An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents.

BACKGROUND AND PURPOSE: Physical therapy (PT) is a management strategy increasingly recognized to facilitate recovery after concussion. The purpose of this study was to investigate the safety and outcomes of multimodal impairment-based PT at varying time points after injury in youth diagnosed with concussion. METHODS: Data were extracted retrospectively from medical records for patients who received PT for concussion-related impairments. Patient records were categorized into 3 cohorts on the basis of the timing of PT implementation: 0-20 days following injury (early intervention), 21 to 41 days following injury (middle intervention), and 42 or more days following injury (late intervention). The primary outcome measure was Post-Concussion Symptom Inventory score from the beginning to the end of the PT episode of care. Additional outcome measures included number of PT sessions, duration of PT episode of care (days), and occurrence of unplanned visits to a health care provider. RESULTS: A total of 120 patient records (mean age of 14.77 years) were analyzed. Thirty-three, 39, and 48 individuals were categorized into the early, middle, and late intervention cohorts, respectively. There were no significant differences between intervention cohorts with regard to symptom change on the Post-Concussion Symptom Inventory from the beginning to the end of the PT episode of care, unplanned health care visits, number of PT sessions, or duration of PT episode of care. DISCUSSION AND CONCLUSIONS: Early initiation of PT may be safe and tolerable. Future prospective studies are needed to explore the efficacy of PT services administered early following injury to help characterize an optimal care plan for youth following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A210).

Structural Connectivity Related to Persistent Symptoms After Mild TBI in Adolescents and Response to Aerobic Training: Preliminary Investigation.

OBJECTIVE: To quantify structural connectivity abnormalities in adolescents with mild traumatic brain injury (mTBI) and to investigate connectivity changes following aerobic training using graph theory and diffusion tensor imaging tractography. SETTING: Outpatient research setting. PARTICIPANTS: Twenty-two children (age: 15.83 ± 1.77 years, 10 females) with 4 to 16 weeks of persistent symptoms after mTBI and a matched healthy comparison group. DESIGN: Randomized clinical trial of aerobic training and stretching comparison combined with case-control comparison. MAIN MEASURES: (1) Five global network measures: global efficiency (Eglob), mean local efficiency, modularity, normalized clustering coefficient (γ), normalized characteristic path length (λ), and small-worldness (σ). (2) The self-reported Post-Concussion Symptom Inventory score. RESULTS: At initial enrollment, adolescents with mTBI had significantly lower Eglob and higher γ, λ, and σ (all P < .05) than healthy peers. After the intervention, significantly increased Eglob and decreased λ (both P < .05) were found in the aerobic training group. Improvement in Post-Concussion Symptom Inventory scores was significantly correlated with the Eglob increase and λ decrease in the aerobic training and λ decrease in the stretching comparison group (all P < .05). CONCLUSION: This pilot study showed initial evidence that structural connectivity analysis was sensitive to brain network abnormalities and may serve as an imaging biomarker in children with persistent symptoms after mTBI.

Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment.

OBJECTIVE: To examine the influence of age, sex, attention-deficit hyperactivity disorder (ADHD) status, previous history of concussion, and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion. DESIGN: Prospective cohort study. SETTING: Hospital-based outpatient clinic. PARTICIPANTS: Seventy-one participants (42 males; 29 females) with mean age 14.14 ± 2.44. INDEPENDENT VARIABLES: Age, sex, previous concussion history, ADHD status, total and severity of postconcussion symptoms, and days since injury. MAIN OUTCOME MEASURES: Total Balance Error Scoring System score, path length, center-of-pressure (COP) area, sample entropy, and Romberg quotient. RESULTS: Pearson product-moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables. Spearman correlation was used to test the association between symptom severity and the postural control variables. Standard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables. Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior-posterior direction for the eyes closed condition. Sex, ADHD status, and previous concussion history did not significantly predict postural control scores. CONCLUSIONS: Age significantly influences scores on common postconcussion postural control assessments. CLINICAL RELEVANCE: This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessments.

Postconcussion Postural Sway Variability Changes in Youth: The Benefit of Structural Variability Analyses.

PURPOSE: The purpose of this study was to evaluate the utility of postural sway variability as a potential assessment to detect altered postural sway in youth with symptoms related to a concussion. METHODS: Forty participants (20 who were healthy and 20 who were injured) aged 10 to 16 years were assessed using the Balance Error Scoring System (BESS) and postural sway variability analyses applied to center-of-pressure data captured using a force plate. RESULTS: Significant differences were observed between the 2 groups for postural sway variability metrics but not for the BESS. Specifically, path length was shorter and Sample and Renyi Entropies were more regular for the participants who were injured compared with the participants who were healthy (P < .05). CONCLUSION: The results of this study indicate that postural sway variability may be a more valid measure than the BESS to detect postconcussion alterations in postural control in young athletes.

Reduced 2-D Frontal Plane Motion During Single-Limb Landing Is Associated With Risk of Future Anterior Cruciate Ligament Graft Rupture After Anterior Cruciate Ligament Reconstruction and Return to Sport: A Pilot Study.

OBJECTIVES: To evaluate the association between 2-D frontal plane movement and second anterior cruciate ligament (ACL) injury risk in young athletes at return to sport (RTS) after ACL reconstruction. DESIGN: Prospective cohort. METHODS: Forty-nine participants who had ACL reconstruction (mean ± SD age, 16.5 ± 3.0 years) performed a single-leg drop landing from a 31-cm box at the time of their RTS. Frontal plane trunk, pelvis, and knee angles were measured using 2-D video analysis at the point of maximum depth during landing. Summated frontal plane angles were calculated by adding trunk, pelvis, and knee angles. Participants were grouped based on whether or not they sustained an ACL graft rupture over the 24 months after RTS. RESULTS: Seven participants (14%) sustained an ipsilateral graft rupture within 24 months after RTS. Participants who suffered a second ACL injury had a significant reduction in the summated frontal plane angle of the trunk, pelvis, and knee (P = .018) and of the trunk and knee (P = .02) compared to those who did not suffer a second injury. For every 5° increase in the summated trunk, pelvis, and knee angle (odds ratio [OR] = 0.54; 95% confidence interval [CI]: 0.31, 0.94) and the summated trunk and knee angle (OR = 0.48; 95% CI: 0.25, 0.94), the athletes were 46% to 52% less likely to sustain a graft rupture. CONCLUSION: Athletes who suffered an ACL graft rupture within 24 months of RTS had a more rigid posture when landing compared to their uninjured peers. The results of this pilot study should be replicated in a larger sample to determine whether this method has merit as a screening tool to identify athletes at high risk for second ACL injury. J Orthop Sports Phys Ther 2021;51(2):82-87. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9302.

Spatial and temporal analysis center of pressure displacement during adolescence: Clinical implications of developmental changes.

This study aimed to provide insight into the development of postural control abilities in youth. A total of 276 typically developing adolescents (155 males, 121 females) with a mean age of 13.23 years (range of 7.11-18.80) were recruited for participation. Subjects performed two-minute quiet standing trials in bipedal stance on a force plate. Center of pressure (COP) trajectories were quantified using Sample Entropy (SampEn) in the anterior-posterior direction (SampEn-AP), SampEn in the medial-lateral direction (SampEn-ML), and Path Length (PL) measures. Three separate linear regression analyses were conducted to predict the relationship between age and each of the response variables after adjusting for individuals' physical characteristics. Linear regression models showed an inverse relationship between age and entropy measures after adjusting for body mass index. Results indicated that chronological age was predictive of entropy and path length patterns. Specifically, older adolescents exhibited center of pressure displacement (smaller path length) and less complex, more regular center of pressure displacement patterns (lower SampEn-AP and SampEn-ML values) compared to the younger children. These findings support prior studies suggesting that developmental changes in postural control abilities may continue throughout adolescence and into adulthood.

PHYSICAL THERAPY INTERVENTION STRATEGIES FOR PATIENTS WITH PROLONGED MILD TRAUMATIC BRAIN INJURY SYMPTOMS: A CASE SERIES.

BACKGROUND AND PURPOSE: Although most patients recover from a mild traumatic brain injury (mTBI) within 7-14 days, 10-30% of people will experience prolonged mTBI symptoms. Currently, there are no standardized treatment protocols to guide physical therapy interventions for this population. The purpose of this case series was to describe the unique, multimodal evaluation and treatment approaches for each of the patients with post-concussion syndrome (PCS). CASE DESCRIPTION: Six pediatric athletes with PCS who had participated in physical therapy and fit the inclusion criteria for review were retrospectively chosen for analysis. Patients received a cervical evaluation, an aerobic activity assessment, an oculomotor screen, and postural control assessment. Each patient participated in an individualized physical therapy treatment plan-of-care based on their presentation during the evaluation. OUTCOMES: Patients were treated for a mean of 6.8 treatment sessions over 9.8 weeks. Four of six patients returned to their pre-injury level of activity while two returned to modified activity upon completion of physical therapy. Improvements were observed in symptom scores, gaze stability, balance and postural control measures, and patient self-management of symptoms. All patients demonstrated adequate self-management of symptoms upon discharge from physical therapy. DISCUSSION/CONCLUSIONS: Physical therapy interventions for pediatric athletes with PCS may facilitate recovery and improve function. Further research is needed to validate effective tools for assessment of patients who experience prolonged concussion symptoms as well as to establish support for specific post-mTBI physical therapy interventions. LEVEL OF EVIDENCE: Level 4.

Reduced hip strength is associated with increased hip motion during running in young adult and adolescent male long-distance runners.

STUDY DESIGN: Controlled laboratory study. BACKGROUND AND PURPOSE: Anterior knee pain is one of the most common running symptoms reported in the literature. While the exact etiology is unknown, a lack of hip strength is suggested to contribute to abnormal running mechanics. The purpose of this research study was to evaluate the association between isokinetic hip strength and 3-D running kinematics. METHODS: 33 male high school and collegiate cross country runners participated in this study. Peak isokinetic hip abductor and hip extensor strength were assessed. Each subject also completed a treadmill running protocol at a self-selected speed (mean = 3.8 m/s). 3-D kinematic data were collected at 240 Hz using a 10-camera motion capture system. Pearson correlation coefficients were used to determine the relationship between hip strength and hip range of motion (ROM) during the stance phase of running (p<0.05). RESULTS: Peak isokinetic hip extensor torque was inversely correlated with transverse plane hip ROM (r = -.387, p = .026) but was not significantly related to sagittal plane hip ROM or frontal plane hip ROM. Peak isokinetic hip abductor torque was inversely correlated with frontal plane hip ROM (r=-.462, p=.008) but was not significantly related to either sagittal plane hip ROM or transverse plane hip ROM. Peak isokinetic hip extensor torque and peak isokinetic hip abductor torque were not significantly related to knee kinematics in any plane. CONCLUSIONS: Peak isokinetic hip extensor torque and peak isokinetic hip abductor torque are associated with transverse plane and frontal plane hip kinematics, but not knee kinematics. LEVELS OF EVIDENCE: Level 3b.

Test-retest consistency of a postural sway assessment protocol for adolescent athletes measured with a force plate.

PURPOSE/BACKGROUND: Postural control assessments can provide a powerful means of detecting concussion-related neurophysiological abnormalities and are considered an important part of the concussion management processes. Studies with college athletes indicate that postural sway analyzed using complexity metrics may provide a sensitive and novel way to detect post-concussion postural control impairments. The purpose of this study was to determine if a postural sway assessment protocol (PSAP) measured using a force plate system can serve as a reliable assessment tool for adolescent athletes. METHODS: The short-term and long-term test-retest reliability of the PSAP was examined in a group of adolescent female athletes under eyes open and eyes closed conditions. Detrended fluctuation analysis was used to evaluate the complexity of the times series data (i.e., degree of self-similarity across time scales). Conventional measures of standard deviation and total path length (distance traveled by the center-of-pressure) were also assessed. RESULTS: The complexity and conventional measures generally demonstrated good reliability coefficients for short-term and long-term test-retest reliability with both eyes open and eyes closed conditions. Intra-class Correlation Coefficient (ICC) values ranged from .38-.90 The highest ICC values corresponded with the short-term reliability for the eyes open condition, while the lower ICC values corresponded with the long-term reliability for the eyes closed condition. CONCLUSIONS: The results of this study indicate that the PSAP demonstrated good short-term and long-term test-retest reliability. In addition, no evidence of learning effects was elicited through this study. Future studies should further explore the validity and feasibility of the use of this protocol for different age groups, different types of athletes, and longitudinal evaluations of post-concussion impairments. CLINICAL RELEVANCE: This study provides preliminary support for the utility of a postural sway assessment protocol measured using a force plate for use with adolescent athletes. LEVEL OF EVIDENCE: Level III.