Journal Article•
Postural Stability and Neuropsychological Deficits After Concussion in Collegiate Athletes.
TL;DR: Athletes with cerebral concussion demonstrated acute balance deficits, which are likely the result of not using information from the vestibular and visual systems effectively, and more research is necessary to determine the best neuropsychological test battery for assessing sport-related concussion.
Abstract: OBJECTIVE: Postural stability and neuropsychological testing are gradually becoming integral parts of postconcussion assessment in athletes. Clinicians, however, sometimes question the viability of instituting preseason baseline testing and the value of these results in making return-to-play decisions. Our purpose was to examine the course of recovery on various postural stability and neuropsychological measures after sport-related concussion. A secondary goal was to determine if loss of consciousness and amnesia, both of which are heavily weighted in most of the concussion classification systems, affect the rate of recovery. DESIGN AND SETTING: All subjects underwent a battery of baseline postural stability and neuropsychological tests before the start of their respective seasons. Any athletes subsequently injured were followed up at postinjury days 1, 3, and 5. Matched control subjects were assessed using the same test battery at the same time intervals. SUBJECTS: We studied 36 Division I collegiate athletes who sustained a concussion and 36 matched control subjects. MEASUREMENTS: We assessed postural stability using the Sensory Organization Test on the NeuroCom Smart Balance Master System and the Balance Error Scoring System. Neurocognitive functioning was measured with several neuropsychological tests: Trail-Making Test, Wechsler Digit Span Test, Stroop Color Word Test, and Hopkins Verbal Learning Test. RESULTS: Injured subjects demonstrated postural stability deficits, as measured on both the Sensory Organization Test and Balance Error Scoring System. These deficits were significantly worse than both preseason scores and matched control subjects' scores on postinjury day 1. Only the results on the Trail-Making Test B and Wechsler Digit Span Test Backward resulted in a logical recovery curve that could explain lowered neuropsychological performance due to concussive injury. Significant differences were revealed between the control and injured groups at day 1 postinjury, but a significant decline between baseline and postinjury scores was not demonstrated. Loss of consciousness and amnesia were not associated with increased deficits or slowed recovery on measures of postural stability or neurocognitive functioning. CONCLUSIONS: Athletes with cerebral concussion demonstrated acute balance deficits, which are likely the result of not using information from the vestibular and visual systems effectively. Neurocognitive deficits are more difficult to identify in the acute stages of concussion, although concentration, working memory, immediate memory recall, and rapid visual processing appear to be mildly affected. More research is necessary to determine the best neuropsychological test battery for assessing sport-related concussion.
Citations
More filters
Florey Institute of Neuroscience and Mental Health1, University of Calgary2, Boston Medical Center3, University of Zurich4, University of Missouri–Kansas City5, International Olympic Committee6, University of Oslo7, University of Toronto8, University of Michigan9, Vanderbilt University Medical Center10, University of Washington11, University of North Carolina at Chapel Hill12, University of British Columbia13, Cornell University14, Burke Rehabilitation Hospital15, University of Ottawa16, Medical College of Wisconsin17, University of New South Wales18, Monash University19, University of Melbourne20, McMaster University21, Princeton University22, University of Medicine and Dentistry of New Jersey23
TL;DR: The 4th International Conference on Concussion in Sport held in Zurich, November 2012 was attended by Paul McCrory, Willem H Meeuwisse, Mark Aubry, Jiří Dvořák, Ruben J Echemendia, Lars Engebretsen, Karen Johnston, Jeffrey S Kutcher, Martin Raftery, Allen Sills and Kathryn Schneider.
2,293 citations
Florey Institute of Neuroscience and Mental Health1, University of Calgary2, Boston University3, University of Missouri–Kansas City4, International Olympic Committee5, University of Michigan6, Veterans Health Administration7, University of North Carolina at Chapel Hill8, University of British Columbia9, Medical College of Wisconsin10, University of Melbourne11, McMaster University12, Rutgers University13
TL;DR: This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussions in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.
Abstract: The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level.
2,269 citations
TL;DR: In this paper, a study of 1631 football players from 15 US colleges found that players with concussions exhibited more severe symptoms (mean GSC score 20.93 [95% confidence interval {CI, 15.65-26.21] points higher than that of controls), cognitive impairments (mean SAC score 2.94 [ 95% CI, 1.41 to 2.06], cognitive functioning improved to baseline levels within 5 to 7 days (day 7 SAC mean difference, −0.33;
Abstract: ContextLack of empirical data on recovery time following sport-related concussion
hampers clinical decision making about return to play after injury.ObjectiveTo prospectively measure immediate effects and natural recovery course
relating to symptoms, cognitive functioning, and postural stability following
sport-related concussion.Design, Setting, and ParticipantsProspective cohort study of 1631 football players from 15 US colleges.
All players underwent preseason baseline testing on concussion assessment
measures in 1999, 2000, and 2001. Ninety-four players with concussion (based
on American Academy of Neurology criteria) and 56 noninjured controls underwent
assessment of symptoms, cognitive functioning, and postural stability immediately,
3 hours, and 1, 2, 3, 5, 7, and 90 days after injury.Main Outcome MeasuresScores on the Graded Symptom Checklist (GSC), Standardized Assessment
of Concussion (SAC), Balance Error Scoring System (BESS), and a neuropsychological
test battery.ResultsNo player with concussion was excluded from participation; 79 players
with concussion (84%) completed the protocol through day 90. Players with
concussion exhibited more severe symptoms (mean GSC score 20.93 [95% confidence
interval {CI}, 15.65-26.21] points higher than that of controls), cognitive
impairment (mean SAC score 2.94 [95% CI, 1.50-4.38] points lower than that
of controls), and balance problems (mean BESS score 5.81 [95% CI, –0.67
to 12.30] points higher than that of controls) immediately after concussion.
On average, symptoms gradually resolved by day 7 (GSC mean difference, 0.33;
95% CI, −1.41 to 2.06), cognitive functioning improved to baseline levels
within 5 to 7 days (day 7 SAC mean difference, −0.03; 95% CI, −1.33
to 1.26), and balance deficits dissipated within 3 to 5 days after injury
(day 5 BESS mean difference, −0.31; 95% CI, −3.02 to 2.40). Mild
impairments in cognitive processing and verbal memory evident on neuropsychological
testing 2 days after concussion resolved by day 7. There were no significant
differences in symptoms or functional impairments in the concussion and control
groups 90 days after concussion.ConclusionsCollegiate football players may require several days for recovery of
symptoms, cognitive dysfunction, and postural instability after concussion.
Further research is required to determine factors that predict variability
in recovery time after concussion. Standardized measurement of postconcussive
symptoms, cognitive functioning, and postural stability may enhance clinical
management of athletes recovering from concussion.
1,484 citations
Cites methods from "Postural Stability and Neuropsychol..."
...Thesedataare also subject to the reliability and validity of the main outcome measures we used,whicharesupportedbyearlierstudies on the accuracy of these measures in detecting theeffectsofconcussion inathletes.(19,20,22,36,39-41) Obtaining a preinjury baseline for all players on these measures provides the most sensitive means to detect reliable change in performance attributable to concussion and trackpostinjuryrecovery....
[...]
TL;DR: This study suggests thatPlayers with a history of previous concussions are more likely to have future concussive injuries than those with no history; 1 in 15 players with a concussion may have additional concussions in the same playing season; and previous concussion may be associated with slower recovery of neurological function.
Abstract: ContextApproximately 300 000 sport-related concussions occur annually
in the United States, and the likelihood of serious sequelae may increase
with repeated head injury.ObjectiveTo estimate the incidence of concussion and time to recovery after concussion
in collegiate football players.Design, Setting, and ParticipantsProspective cohort study of 2905 football players from 25 US colleges
were tested at preseason baseline in 1999, 2000, and 2001 on a variety of
measures and followed up prospectively to ascertain concussion occurrence.
Players injured with a concussion were monitored until their concussion symptoms
resolved and were followed up for repeat concussions until completion of their
collegiate football career or until the end of the 2001 football season.Main Outcome MeasuresIncidence of concussion and repeat concusion; type and duration of symptoms
and course of recovery among players who were injured with a concussion during
the seasons.ResultsDuring follow-up of 4251 player-seasons, 184 players (6.3%) had a concussion,
and 12 (6.5%) of these players had a repeat concussion within the same season.
There was an association between reported number of previous concussions and
likelihood of incident concussion. Players reporting a history of 3 or more
previous concussions were 3.0 (95% confidence interval, 1.6-5.6) times more
likely to have an incident concussion than players with no concussion history.
Headache was the most commonly reported symptom at the time of injury (85.2%),
and mean overall symptom duration was 82 hours. Slowed recovery was associated
with a history of multiple previous concussions (30.0% of those with ≥3
previous concussions had symptoms lasting >1 week compared with 14.6% of those
with 1 previous concussion). Of the 12 incident within-season repeat concussions,
11 (91.7%) occurred within 10 days of the first injury, and 9 (75.0%) occurred
within 7 days of the first injury.ConclusionsOur study suggests that players with a history of previous concussions
are more likely to have future concussive injuries than those with no history;
1 in 15 players with a concussion may have additional concussions in the same
playing season; and previous concussions may be associated with slower recovery
of neurological function.
1,450 citations
Cites methods or result from "Postural Stability and Neuropsychol..."
...The signs and symptoms present at the time of injury observed in our study are consistent with those reported by other authors.(2,12,14,20,31,34,47-52) Most concussion grading scales are weighted heavily on the presence of LOC and/or amnesia at the time of injury and for a brief period thereafter....
[...]
...Although the GSC may be limited by its subjectivity, it has been used in earlier sports concussion studies.(31-34) In addition, we asked the certified athletic trainer evaluating the concussion to complete a series of questions describing the player’s course of recovery after concussion....
[...]
01 Jan 2003
TL;DR: Departments of Exercise andSport Science (Drs Guskiewicz and Cantu), Ortho-paedics, Orthopaedics and Epidemi-ology (Dr Marshall), and Injury Prevention ResearchCenter (Dr Onate), University ofNorth Carolina at Chapel Hill; Neuroscience Center,Waukesha Memorial Hospital, Waukeha, Wis (DrMcCrea); Department of Neurology, Medical Collegeof Wisconsin, Milwaukee (Dr McCrea); NeurosurgeryService, Emerson Hospital, Concord, Mass(Dr Cantu); Chicago Neurological Institute (D
Abstract: Departments of Exercise andSport Science (Drs Guskiewicz and Cantu), Ortho-paedics (Drs Guskiewicz and Marshall), and Epidemi-ology (Dr Marshall), and Injury Prevention ResearchCenter (Drs Guskiewicz and Marshall), University ofNorth Carolina at Chapel Hill; Neuroscience Center,Waukesha Memorial Hospital, Waukesha, Wis (DrMcCrea); Department of Neurology, Medical Collegeof Wisconsin, Milwaukee (Dr McCrea); NeurosurgeryService, Emerson Hospital, Concord, Mass(Dr Cantu); Chicago Neurological Institute (Drs Ran-dolph and Kelly) and Department of Neurology,Northwestern University Feinberg School of Medicine(Dr Kelly), Chicago, Ill; Department of Neurology,Loyola University Medical School, Maywood, Ill (DrRandolph); Department of Neurology, New YorkUniversity School of Medicine, New York (Dr Barr);and Department of Rehabilitation Sciences AthleticTraining Program, Sargent College of Health andRehabilitation Sciences, Boston University, Boston,Mass (Dr Onate).
1,439 citations
References
More filters
TL;DR: The authors studied 538 patients who had sustained minor head trauma, which was defined as a history of unconsciousness of 20 minutes or less, a Glasgow Coma Scale score of 13 to 15, and hospitalization not exceeding 48 hours.
Abstract: The authors studied 538 patients who had sustained minor head trauma, which was defined as a history of unconsciousness of 20 minutes or less, a Glasgow Coma Scale score of 13 to 15, and hospitalization not exceeding 48 hours. Of these patients, 424 were evaluated 3 months after injury. The follow-u
1,005 citations
TL;DR: Assessment of standing balance is essential to the treatment of instability in the neurologic patient and the development of clinical techniques for evaluating instability is dependent on a thorough understanding of sensory and motor processes underlying normal balance control.
Abstract: Assessment of standing balance is essential to the treatment of instability in the neurologic patient. The development of clinical techniques for evaluating instability is dependent on a thorough understanding of sensory and motor processes underlying normal balance control. Motor processes in balance control coordinate the action of trunk and leg muscles into discrete synergies that minimize sway and maintain the body's center of mass within its base of support.1,2
Sensory processes in balance control involve interaction among orientation inputs from somatosensory (proprioceptive, cutaneous, and joint), visual, and vestibular systems. Despite the availability of multiple sensory inputs, the central nervous system generally relies on only one sense at a time for orientation information.3 For healthy adults, the preferred sensory input for the control of balance is somatosensory information from the feet in contact with the support surface.…
948 citations
TL;DR: This review will provide a framework for clinical management of the patient with mild TBI, and the clinical deficits caused by the neurologic injury can be understood as manifestations of impaired attention.
Abstract: Mild traumatic brain injury (TBI) is one of the most common neurologic disorders, with only migraine and herpes zoster having higher incidences and only migraine having a higher preva1ence.l Most patients with mild TBI recover within weeks to months without specific intervention, but at 1 year after injury approximately 15% of patients still have disabling symptom^.^^^ The incidence of mild TBI patients who will be persistently symptomatic is approximately 27/100,000, estimated as 15% of 180/100,000 mild TBI incidence.l This is equal to the annual incidence of Parkinson’s disease (20/100,000), multiple sclerosis (3/100,000), Guillain-Barre syndrome (2/100,000), motor neuron disease (2/100,000), and myasthenia gravis (0.4/100,000) combinedl (27.4/100,000). The modal persistently symptomatic patient is a man in his 20s or 30s. Only myasthenia gravis has a similar preponderance of young patients. Since mild TBI does not affect life expectancy, this generally young cohort potentially faces decades of disability. Postgraduate teaching in neurology does not mirror the high prevalence of this disorder-ie, most residents probably do not get proportionate instruction in the diagnosis and management of mild TBI. There are many reasons for this apparent failure to consider such a common disorder. First, treatment of the acute phase is not usually provided by neurologists but rather by neurosurgeons, emergency room physicians, and primary care physicians. Second, most patients get better on their own. Third, the persistently symptomatic patients are often viewed-sometimes correctly-as unpleasant clinical assignments; litigation, compensation, and suspicion of malingering (or at least exaggerating) often accompany them. Fourth, there are frequently vaguely specified psychological issues that seem to-and often do-impede straightforward treatment. Fifth, the disorder is not intellectually compelling when compared with drug management of complex Parkinson’s disease, plasmapheresis, or modern treatment of multiple sclerosis. Sixth, there is no academic reward from these patients; review of the three major American neurology journals from 1990 to 1992 revealed only one article4 on mild TBI, and that article described the effect of mild TBI on the natural history of Parkinson’s disease. The clinical phenomenology of mild TBI follows coherently from the neuropathology. The clinical deficits caused by the neurologic injury can be understood as manifestations of impaired attention. The natural course of recovery can be anticipated. The associated injuries that contribute symptoms to the clinical picture have reasonably specific treatments. The risk factors for developing persistent symptoms can be recognized. Recognition and appropriate management of the risk factors may block development of chronic disability. This review will provide a framework for clinical management of the patient with mild TBI.
885 citations
TL;DR: Players who sustained one concussion in a season were three times more likely to sustain a second concussion in the same season compared with uninjured players, and contact with artificial turf appears to be associated with a more serious concussion than contact with natural grass.
Abstract: Despite evolutionary changes in protective equipment, head injury remains common in football. We investigated concussion in football and associated epidemiologic issues such as 1) incidence of injury, 2) common signs and symptoms, and 3) patterns in making return-to-play decisions. We received 242 of 392 surveys (62%) that were sent to high school and collegiate certified athletic trainers at the beginning of three football seasons. Of the 17,549 football players represented, 888 (5.1%) sustained at least one concussion, and 131 (14.7% of the 888) sustained a second injury during the same season. The greatest incidence of concussion was found at the high school (5.6%) and collegiate division III (5.5%) levels, suggesting that there is an association between level of play and the proportion of players injured. Players who sustained one concussion in a season were three times more likely to sustain a second concussion in the same season compared with uninjured players. Contact with artificial turf appears to be associated with a more serious concussion than contact with natural grass. Only 8.9% of all injuries involved loss of consciousness, while 86% involved a headache. Overall, 30.8% of all players sustaining a concussion returned to participation on the same day of injury.
874 citations
TL;DR: It is suggested that neuropsychological assessment is a useful indicator of cognitive functioning in athletes and that both history of multiple concussions and learning disability are associated with reduced cognitive performance.
Abstract: ContextDespite the high prevalence and potentially serious outcomes associated
with concussion in athletes, there is little systematic research examining
risk factors and short- and long-term outcomes.ObjectivesTo assess the relationship between concussion history and learning disability
(LD) and the association of these variables with neuropsychological performance
and to evaluate postconcussion recovery in a sample of college football players.Design, Setting, and ParticipantsA total of 393 athletes from 4 university football programs across the
United States received preseason baseline evaluations between May 1997 and
February 1999. Subjects who had subsequent football-related acute concussions
(n=16) underwent neuropsychological comparison with matched control athletes
from within the sample (n=10).Main Outcome MeasuresClinical interview, 8 neuropsychological measures, and concussion symptom
scale ratings at baseline and after concussion.ResultsOf the 393 players, 129 (34%) had experienced 1 previous concussion
and 79 (20%) had experienced 2 or more concussions. Multivariate analysis
of variance yielded significant main effects for both LD (P<.001) and concussion history (P=.009),
resulting in lowered baseline neuropsychological performance. A significant
interaction was found between LD and history of multiple concussions and LD
on 2 neuropsychological measures (Trail-Making Test, Form B [P=.007] and Symbol Digit Modalities Test [P=.009]),
indicating poorer performance for the group with LD and multiple concussions
compared with other groups. A discriminant function analysis using neuropsychological
testing of athletes 24 hours after acute in-season concussion compared with
controls resulted in an overall 89.5% correct classification rate.ConclusionsOur study suggests that neuropsychological assessment is a useful indicator
of cognitive functioning in athletes and that both history of multiple concussions
and LD are associated with reduced cognitive performance. These variables
may be detrimentally synergistic and should receive further study.
835 citations