Recovery of cognitive and dynamic motor function following concussion
TL;DR: In order to fully examine the effects of concussion and determine the optimal time for a safe return to activity, a multi-factorial approach, including both cognitive and motor tasks, should be employed.
Abstract: Objective: Neuropsychological testing has been advocated as an important tool of proper post-concussion management. Although these measures provide information that can be used in the decision of when to return an individual to previous levels of physical activity, they provide little data on motor performance following injury. The purpose of this investigation was to examine the relationship between measures of dynamic motor performance and neuropsychological function following concussion over the course of 28 days. Methods: Participants completed two experimental protocols: gait stability and neuropsychological testing. The gait stability protocol measured whole-body centre of mass motion as subjects walked under conditions of divided and undivided attention. Neuropsychological testing consisted of a computerised battery of tests designed to assess memory, reaction time, processing speed and concussion symptoms. Correlation coefficients were computed between all neuropsychological and gait variables and comparisons of neuropsychological and gait stability post-concussion recovery curves were assessed. Results: Dynamic motor tasks, such as walking under varying conditions of attention, are complex and demanding undertakings, which require a longer recovery time following a concussion than cognitive measures. Little statistical relationship was found between the neuropsychological and gait variables, and the recovery curves of neuropsychological and gait domains were observed to be independent. Conclusions: In order to fully examine the effects of concussion and determine the optimal time for a safe return to activity, a multi-factorial approach, including both cognitive and motor tasks, should be employed.
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TL;DR: The focus of this review is on the current status of PPCS as a clinical entity from the perspective of recent advances in the biomechanical modeling of concussion in human and animal studies, particularly directed at a better understanding of the neuropathology associated with concussion.
Abstract: On the mild end of the acquired brain injury spectrum, the terms concussion and mild traumatic brain injury (mTBI) have been used interchangeably, where persistent post-concussive syndrome (PPCS) has been a label given when symptoms persist for more than three months post-concussion. Whereas a brief history of concussion research is overviewed, the focus of this review is on the current status of PPCS as a clinical entity from the perspective of recent advances in the biomechanical modeling of concussion in human and animal studies, particularly directed at a better understanding of the neuropathology associated with concussion. These studies implicate common regions of injury, including the upper brainstem, base of the frontal lobe, hypothalamic-pituitary axis, medial temporal lobe, fornix, and corpus callosum. Limitations of current neuropsychological techniques for the clinical assessment of memory and executive function are explored and recommendations for improved research designs offered, that may enhance the study of long-term neuropsychological sequelae of concussion. (JINS, 2008, 14, 1–22.)
401 citations
Cites background or methods from "Recovery of cognitive and dynamic m..."
..., & Povlishock, J.T. (2005). Myelinated and unmyelinated axons of the corpus callosum differ in vulnerability and functional recovery following traumatic brain injury. Experimental Neurology, 196, 126–137. Ropper, A.H. & Gorson, K.C. (2007). Clinical practice. Concussion. New England Journal of Medicine, 356, 166–172. Ross, S.R., Putnam, S.H., & Adams, K.M. (2006a). Psychological disturbance, incomplete effort, and compensation-seeking status as predictors of neuropsychological test performance in head injury....
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..., & Povlishock, J.T. (2005). Myelinated and unmyelinated axons of the corpus callosum differ in vulnerability and functional recovery following traumatic brain injury....
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..., & Povlishock, J.T. (2005). Myelinated and unmyelinated axons of the corpus callosum differ in vulnerability and functional recovery following traumatic brain injury. Experimental Neurology, 196, 126–137. Ropper, A.H. & Gorson, K.C. (2007). Clinical practice. Concussion. New England Journal of Medicine, 356, 166–172. Ross, S.R., Putnam, S.H., & Adams, K.M. (2006a). Psychological disturbance, incomplete effort, and compensation-seeking status as predictors of neuropsychological test performance in head injury. Journal of Clinical Experimental Neuropsychology, 28, 111–125. Ross, S.R., Putnam, S.H., Millis, S.R., Adams, K.M., & Krukowski, R.A. (2006b). Detecting insufficient effort using the Seashore Rhythm and Speech-Sounds Perception Tests in head injury. Clinical Neuropsychology, 20, 798–815. Roy, K., Murtie, J.C., El-Khodor, B.F., Edgar, N., Sardi, S.P., Hooks, B.M., Benoit-Marand, M., Chen, C., Moore, H., O’Donnell, P., Brunner, D., & Corfas, G. (2007). Loss of erbB signaling in oligodendrocytes alters myelin and dopaminergic function, a potential mechanism for neuropsychiatric disorders....
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..., & Povlishock, J.T. (2005). Myelinated and unmyelinated axons of the corpus callosum differ in vulnerability and functional recovery following traumatic brain injury. Experimental Neurology, 196, 126–137. Ropper, A.H. & Gorson, K.C. (2007). Clinical practice. Concussion. New England Journal of Medicine, 356, 166–172. Ross, S.R., Putnam, S.H., & Adams, K.M. (2006a). Psychological disturbance, incomplete effort, and compensation-seeking status as predictors of neuropsychological test performance in head injury. Journal of Clinical Experimental Neuropsychology, 28, 111–125. Ross, S.R., Putnam, S.H., Millis, S.R., Adams, K.M., & Krukowski, R.A. (2006b). Detecting insufficient effort using the Seashore Rhythm and Speech-Sounds Perception Tests in head injury....
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...Assessment in sports concussion has recognized the need to move beyond traditional neuropsychological assessment with the development of more tailored assessment tools in the athlete with concussion (Broglio et al., 2007; Parker et al., 2007)....
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TL;DR: Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest, indicating that vestibular Rehabilitation may equally benefit both children and adults.
Abstract: Background and Purpose: Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion. Methods: A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8 –18 years]; 47 adults older than 18 years [mean, 41 years; range, 19 –73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures. Results: The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P .05). Children improved by a greater amount in dizziness severity (P .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P .025). Discussion: Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults.
387 citations
TL;DR: Assessment of neurocognitive function and balance can provide clinicians with an additional piece of the concussion puzzle, remove some of the guesswork in uncovering less obvious symptoms, and assist in determining readiness to return safely to participation.
252 citations
TL;DR: There is evidence to suggest that cognitive or motor-cognitive methods positively affects physical functioning, such as postural control, walking abilities and general functions of the upper and lower extremities, respectively, in older adults over the age of 65.
Abstract: Several types of cognitive or combined cognitive-motor intervention types that might influence physical functions have been proposed in the past: training of dual-tasking abilities, and improving cognitive function through behavioral interventions or the use of computer games. The objective of this systematic review was to examine the literature regarding the use of cognitive and cognitive-motor interventions to improve physical functioning in older adults or people with neurological impairments that are similar to cognitive impairments seen in aging. The aim was to identify potentially promising methods that might be used in future intervention type studies for older adults. A systematic search was conducted for the Medline/Premedline, PsycINFO, CINAHL and EMBASE databases. The search was focused on older adults over the age of 65. To increase the number of articles for review, we also included those discussing adult patients with neurological impairments due to trauma, as these cognitive impairments are similar to those seen in the aging population. The search was restricted to English, German and French language literature without any limitation of publication date or restriction by study design. Cognitive or cognitive-motor interventions were defined as dual-tasking, virtual reality exercise, cognitive exercise, or a combination of these. 28 articles met our inclusion criteria. Three articles used an isolated cognitive rehabilitation intervention, seven articles used a dual-task intervention and 19 applied a computerized intervention. There is evidence to suggest that cognitive or motor-cognitive methods positively affects physical functioning, such as postural control, walking abilities and general functions of the upper and lower extremities, respectively. The majority of the included studies resulted in improvements of the assessed functional outcome measures. The current evidence on the effectiveness of cognitive or motor-cognitive interventions to improve physical functioning in older adults or people with neurological impairments is limited. The heterogeneity of the studies published so far does not allow defining the training methodology with the greatest effectiveness. This review nevertheless provides important foundational information in order to encourage further development of novel cognitive or cognitive-motor interventions, preferably with a randomized control design. Future research that aims to examine the relation between improvements in cognitive skills and the translation to better performance on selected physical tasks should explicitly take the relation between the cognitive and physical skills into account.
167 citations
Cites background from "Recovery of cognitive and dynamic m..."
...The patterns of cognitive decline observed in patients after traumatic brain injury resembles that of classic aging processes [35,39,40]....
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TL;DR: Sport concussions were associated with pervasive changes in postural control and more M1 intracortical inhibition, providing neurophysiologic and behavioral evidence of lasting, subclinical changes in motor system integrity in concussed athletes.
Abstract: Context: The known detrimental effects of sport concussions on motor system function include balance problems, slowed motor execution, and abnormal motor cortex excitability. Objective: To assess whether these concussion-related alterations of motor system function are still evident in collegiate football players who sustained concussions but returned to competition more than 9 months before testing. Design: Case-control study. Setting: University laboratory. Patients or Other Participants: A group of 21 active, university-level football players who had experienced concussions was compared with 15 university football players who had not sustained concussions. Intervention(s): A force platform was used to assess center-of-pressure (COP) displacement and COP oscillation regularity (approximate entropy) as measures of postural stability in the upright position. A rapid alternating-movement task was also used to assess motor execution speed. Transcranial magnetic stimulation over the motor cortex was used to ...
164 citations
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TL;DR: The 2nd International Symposium on Concussion in Sport was organised by the same group and held in Prague, Czech Republic in November 2004 and resulted in a revision and update of the Vienna consensus recommendations, which are presented here.
Abstract: In November 2001, the 1st International Symposium on Concussion in Sport was held in Vienna, Austria to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, football (soccer), and other sports. The 2nd International Symposium on Concussion in Sport was organised by the same group and held in Prague, Czech Republic in November 2004. It resulted in a revision and update of the Vienna consensus recommendations, which are presented here.
866 citations
TL;DR: The Concussion in Sport Group (CISG) as discussed by the authors is a group of experts from epidemiology, basic and clinical science, grading systems, cognitive assessment, new research methods, protective equipment, management, prevention, and long term outcome.
Abstract: Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries
In November 2001, the first International Symposium on Concussion in Sport was held in Vienna, Austria. This symposium was organised by the International Ice Hockey Federation (IIHF), the Federation Internationale de Football Association Medical Assessment and Research Centre (FIFA, F-MARC), and the International Olympic Committee Medical Commission (IOC).
The aim of the symposium was to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, football (soccer), and other sports. To this end a range of experts were invited to address specific issues of epidemiology, basic and clinical science, grading systems, cognitive assessment, new research methods, protective equipment, management, prevention, and long term outcome, and to discuss a unitary model for understanding concussive injury. At the conclusion of the conference, a small group of experts were given a mandate by the conference delegates and organising bodies to draft a document describing the agreement position reached by those in attendance at that meeting. For the purpose of this paper, this group will be called the Concussion in Sport Group (CISG).
This review seeks to summarise the findings of the Vienna conference and to provide a working document that will be widely applicable to sport related concussion. This document is developed for use by doctors, therapists, health professionals, coaches, and other people involved in the care of injured athletes, whether at the recreational, elite, or professional level.
During the course of the symposium, a persuasive argument was made that a comprehensive systematic approach to concussion would be of potential benefit to aid the injured athlete and direct management decisions.1 This protocol represents a work in progress, and, as with all other guidelines or proposals, it must undergo revision …
672 citations
TL;DR: This practice parameter for the management of concussion in sports is not intended to justify boxing as a legitimate sport, nor should it be construed to conflict with the official stance of the American Academy of Neurology, which has called for a ban on boxing.
Abstract: The Quality Standards Subcommittee of the American Academy of Neurology is charged with developing guidelines for neurologists for diagnostic procedures, treatment modalities, and clinical disorders. The selection of topics for which practice parameters are developed is based on the prevalence, frequency of use, economic impact, membership need, controversy, urgency, external constraints, and resources required. Based upon the quality of the evidence, the Quality Standards Subcommittee determines whether the parameter is a standard, guideline, or option.
By training and knowledge, neurologists and neurosurgeons are qualified to develop and disseminate guidelines for managing the athlete who suffers a concussion in sports. Questions addressed during neurologic or neurosurgical consultation for sports-related concussion require advice to the patient that is guided by neuroscience and the consensus of experts, rather than local lore and individual opinion. Most importantly, consultation to prevent catastrophic outcome and cumulative neurobehavioral deficits from repeated concussions can best be provided by the well-informed physician. This practice parameter is based on a background paper [1] written by James P. Kelly, MD, and Jay H. Rosenberg, MD, and on sports concussion guidelines published by the Colorado Medical Society. [2] This practice parameter for the management of concussion in sports is not intended to justify boxing as a legitimate sport, nor should it be construed to conflict with the official stance of the American Academy of Neurology, which has called for a ban on boxing.
Concussion, a common consequence of trauma to the head in contact sports, can also occur from collisions or falls in all forms of athletic activity. Close observation and assessment of the injured athlete could be critical to the prevention of catastrophic brain injury [3-5] and cumulative neuropsychological deficits. [6-8] Repeated concussions can cause cumulative brain injury in an individual injured over months or years. The problem faced by the …
637 citations
TL;DR: The 2nd International Symposium on Concussion in Sport was organised by the same group and held in Prague, Czech Republic in November 2004 and resulted in a revision and update of the Vienna consensus recommendations, which are presented here.
Abstract: In November 2001, the 1st International Symposium on Concussion in Sport was held in Vienna, Austria to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, football (soccer), and other sports. The 2nd International Symposium on Concussion in Sport was organised by the same group and held in Prague, Czech Republic in November 2004. It resulted in a revision and update of the Vienna consensus recommendations, which are presented here.
618 citations
TL;DR: Acute effects (within 24 hr of injury) of concussion were greatest for delayed memory, memory acquisition, and global cognitive functioning, but no residual neuropsychological impairments were found when testing was completed beyond 7 days postinjury.
Abstract: There is increasing interest in the potential neuropsychological impact of sports-related concussion. A meta-analysis of the relevant literature was conducted to determine the impact of sports-related concussion across six cognitive domains. The analysis was based on 21 studies involving 790 cases of concussion and 2014 control cases. The overall effect of concussion (d = 0.49) was comparable to the effect found in the non-sports-related mild traumatic brain injury population (d = 0.54; Belanger et al., 2005). Using sports-concussed participants with a history of prior head injury appears to inflate the effect sizes associated with the current sports-related concussion. Acute effects (within 24 hr of injury) of concussion were greatest for delayed memory, memory acquisition, and global cognitive functioning (d = 1.00, 1.03, and 1.42, respectively). However, no residual neuropsychological impairments were found when testing was completed beyond 7 days postinjury. These findings were moderated by cognitive domain and comparison group (control group versus preconcussion self-control). Specifically, delayed memory in studies utilizing a control group remained problematic at 7 days. The implications and limitations of these findings are discussed.
511 citations