groin. The complex anatomy of the buttock and pelvis, variability of presentation and non specific nature of signs and symptoms make the diagnostic process difficult. To date the approaches to this problem have focused on individual pathologies. The paper proposes a novel educational system based on patho-anatomic concepts. Anatomical reference points were selected to form a diagnostic triangle, which provides the discriminative power to restrict the differential diagnosis, and form the basis of ensuing investigation. This paper forms part of a series addressing the three dimensional nature of proximal lower limb pathology. The 3G approach (groin, gluteal and greater trochanter triangles) acknowledges this, permitting the clinician to move throughout the region, considering pathologies appropriately. These papers should be read in conjunction with one another in order to fully understand the conceptual approach.

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.

The greater trochanter triangle; a pathoanatomic approach to the diagnosis of chronic, proximal,lateral, lower limb [corrected] pain in athletes.

Chronic pain experienced in the proximal, lateral, lower limb may arise from the femoro-acetabular joint, from the muscles and tendons that act upon it, from any of the structures that traverse the area, and from more remote structures such as the lumbar spine. The aetiology of pathology in this area is not confined to either trauma or overuse. As a result many different sporting activities may have a causal role. Without a clear clinical/pathological diagnosis, the subsequent management of chronic groin pain is difficult. The combination of complex anatomy, variability of presentation and the non-specific nature of the signs and symptoms makes the diagnostic process problematic. The paper proposes a novel educational model based on pathoanatomic concepts. Anatomical reference points were selected to form a triangle, which provides the discriminative power to restrict the differential diagnosis, and form the basis of ensuing investigation. This paper forms part of a series addressing the three-dimensional nature of proximal lower limb pathology. The 3G approach (groin, gluteal, and greater trochanter triangles) acknowledges this, permitting the clinician to move throughout the region, considering pathologies appropriately.

The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes.

Chronic groin pain is a common presentation in sports medicine. It is most often a problem in those sports that involve kicking and twisting movements while running. The morbidity of groin pain should not be underestimated, ranking behind only fracture and anterior cruciate ligament reconstruction in terms of time out of training and play. Due to the insidious onset and course of pathology in the groin region it commonly presents with well-established pathology. Without a clear clinical/pathological diagnosis, the subsequent management of chronic groin pain is difficult. The combination of complex anatomy, variability of presentation and the non-specific nature of the signs and symptoms make the diagnostic process problematical. This paper proposes a novel educational model based on patho-anatomical concepts. Anatomical reference points were selected to form a triangle, which provides the discriminative power to restrict the differential diagnosis and form the basis of ensuing investigation. This paper forms part of a series addressing the three-dimensional nature of proximal lower limb pathology. The 3G approach (groin, gluteal and greater trochanter triangles) acknowledges this, permitting the clinician to move throughout the region, considering pathologies appropriately.

Is protective equipment useful in preventing concussion? A systematic review of the literature.

OBJECTIVE: To determine if there is evidence that equipment use reduces sport concussion risk and/or severity. DATA SOURCES: 12 electronic databases were searched using a combination of Medical Subject Headings and text words to identify relevant articles. REVIEW METHODS: Specific inclusion and exclusion criteria were used to select studies for review. Data extracted included design, study population, exposure/outcome measures and results. The quality of evidence was assessed based on epidemiologic criteria regarding internal and external validity (ie, strength of design, sample size/power calculation, selection bias, misclassification bias, control of potential confounding and effect modification). RESULTS: In total, 51 studies were selected for review. A comparison between studies was difficult due to the variability in research designs, definition of concussion, mouthguard/helmet/headgear/face shield types, measurements used to assess exposure and outcomes, and variety of sports assessed. The majority of studies were observational, with 23 analytical epidemiologic designs related to the subject area. Selection bias was a concern in the reviewed studies, as was the lack of measurement and control for potentially confounding variables. CONCLUSIONS: There is evidence that helmet use reduces head injury risk in skiing, snowboarding and bicycling, but the effect on concussion risk is inconclusive. No strong evidence exists for the use of mouthguards or face shields to reduce concussion risk. Evidence is provided to suggest that full facial protection in ice hockey may reduce concussion severity, as measured by time loss from competition.

Payments to injured professional jockeys in British horse racing (1996-2006).

OBJECTIVE: To determine the direct and indirect cost of injuries in professional jockeys as a result of race riding. DESIGN: Cohort study. SETTING: Professional horse racing. PARTICIPANTS: Professional jockeys in the UK registered with the Jockey Club. MAIN OUTCOME MEASURES: Payouts under the Professional Riders Insurance Scheme (PRIS) for injuries sustained by professional jockeys, which were recorded by the Jockey Club injury database between 1996 and 2006 inclusive. RESULTS: In the 11-year period of the study, there were 1328 injuries that resulted in jockeys missing a total of 71,509 days of racing, and as a result PRIS paid out 4,496,019 pounds sterling in compensation. Most injuries were minor, with a third of injured jockeys returning to race riding within 2 weeks and 45% of the claims receiving a payout of < 1000 pounds sterling. Almost half the claims were due to fractures, with the clavicle being the most common site of injury. Joint dislocations accounted for the highest insurance payout and the longest time off racing. CONCLUSIONS: Horse racing is a sport known to have a high risk of injury. This study has found that almost 4.5 million pounds sterling was spent on the injuries that were reported to PRIS during the 11-year time period 1996-2006. This study sheds light on the overall injury cost in professional horse racing and will form the basis for more formal health economic analysis.

Career-ending injuries to professional jockeys in British horse racing (1991-2005).

BACKGROUND: It has been previously shown that professional jump and flat racing jockeys suffer a high incidence of injury as a consequence of their profession. This paper specifically examines career-ending injuries to professional jockeys in Great Britain. AIMS: To investigate career-ending injuries in professional jockeys. METHOD: Analysis of prospectively collected injury database on professional jockeys. RESULTS: The majority of injuries in this study occurred to the head, shoulder or torso. Fractures were the most common type of injury that led to a decision to end a career, followed by neurological injury to the head and/or spine. CONCLUSION: Injuries to the head are the most common career-ending injuries, and consideration of injury counter measures could be an important strategy in equestrian sports.

Physiotherapists' use of information in identifying a concussion: an extended Delphi approach.

OBJECTIVE: To determine the relative importance of signs and symptoms that a selected cohort of sports physiotherapists use to identify a sports concussion. METHODS: A two-round Delphi methodology was used to achieve consensus in a cohort of 21 sports physiotherapists. A subsequent round involving an educational intervention provided the participants with an opportunity to modify their knowledge base through the provision of a relevant resource article. RESULTS: Participants provided 123 responses, which were grouped into eight descriptive categories with consensus (>80%) being reached for the importance of: cognition/orientation, memory, motor dysfunction and state of consciousness. The category "state of consciousness" remained the most important information source at the completion of the study. CONCLUSION: Participants placed considerable importance on the player's level of consciousness in their decision making. This would appear to be in conflict with recent trends to place greater importance on the role of symptoms in identifying a concussion.

The effect of exercise on motor performance tasks used in the neurological assessment of sports-related concussion.

Sports-related concussion is assessed using both cognitive and motor performance tasks. There is limited understanding of how exercise affects these measures. The purpose of this study was to investigate the effect of moderate-intensity exercise on three selected measures of motor performance. A repeated measures design was used to compare baseline motor performance scores with post-exercise scores with an exercise intervention modelled on the physiological demands of a team sport. 30 physically active subjects performed timed motor performance tasks: Finger-to-Nose (FTN), Tandem Gait (TG) and Single Leg Stance (SLS). The tasks were administered twice pre-exercise and twice post-exercise. FTN, TG and SLS demonstrated high test-retest reliability (ICC values >0.8). 15 minutes of moderate-intensity exercise caused a significant improvement in FTN (T2 = 2.66 (SD 0.38), T3 = 2.49 (0.32); p<0.001) and TG (T2 = 13.08 (2.84), T3 = 12.23 (2.22); p = 0.001), but not in SLS (T2 = 5.94 (4.99), T3 = 5.91 (5.54); p = 0.507). Improvement in the performance of motor tasks after exercise has implications for the immediate assessment of sports-related concussion, given that measures of motor performance are utilised in concussion assessment instruments.

Overview of concussion consensus statements since 2000.

More refereed publications on sports-related concussion have appeared since 2000 than in all previous years combined. Three international consensus statements, documents from the National Athletic Trainers' Association (NATA) and the American College of Sports Medicine (ACSM), and entire issues of the Clinical Journal of Sport Medicine and the Journal of Athletic Training have been devoted to this subject. The object of this article is to critique the consensus statements and NATA and ACSM documents, pointing out areas of controversy.