Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review

Makdissi, Michael; Schneider, Kathryn; Feddermann-Demont, Nina; Guskiewicz, Kevin M.; Hinds, Sidney; Leddy, John J.; McCrea, Michael; Turner, Michael S.; Johnston, Karen

doi:10.1136/bjsports-2016-097470

Cited by 140 publications

(102 citation statements)

References 64 publications

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“…EPIC treatment addresses these two characteristics, largely through aerobic exercise. The work of Leddy et al [24,[89][90][91]93,[99][100][101][102][103] provide support to our proposed theory concerning CVR restoration and ANS re-regulation. Concerning local blood flow regulation, NVC dysregulation significantly contributes to PCS pathology.…”

Section: Resultssupporting

confidence: 80%

“…Upon identification of neural regions of interest showing deficits in NVC, EPIC treatment integrates three fundamental neurocognitive rehabilitation components: Prepare, activate and rest. Therapeutic activities used in each of these three phases are the result of research, clinical experience, screening and empirical testing [88][89][90][91][92][93]. The preparatory stage includes aerobic exercise and neuromuscular therapy, titrated to patients exercise tolerance and lasts 50 min.…”

Section: Enhanced Performance In Cognition (Epic) Treatmentmentioning

confidence: 99%

“…Leddy et al have played a major role in investigating exercise in patients with PCS [24,25,[89][90][91]93,[99][100][101][102][103]. They demonstrated the safety and efficacy of a graduated treadmill exercise test in patients with PCS.…”

Section: Re-regulation Of Ans and CDmentioning

confidence: 99%

“…As previously mentioned, Leddy et al [24,25,[89][90][91]93,[99][100][101][102][103] have played major roles in investigating aerobic exercise in patients with PCS. One study investigated the use of sub-symptomatic threshold aerobic exercise in normalizing some of the physiologic disturbances seen in PCS, particularly BP, minute ventilation (VE), PETCO 2 and CBF velocity (CBFV) measured by transcranial Doppler [101].…”

Section: Restoration Of Cvrmentioning

confidence: 99%

“…Much of our understanding of ANS/CA re-regulation and restoration of CVR through aerobic exercise has been due to the work performed by Leddy et al [24,[89][90][91]93,[99][100][101][102][103]. EPIC treatment seeks to maximize the benefits of aerobic exercise to re-regulate ANS/CA and to restore CVR.…”

Section: Nvc Re-regulationmentioning

confidence: 99%

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Neurovascular Coupling: A Unifying Theory for Post-Concussion Syndrome Treatment and Functional Neuroimaging

Ct¹,

Allen²

2017

J Neurol Neurophysiol

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Post-concussion syndrome (PCS) occurs in a significant percentage of concussion patients and is defined as having a history of traumatic brain injury with persistence of three or more symptoms. Standard structural clinical neuroimaging studies show no abnormal findings for the majority of PCS patients as opposed to functional MRI, which often reveals irregularities in the blood-oxygen level dependent (BOLD) signal. This suggests that dysregulation of neurovascular coupling, which causes abnormal BOLD signals, plays a significant role in PCS pathology. However, compared to the pathophysiologic mechanisms occurring in acute concussion, the underlying neuropathophysiology of chronic concussive sequelaeor PCS is less understood, though becoming clearer with emerging research. We present a treatment approach grounded in the physiological theory presented here called Enhanced Performance in Cognition (EPIC), which has shown strong clinical success. Dysregulation of neurovascular coupling (NVC), along with disruptions in cerebrovascular reactivity (CVR) and autonomic nervous system (ANS) dysregulation are the targets of EPIC treatment. Success of the approach itself tentatively supports the hypothesis that these three features figure prominently in the neuropathophysiology of PCS. The aim of this report is to provide a theory of the underlying mechanisms of PCS pathology and its treatment that is in accord with the current corpus of research and explains the recent therapeutic success seen in PCS patient using the EPIC treatment. We propose a novel theory concerning the mechanisms by which NVC dysregulation is normalized. This includes focused, intense and repetitive neurocognitive challenges during post-exercise cognitive boost and the avoidance of intracerebral steal in the setting of restored and re-regulated CVR and ANS. It is intended that both the theory and treatment approach are presented explicitly enough to generate empirical studies with clear hypothetical predictions from the theory as well as clinical innovations with significant relevance to improve current practices.

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Section: Resultssupporting

confidence: 80%

Section: Enhanced Performance In Cognition (Epic) Treatmentmentioning

confidence: 99%

Section: Re-regulation Of Ans and CDmentioning

confidence: 99%

Section: Restoration Of Cvrmentioning

confidence: 99%

Section: Nvc Re-regulationmentioning

confidence: 99%

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Neurovascular Coupling: A Unifying Theory for Post-Concussion Syndrome Treatment and Functional Neuroimaging

Ct¹,

Allen²

2017

J Neurol Neurophysiol

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Characteristics of Pediatric Mild Traumatic Brain Injury and Recovery in a Concussion Clinic Population

et al. 2020

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IMPORTANCEPediatric mild traumatic brain injury (TBI) and concussion are a public health challenge with up to 30% of patients experiencing prolonged recovery. Pediatric patients presenting to concussion clinics often have ongoing impairments and may be at increased risk for persistent symptoms. Understanding this population is critical for improved prognostic estimates and optimal treatment. OBJECTIVE To describe pediatric patients presenting to concussion clinics and characterize factors associated with their recovery. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included patients enrolled at multicenter concussion specialty clinics from the Four Corners Youth Consortium from December 2017 to July 2019, with up to 12-month follow-up. Patients were eligible if they were aged 5 to 18.99 years with a diagnosis of mild TBI or concussion presenting to participating clinics within 8 weeks of injury. Patients were excluded if the patient or their parents were unable to read or sign the consent document, or if the patient had a Glasgow Coma Scale score less than 13 or a penetrating injury. Data were analyzed from February 2019 to April 2020. EXPOSURES Diagnosis of mild TBI or concussion. MAIN OUTCOMES AND MEASURES This study used National Institute of Neurological Disorders and Stroke common data elements, including data on demographic characteristics, injury details, history, neurological and neuropsychological assessments, and treatment. RESULTS A total of 600 patients were consecutively enrolled, among whom 324 (54.0%) were female and 435 (72.5%) were adolescents (ie, aged 13-18 years). A higher proportion of girls and women (248 patients [76.5%]) were adolescents compared with boys and men (187 patients [67.8%]) (P = .02), and girls and women reported significantly more preexisting anxiety compared with boys and men (80 patients [26.7%] vs 46 patients [18.7%]; P = .03). Significantly more adolescents reported preexisting migraines compared with preadolescents (82 patients [20.9%] vs 15 patients [10.9%]; P = .01). Girls and women recovered more slowly than boys and men (persistent symptoms after injury: week 4, 217 patients [81.6%] vs 156 patients [71.2%]; week 8, 146 patients [58.9%] vs 89 patients [44.3%]; week 12, 103 patients [42.6%] vs 58 patients [30.2%]; P = .01). Patients with history of migraine or anxiety or depression recovered more slowly than those without, regardless of sex.(continued) Key Points Question What factors are associated with recovery in pediatric patients with mild traumatic brain injury or concussion? Findings In this cohort study of 600 pediatric patients presenting to concussion clinics in 3 centers, girls and women experienced slower recovery and were more likely to have preexisting anxiety compared with boys and men. Independent of sex, patients with anxiety or depression or migraine recovered more slowly than those without these comorbidities. Meaning These findings suggest that factors, such as sex and comorbidities, in pediatric patients with mild traumatic brain ...

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Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents

et al. 2021

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IMPORTANCE Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. OBJECTIVE To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. DESIGN, SETTING, AND PARTICIPANTS The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreationalrelated concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. INTERVENTIONS The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. MAIN OUTCOMES AND MEASURES Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parentreported symptoms. RESULTS Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3-to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, −6.6 to −0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, −7.7 to −0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes.

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Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review

Cited by 140 publications

References 64 publications

Neurovascular Coupling: A Unifying Theory for Post-Concussion Syndrome Treatment and Functional Neuroimaging

Neurovascular Coupling: A Unifying Theory for Post-Concussion Syndrome Treatment and Functional Neuroimaging

Characteristics of Pediatric Mild Traumatic Brain Injury and Recovery in a Concussion Clinic Population

Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents

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