Use of Virtual Care Strategies to Join Multidisciplinary Teams Evaluating Work-Related Injuries in Rural Residents.

Background: Rural injured workers requiring multidisciplinary assessments for musculoskeletal disorders face health access disparities, which include travel to urban centers. Virtual care can enhance access to multidisciplinary team care for musculoskeletal conditions in rural areas. Materials and Methods: A retrospective chart audit of 136 multidisciplinary assessment reports of injured workers was conducted. Comprehensive management recommendations from the health care assessment team were extracted for analysis. The health care team used virtual technologies to join with patients and at least one local rural health practitioner in one of three locations. Remote presence robotics (RPR; Xpress Technology™) or laptop-based telehealth was used to complete the assessments. Results: RPR were used in 46% of assessments over two sites, with 54% using laptop-based telehealth at a third site. Frequencies of team members' assessment using technologies were as follows: physical therapist (100%), psychologist (78%), plastic surgeon (8%), and physician (43%). Spine (42%) and shoulder (32%) disorders were the most common problems. Most workers (79%) were 3 or more months postinjury. The most common management recommendation was the need for daily comprehensive rehabilitation care (76%). Travel time was saved by 89% of participants. Conclusions: Virtual care was used to unite multidisciplinary assessment teams for the evaluation of injured rural workers with complex musculoskeletal injuries. Future research recommendations include comparing between virtual and fully in-person multidisciplinary assessment and recommendation findings, and evaluation of patient and practitioner experiences with comprehensive virtual team assessments.

Why exercise may be beneficial in concussion rehabilitation: A cellular perspective.

INTRODUCTION: Concussion diagnosis and rehabilitation management has become a prevalent area of research, and yet much is still unknown about these complex injuries. Historically, exercise prescription post-concussion was conservatively used for rehabilitation due to the suspected harmful effects that exercise can have on damaged neurons, and increase in symptoms. However, there has been a shift to implement exercise earlier into recovery as several studies have demonstrated positive outcomes. OBJECTIVE: The objective of this literature review is to update the reader about new advances in concussion research related to the beneficial effects of physical activity from both a neurometabolic and a broader physiological perspective, using gene expression as a vehicle to demonstrate why and how physical activity has the capacity to optimize recovery from a cellular perspective. To further this clinical guideline, the evidence must continue to support these positive outcomes from an inductive and deductive physiologic approach (i.e., the clinical evidence aligned from a micro- to macroscopic approach and vice versa). DESIGN: Narrative review. METHODS: Pubmed and Medline were used with the following key words: concussion and, physical activity, neurometabolic, gene regulation, trauma, nervous system, mild head injury, acute exercise, cellular physiology and pathophysiology. CONCLUSION: It is our contention that understanding the cellular perspective will help guide clinical management, and promote research into post-concussion exercise.

An Evidence-Based Objective Study Protocol for Evaluating Cardiovascular and Cerebrovascular Indices Following Concussion: The Neary Protocol.

INTRODUCTION: The prevalence and incidence of sport-related concussion have continued to increase over the past decade, and researchers from various backgrounds strive for evidenced-based clinical assessment and management. When diagnosing and managing a concussion, a battery of tests from several domains (e.g., symptom reporting, neurocognitive, physiology) must be used. In this study, we propose and develop an objective, evidence-based protocol to assess the pathophysiology of the brain by using non-invasive methods. METHODS: Contact sport athletes (n = 300) will be assessed at the beginning of the season in a healthy state to establish baseline values, and then prospectively followed if a mild traumatic brain injury (mTBI) occurs on approximately days 1-2, 3-5, 7-10, 21, 30, and subsequently thereafter, depending on the severity of injury. The protocol includes spontaneous measurements at rest, during head postural change, controlled breathing maneuvers for cerebrovascular reactivity, a neurovascular coupling stimuli, and a baroreflex/autoregulation maneuver. Physiological data collection will include cerebral blood flow velocity, cerebral oxygenation, respiratory gases for end-tidal oxygen and carbon dioxide, finger photoplethysmography for blood pressure, seismocardiography for cardiac mechanics, and electrocardiography. Conclusion, Limitations, and Ethics: The protocol will provide an objective, physiological evidence-based approach in an attempt to better diagnose concussion to aid in return-to-play or -learn. Ethics approval has been granted by the University Research Ethics Board.

Assessing prefrontal cortex oxygenation after sport concussion with near-infrared spectroscopy.

BACKGROUND: Clinicians typically rely on neuropsychological and balance tests to track concussion recovery. The aforementioned tests imply impairments that are based on performance, but these tests do not directly measure brain physiology throughout concussion recovery. Because of these issues, an objective biomarker that can index severity and the recovery timeline is needed. Moreover, the number of concussions occurring at a recreational level requires the biomarker to be easily administered in a cost effective manner, and the results easily interpreted. METHODS: To address these issues, near-infrared spectroscopy was used to assess the relative changes in oxy (HbO2 )- and deoxyhaemoglobin and the associated standard deviations (SD) in the prefrontal cortex. Resting haemoglobin, and haemoglobin changes in response to hypercapnia (five repeated 20s breath holds), was measured in all participants. Data were aggregated into healthy baselines (n = 115), and concussed participants on days 1-3 (n = 14), 4-6 (n = 8), and 7-14 (n = 11). The data were statistically compared using a 1 × 4 ANOVA. RESULTS: Resting HbO2 values progressively lowered from days 1-3 to 7-14 (with no differences compared to controls). The second major finding showed that hypercapnic HbO2 SD was significantly lower than resting values on days 1-3 and 4-6, but reversed back towards the healthy control group on day 7-14. CONCLUSION: Monitoring cerebral oxygenation changes is a viable biomarker to assess the physiological state of the brain following concussion.

Heart rate variability and implication for sport concussion.

Finding sensitive and specific markers for sports-related concussion is both challenging and clinically important. Such biomarkers might be helpful in the management of patients with concussion (i.e. diagnosis, monitoring and risk prediction). Among many parameters, blood flow-pressure metrics and heart rate variability (HRV) have been used to gauge concussion outcomes. Reports on the relation between HRV and both acute and prolonged concussion recovery are conflicting. While some authors report on differences in the low-frequency (LF) component of HRV during postural manipulations and postexercise conditions, others observe no significant differences in various HRV measures. Despite the early success of using the HRV LF for concussion recovery, the interpretation of the LF is debated. Recent research suggests the LF power is a net effect of several intrinsic modulatory factors from both sympathetic and parasympathetic branches of the autonomic nervous system, vagally mediated baroreflex and even some respiratory influences at lower respiratory rate. There are only a few well-controlled concussion studies that specifically examine the contribution of the autonomic nervous system branches with HRV for concussion management. This study reviews the most recent HRV- concussion literature and the underlying HRV physiology. It also highlights cerebral blood flow studies related to concussion and the importance of multimodal assessment of various biological signals. It is hoped that a better understanding of the physiology behind HRV might generate cost-effective, repeatable and reliable protocols, all of which will improve the interpretation of HRV throughout concussion recovery.