A systematic review, The Concussion Recognition Tool 5th Edition (CRT5): background and rationale, The Sport Concussion Assessment Tool 5th Edition (SCAT5): background and rationale, Cervical spine dysfunction following pediatric sports-related head trauma, A systematic review of psychiatric, psychological, and behavioural outcomes following mild traumatic brain injury in children and adolescents, What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review, Detecting gait abnormalities after concussion or mild traumatic brain injury: a systematic review of single-task, dual-task, and complex gait, Active rehabilitation for children who are slow to recover following sport-related concussion, A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion, Helmet fit assessment and concussion risk in youth ice hockey players ages 11–18 years [abstract], Attention problems as a risk factor for concussion in youth ice-hockey players [abstract], Concussions among United States high school and collegiate athletes, Inadequate helmet fit increases concussion severity in American high school football players, Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline, The International Classification of Headache Disorders, 3rd edition, Contact technique and concussions in the South African under-18 Coca-Cola Craven Week Rugby tournament, Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial, Mild traumatic brain injury among a cohort of rugby union players: predictors of time to injury, Is there a relationship between whiplash-associated disorders and concussion in hockey? In some cases, targeted rehabilitation (eg, vestibular rehabilitation, cervical spine rehabilitation, subsymptom threshold aerobic exercise) is warranted.106 In other cases, further medical investigations, referral to additional interdisciplinary health care professionals, or referral for interdisciplinary care may be required (FIGURE 4). Symptoms may be reported by the player, such as headaches, dizziness, nausea, sensitivity to light or noise, fatigue, and feeling as though in a fog. This model considers the implications of repeated exposure, whether such exposure produces adaptation, maladaptation, injury or complete/incomplete recovery from injury. American Medical Society for Sports Medicine position statement: concussion in sport. A systematic review, Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York, Sleep quantity and quality during acute concussion: a pilot study, Cervicocephalic kinesthetic sensibility in patients with cervical pain, Trigger point injections for headache disorders: expert consensus methodology and narrative review, Association of returning to work with better health in working-aged adults: a systematic review, Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline, Are clinical measures of cervical spine strength and cervical flexor endurance risk factors for concussion in elite youth ice hockey players? Sports injuries aetiology investigations have assumed a reductionist view in which a phenomenon has been simplified into units and analysed as the sum of its basic parts and causality has been seen in a linear and unidirectional way. as well as cognitive, emotional. Treatment of sleep disorders often includes pharmacological and nonpharmacological management.123,124 Education regarding sleep hygiene may improve sleep quality. Headaches are the most frequent symptom following concussion. In part 2, we address concussion assessment and management. A preliminary study, Predictors of clinical recovery from concussion: a systematic review, Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients, A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache, Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test, GH and pituitary hormone alterations after traumatic brain injury, Epidemiology of football injuries in the National Collegiate Athletic Association, 2004–2005 to 2008–2009, Concussion symptoms and return to play time in youth, high school, and college American football athletes, Dual-task assessment protocols in concussion assessment: a systematic literature review, Noninvasive brain stimulation for persistent postconcussion symptoms in mild traumatic brain injury, Sensorimotor function and dizziness in neck pain: implications for assessment and management, Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: an exploratory randomized clinical trial, Neuroendocrine dysfunction in a young athlete with concussion: a case report, Pain and sleep in post-concussion/mild traumatic brain injury, Brain or strain? Br J Sports Med. J Orthop Sports Phys Ther. In this section, we summarize the key intrinsic and extrinsic risk factors for concussion. Combining specific exercises with manual therapy is effective for treating cervical spine pain.54 After concussion, include neuromotor control, sensorimotor control, manual therapy, and soft tissue techniques, in combination with vestibular rehabilitation.106 A sequential approach to addressing headaches and cervical spine findings (including neuromotor control) as an initial step of rehabilitation is appropriate, given the connections between the upper cervical spine and the vestibular and visual systems. Diagnosis directs appropriate management. Irritability, sadness, anxiety, and feeling more emotional than normal are often reported following concussion, although they may not be acute.58 The psychological response to concussion may be similar to that to musculoskeletal injury, and improves over time.121 Some adults may have generalized anxiety disorder, panic attacks, and posttraumatic stress disorder following injury, which may reflect a new diagnosis or an exacerbation of a previous condition.128 Anxiety and depression are more common in women than in men, and may predict a longer recovery.52,109 Ongoing psychological or psychiatric problems are rare in children and youth without preinjury problems.31 Management of mental health problems will depend on the specific diagnosis (eg, pharmacological or psychological treatment). Each individual can present with a unique set of symptoms and aggravating or relieving factors following concussion.84 Individualized assessments are imperative to best understand the etiology of symptoms.37,78,102,106 A multifaceted, interdisciplinary approach to assessment and management is vital. doi:10.2519/jospt.2019.8926, Sport-related concussion is among the most frequently reported injuries in sport and recreation.80 A sport-related concussion is “a traumatic brain injury induced by biomechanical forces.”84 Symptoms and signs that occur following a concussion are believed to represent a functional rather than structural injury, as structural neuroimaging studies do not detect abnormalities.84 Recovery can occur in the initial days to weeks for most adults, but up to one third of children and youth may take longer than 4 weeks to recover.108,127. The purpose of this clinical commentary was to summarize prevention, detection, assessment, and treatment factors that affect individuals across the continuum of concussion care, using the dynamic, recursive model of sport injury88 framework. In many cases, medical management is required; for some headache types, such as cervicogenic headaches, physical therapy may be of benefit.54,125 Botulinum toxin injection can be considered for posttraumatic chronic migraine headaches.24 Repetitive transcranial magnetic stimulation may be effective in the treatment of posttraumatic headache.60,69,70 Often, a multimodal approach to headache management includes both acute and prophylactic medication. Introduction 3 It is important for sports professionals to know why certain athletes may be at risk of injury risk factors and how injuries occur (i… injury leading to either return to competition or a period of absence from competition. [abstract], Sport-related concussion: optimizing treatment through evidence-informed practice, Rest and treatment/rehabilitation following sport-related concussion: a systematic review, Cervicovestibular rehabilitation following sport-related concussion [letter], Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players, Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial, Changes in measures of cervical spine function, vestibulo-ocular reflex, dynamic balance, and divided attention following sport-related concussion in elite youth ice hockey players, Concussion burden, recovery, and risk factors in elite youth ice hockey players, Prevalence of and risk factors for anxiety and depressive disorders after traumatic brain injury: a systematic review, Near point of convergence after concussion in children, Vestibular rehabilitation is associated with visuovestibular improvement in pediatric concussion, Individuals with pain need more sleep in the early stage of mild traumatic brain injury. If symptoms persist following the initial days to weeks following injury, a multifaceted assessment to identify areas that may require rehabilitation is warranted.37,65,78,103 Refer the patient for additional assessment and rehabilitation if the individual has not recovered in the 10 to 14 days following injury. A great number of injuries occur in the context of recreational physical activities and competitive athletics. Adapting the dynamic, recursive model of sport injury to concussion: an individualized approach to concussion prevention, detection, assessment, and treatment - Schneider KJ, Emery CA, Black A, Yeates KO, Debert CT, Lun V, Meeuwisse WH. Thus, consideration of sport-specific skills should be an integral part of a rehabilitation program. You can not learn DP without knowing recursion.Before getting into the dynamic programming lets learn about recursion.Recursion is a These factors may change over time. Emotional Responses to Athletic Injury Questionnaire. In youth rugby players, there was a reduction in overall risk of game-related concussion when a neuromuscular training program was performed at least 3 times weekly.49 A vision training program may reduce the risk of concussion in collegiate football players.18 There was a 67% reduction in the risk of concussion in youth ice hockey following rule changes to disallow bodychecking.32 Tackle training and rules related to tackling in rugby as a way of decreasing risk of concussion are areas of ongoing evaluation.47 Finally, restricting the number of collision practices in youth football may reduce the frequency of head impacts in games and practice.14. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. A dynamic, recursive model of etiology in sport injury. . In addition, decisions regarding return to sport may be affected by the intrinsic and extrinsic factors that characterize the individual athlete. Interventions Can Mitigate Risk The protective effects of helmets in reducing the risk of more severe traumatic brain injury are well documented,76 as is the protective effect of mouthguards in reducing orofacial injury. Evidence for cognitive remediation following concussion is very limited. Neurological examination, assessment of vestibulo-ocular reflex function, static balance, dynamic balance, assessment of nystagmus with and without fixation, positional testing, and vestibular function testing can inform diagnosis and management. Considerations for Diagnosis and Management of Concussion. During sport, athletes are exposed to different events in which no concussion or injury occurs. ERAIQ. E-mail: The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). The Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary is one of eleven International Research Centres supported by the International Olympic Committee for Prevention of Injury and Protection of Athlete Health. Evaluating the dynamic model of psychological response to sport injury and rehabilitation Diane M. Wiese-Bjornstal , Courtney B. Albinson, Shaine E. Henert, Elizabeth A. Arendt , Susan J. Schwenz, Shelly S. Myers, Diane M. Gardetto-Heller The return-to-school protocol includes 4 steps: (1) daily activities that do not provoke symptoms, (2) school activities outside of school, (3) part-time return to school, and (4) full-time return to school (FIGURE 3).29,84 To facilitate return to school, a medical letter including recommendations for individual accommodations is recommended.94 Accommodations at school may include reduced hours at school, more time to complete assignments and examinations, frequent breaks, reduced screen time, and working in a quiet area.21 Return to school should occur before return to contact activity or full competition. 2019 Nov;49(11):799-810. doi: 10.2519/jospt.2019.8926. Clinicians should use a multifaceted assessment that includes symptoms, a neurological screen, and assessment of multiple clinical domains.27,37 The Sport Concussion Assessment Tool Fifth Edition (SCAT5)29 includes an immediate/on-field assessment that incorporates red flags, observable signs, memory assessment (ie, the Maddocks questions), the Glasgow Coma Scale, and a cervical spine assessment. Cognitive symptoms can include difficulties remembering and concentrating, slowed processing, decreased attention, and difficulty with learning.58,86 Cognitive symptoms often resolve over the initial days to weeks following injury. The duration of a dizziness episode can also provide a clue as to the source of dizziness following concussion. Sports physiotherapists and other sports professionals recognise that the identification of the causes of injury is an important step in injury prevention as this can lead to the development of effective injury prevention programs. Pituitary dysfunction after traumatic brain injury: a clinical and pathophysiological approach, Hypopituitarism due to sports related head trauma and the effects of growth hormone replacement in retired amateur boxers, Pituitary function in subjects with mild traumatic brain injury: a review of literature and proposal of a screening strategy, Gender differences in head–neck segment dynamic stabilization during head acceleration, Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain, Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma, Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: a prospective randomized study comparing three exercise programs, Comparison of psychological response between concussion and musculoskeletal injury in collegiate athletes, Incidence, severity, aetiology and prevention of sports injuries. Neuroendocrine dysfunction, caused by injury to the hypothalamic-pituitary axis following mild to severe traumatic brain injury5,6,90,114 and sport-related concussion,72,113,114,116 has been reported. Integrated Model of Psychological Responses to Sport Injury. NIH Injury prediction is one of the most challenging issues in sports and a key component for injury prevention. Individuals with visual symptoms following concussion may benefit from accommodations to enable earlier return to school or work in a less visually provocative environment (eg, printed materials rather than electronic, change in contrast on a screen).94 Frequent breaks, pacing of activities, and working in a quieter environment may facilitate return to function. USA.gov. An integrated model is illustrated which provides a syn- thesis of existing conceptual models depicting the dynamic process of psycholog- ical response to sport injury. and behavioral responses of athletes to sport injury. 49, No. A DYNAMIC, RECURSIVE MODEL OF SPORT INJURY In a real life sporting environment, a participant’s risks are dynamic and can change frequently. Keywords: Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. This model builds on the previous work, while emphasizing the fact that adaptations occur within the context of sport (both in the presence and absence of injury) that alter risk and affect etiology in a dynamic, recursive fashion. Intrinsic Risk Factors for Concussion Intrinsic risk factors may be modifiable (such as neuromuscular or sensorimotor control) or nonmodifiable (such as previous history of concussion, sex, age, and genetics). Sport-specific and performance-related skills may be necessary to return to full participation. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. A systematic review, Risk of injury associated with body checking among youth ice hockey players, Injury rates, risk factors, and mechanisms of injury in minor hockey, Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice, What domains of clinical function should be assessed after sport-related concussion? In part 1 of this commentary, we address etiology, risk factors, and detection of concussion.  |  Sometimes, cognitive symptoms persist and may be associated with ongoing difficulties with school and with occupational, sport, and social activities.86 Cognitive symptoms often occur in the presence of other symptoms, such as pain, headaches, difficulties with vision, and sleep problems.87 Referral to a neuropsychologist may be warranted for a thorough assessment to clarify the etiology of the cognitive complaints and to assist in developing an individualized management plan. Blurred vision, double vision, and difficulty reading may be reported following a concussion. Return to school and return-to-sport strategies can occur simultaneously.84 Each step of the return-to-school and return-to-sport protocols should take a minimum of 24 hours. In other cases, findings suggest that central vestibular involvement may be present. a dynamic, recursive model for risk and causes of sports injuries, considering that the injury has a non-linear behavior. 11. Individual athletes have their own risk factors that predispose them to concussion (FIGURE 1). Add to My Bookmarks Export citation. A multifaceted assessment for each patient should include postconcussive symptom reports; a neurological screen; assessment of cervical spine, vestibular, visual, and exertion-related symptoms; plus sleep, mood, cognitive, and related domains. Findings of convergence insufficiency have been identified in children following concussion; however, further research is needed to identify whether these deficits are pre-existing or have their onset following trauma. 1, pp. The initial management of concussion involves both cognitive and physical rest for the first 24 to 48 hours following injury.84,103 After this time, gradually and progressively increase activities of daily living, as long as symptoms do not increase.84,103 Once concussion-related symptoms have resolved with typical activities, gradually resume physical and cognitive activities (FIGURE 2). Get the latest public health information from CDC: https://www.coronavirus.gov. For individuals with ongoing dizziness, neck pain, and headaches, cervicovestibular physical therapy can be beneficial.103,104,106 Sport-specific training, related to the context in which the individual would be participating, should form an integral part of the rehabilitation program.106 For children and adolescents with visual and vestibular findings, vestibular rehabilitation may be of benefit.111 In addition, low-level aerobic exercise may promote recovery following concussion.40,62,67, Collaborative care, including cognitive-behavioral therapy, care management, and psychopharmacological evaluation, has positive effects on symptom reduction after 6 months.83 An active approach to rehabilitation, including aerobic exercise, visualization, and coordination, has positive effects on symptoms and function.39,40 Future research to best understand timing, order, frequency, and other parameters of combination treatments is warranted.103. Recursion and dynamic programming (DP) are very depended terms. There may be alterations in gait, reduced gait velocity, and increased sway when dividing attention following concussion.38,59 Further research to better understand changes in the ability to divide attention while accounting for growth and development is warranted. Ericsson, K. A. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of ... Issue 3 Page start 215 Page end 219 DOI 10.1097/JSM.0b013e3180592a48 Is part of Journal Title Clinical Journal of Sport Medicine ISSN 1050-642X Short title Clinical Journal of Sport Medicine. Clipboard, Search History, and several other advanced features are temporarily unavailable. Symptoms are often provoked with rapid head motions, and blurred vision may be reported in association with head movement (suggesting altered vestibulo-ocular reflex dysfunction). 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941. In the presence of ongoing cervical spine findings, further interventional procedures, such as comparative controlled medial branch blocks (to confirm facet joint–mediated pain), trigger point injections (in the presence of ongoing myofascial pain), and greater occipital nerve blockades (in the presence of greater occipital neuralgia), may be considered.26,98, Dizziness is typically the second most common symptom following concussion.7 As with headache, identifying the source of dizziness is important to direct treatment—some disorders respond well to physical therapy (eg, benign paroxysmal positional vertigo [BPPV], unilateral peripheral vestibular hypofunction), while others require medical evaluation and management (eg, superior semicircular canal dehiscence).2,45,48. Interventions aimed at primary prevention have shown promise in decreasing the risk of concussion. Injury frequently occurs in a team sport, important for athletes and their sports organizations, financial, physical, and psychological. In addition to a thorough history, targeted assessment tests help clinicians to understand the source of dizziness. HHS Is there a gender difference in concussion incidence and outcomes? In this section, we outline 9 common persistent symptoms following concussion,7,58,106 describe differential diagnoses, and offer an overview of evidence-based rehabilitation approaches. 5-25. Cervical spine pain may be accompanied by cervicogenic headache or cervicogenic dizziness.7,106 Cervical spine findings are common following concussion (eg, impairments following anterolateral strength, the head perturbation test, joint position to the left, or the cervical flexor endurance test).107 Many of the symptoms reported following whiplash are similar to those reported following concussion,51 suggesting that cervical spine injury might have occurred at the same time as the concussion. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation.
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