Use case 1: Survival analysis a. Pre-injury factors lead to post-injury responses Dynamic Core of Model: Cognitive appraisals, emotional responses, behavioral responses, recovery outcomes. Injury, Illness, and Training Load in a Professional Contemporary Dance Company: A Prospective Study. J Athl Train. Headaches are the most frequent symptom following concussion. doi: 10.1016/j.csm.2007.10.008. Types of models c. Dataset i. Exploratory analysis d. Analysis e. Results f. Summary and exercises 6. Contact and collision sports, such as rugby, American football, and ice hockey, have the highest reported incidence of concussion.93 In youth ice hockey leagues where bodychecking is permitted, there is nearly a 4-fold increase in risk of concussion in the 11- to 12-year age group (Pee Wee).33 Game play has greater concussion risk than practice.1,22,57. Blurred vision, double vision, and difficulty reading may be reported following a concussion. Survival analysis i. Growth hormone is the most commonly affected hormone following concussion.56,63,114,115 Individuals with symptoms consistent with alteration in sex hormones, hypothyroidism, adrenal dysfunction, diabetes insipidus, syndrome of inappropriate antidiuretic hormone secretion, or growth hormone deficiency (fatigue, disrupted sleep patterns, and cognitive difficulties) should be investigated for hypothalamic-pituitary axis dysfunction.114, People with more, and more severe, acute and subacute symptoms take longer to recover following concussion.52 Adolescent age, female sex, the presence of a migraine history, and pre-existing mental health problems are predictors of slower recovery.52 Many other factors (eg, previous history of concussion, preschool age, race, genetics) have been evaluated as potential predictors of longer recovery, with mixed results.52 Attention deficit hyperactivity disorder and learning disabilities are unlikely to be risk factors for prolonged recovery.52 Among youths 5 to 18 years of age who presented to an emergency department, female sex, older than 13 years of age, migraine history, previous concussion with symptoms for greater than 1 week, sensitivity to noise, fatigue, headache, parent reporting that the child answers questions slowly, and more than 3 errors on the Balance Error Scoring System-tandem stance were predictors of longer recovery.127 Children with visual, vestibular, and cervical spine findings also recover more slowly.30,81, After an initial 24 to 48 hours of cognitive and physical rest,84,103 initiate a strategy of gradual return to school and sport.84 If symptoms persist beyond 7 to 10 days following injury, targeted treatment may be warranted.84,103 Rehabilitation following concussion should be informed by a multifaceted, interdisciplinary assessment aimed at identifying underlying sources of ongoing symptoms.78,103, In the presence of headache, differential diagnosis of headache type is imperative to inform management. In part 1 of this commentary, we address etiology, risk factors, and detection of concussion. FIGURE 2. Clin Sports Med. Evidence for cognitive remediation following concussion is very limited.  |  If symptoms recur, then the athlete should move back to the previous step. The purpose of this manuscript is to outline a new model representing a dynamic approach that incorporates the consequences of repeated participation in sport, both with and without injury. Exercise may facilitate recovery following concussion.40,66,67 Two different paradigms of exercise have demonstrated benefit for symptoms and function: (1) subsymptom aerobic exercise training at 80% of the maximal heart rate that was achieved on the Buffalo Concussion Treadmill Test, 5 days per week67; and (2) exercising at 60% of maximal heart rate (calculated as 220 − age × 60%) for up to 15 minutes, combined with guided imagery and sport-specific coordination exercises.39,40 However, some studies have reported an increase in symptoms with exercise in children and youth, and others have reported no change.77,103 Given the known general positive benefits of exercise, consideration of aerobic exercise training following the initial return to activity after concussion is warranted in the absence of contraindications to exercise.103. The purpose of this manuscript is to outline a new model representing a dynamic approach that incorporates the consequences of repeated participation in sport, both with and without injury. The Farley JB, Barrett LM, Keogh JWL, Woods CT, Milne N. Sports Med Open. 16.4. When feasible, future studies on sport injury prevention should adopt a methodology and analysis strategy that takes the cyclic nature of changing risk factors into account to create a dynamic, recursive picture of etiology. Sports injury incidence should preferably be expressed as the number of sports injuries per exposure time (e.g. The return-to-sport strategy includes 6 steps: (1) symptom-limited activity, (2) light aerobic exercise, (3) sport-specific exercise, (4) noncontact training drills, (5) full-contact practice, and (6) return to sport (FIGURE 3).29,84 Medical clearance to return to sport occurs once the individual is able to complete the return-to-sport protocol with no symptom exacerbation and when no other clinical assessment findings suggest ongoing problems that would preclude returning to sport.84, Return-to-work recommendations are based on similar principles as those of return to school and return to sport.91 Gradually and progressively increase activities, provided there is no increase in symptoms. 49, No. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment Journal of Orthopaedic&Sports Physical Therapy, Ahead of Print. 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. The Journal of Sport Rehabilitation (JSR) is your source for the latest peer-reviewed research in the field of sport rehabilitation.All members of the sports-medicine team will benefit from the wealth of important information in each issue. Med Sci Sports Exerc. The questions - how do I get better and how do I stay healthy - are part a dynamic and constantly changing system. If symptoms recur or are exacerbated, reduce the demands of the task to a level that does not provoke symptoms. 2020 Sep 14;6(1):45. doi: 10.1186/s40798-020-00264-9. Less common diagnoses may include temporal bone fracture (with resultant damage to the eighth cranial nerve), labyrinthine concussion, peri-lymphatic fistula, and semicircular canal dehiscence.12,35, Vestibular rehabilitation may be of benefit for individuals with peripheral vestibular disorders (including BPPV) and stable central vestibular disorders.8,45,75 Positive effects on recovery following vestibular rehabilitation after concussion have been reported in the literature.2,106 Typically, vestibular rehabilitation includes canalith repositioning maneuvers (for BPPV) and individually targeted exercises aimed at facilitating sensorimotor compensation (including adaptation, habituation, substitution, and standing and dynamic balance exercises).3,8,106. Discussion among the health care team and with the individual and his or her family can facilitate appropriate return-to-sport and return-to-school decisions. A widely referenced model in the area of sport injury research has proposed that multiple factors influence the etiology of sport injury.88 Various etiological factors can vary over time and change the risk that is associated with injury.88 The literature in the area of concussion is evolving and, as such, enables adaptation of this model to better understand the etiology of concussion. The office (off-field) assessment portion of the SCAT5 includes history, symptoms, cognitive screening (from the Standardized Assessment of Concussion, which includes orientation, immediate and delayed memory questions, and digits and months of the year in reverse order), a neurological screen (including reading, cervical spine range of motion, ocular motor function, coordination, and balance), and a modified version of the Balance Error Scoring System.29 The Child Sport Concussion Assessment Tool Fifth Edition should be used with children aged 5 to 12 years.21, The clinical utility of the SCAT5 diminishes after the initial 3 to 5 days following injury.84 However, the symptom scale on the SCAT5 can be used to evaluate change in symptoms over time. a dynamic model that accounts for the multifactorial nature of sports injuries, and in addition, takes the sequence of events eventually leading to an injury into account. Lower limb MSK injuries among school-aged rugby and football players: a systematic review. 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. Front Psychol. Studies in basketball, hockey, and rugby have suggested a protective effect of mouthguards on concussion risk; however, a meta-analysis found no significant effect.32 In American youth football, appropriate helmet fit was associated with lower symptom severity and shorter duration of symptoms.44 In ice hockey, appropriate helmet fit may protect against concussion, although further research is needed.41 Studies examining the use of headgear in rugby and soccer are inconclusive.32,95 Further research is needed to better understand the role of protective equipment by sport. In this section, we summarize the key intrinsic and extrinsic risk factors for concussion. Recursive Preferences. Knowledge of modifiable risk factors helps to efficiently direct injury prevention efforts, and knowledge of nonmodifiable risk factors helps the clinician achieve an understanding of the overall risk to the athlete and informs return-to-play decision making. Every step, competition or practice is an exposure that impacts the body. This model has been adapted and graphically represented in ... A dynamic model of etiology in sport injury: the recursive nature of risk and causation. Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury, Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms, A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome, Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment, rTMS in alleviating mild TBI related headaches — a case series, Left dorsolateral prefrontal cortex rTMS in alleviating MTBI related headaches and depressive symptoms, Trends in concussion incidence in high school sports: a prospective 11-year study, Utility of serum IGF-1 for diagnosis of growth hormone deficiency following traumatic brain injury and sport-related concussion, Posttraumatic headache: clinical characterization and management, A prospective study of prevalence and characterization of headache following mild traumatic brain injury, Variables affecting treatment in benign paroxysmal positional vertigo, Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study, Factors affecting time to recovery from sports concussion [abstract], Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review, Epidemiology of concussions among United States high school athletes in 20 sports, Epidemiology of sports-related concussion in seven US high school and collegiate sports, Vision and vestibular system dysfunction predicts prolonged concussion recovery in children, Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis, Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial, Consensus statement on concussion in sport—the 5, Vestibular and oculomotor assessments may increase accuracy of subacute concussion assessment, Mild traumatic brain injury (mTBI) and chronic cognitive impairment: a scoping review, Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study, A dynamic model of etiology in sport injury: the recursive nature of risk and causation, A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings, Abnormalities of pituitary function after traumatic brain injury in children, Insomnia in patients with traumatic brain injury: frequency, characteristics, and risk factors, The incidence of concussion in youth sports: a systematic review and meta-analysis, What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? During sport, athletes are exposed to different events in which no concussion or injury occurs. Dizziness symptoms can be vertigo (ie, sensation of spinning of the environment or the person), light-headedness, presyncope, or a sense of disorientation. Cumulative, high-stress calls impacting adverse events among law enforcement and the public. 49, No. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. For instance, the skills required of a volleyball player will differ from those expected of an ice hockey player. Integrated model of psychological response to the sport injury and rehabilitation Psychological Responses Having discussed the integrated model that depicts how the psycho- logical consequences of sport injury relate to the overall injury experi- Risk behaviors in high school and college sport. 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. Assessment of the cervical spine should include range of motion, manual spinal exam, general strength, and cervical sensorimotor and neuromotor control.61,118,120 The clinical tests that have established utility in the cervical spine literature, including joint position sense, cervical movement control, the craniocervical flexion test, cervical flexor and extensor endurance, the cervical flexion-rotation test, and manual spinal exam, may be useful in identifying potential areas of dysfunction in concussion.53,55,61,97,106,107,119. J. In part 2, we address concussion assessment and management. Extrinsic Risk Factors for Concussion The environment in which an athlete plays includes factors that can influence the risk of concussion, many of which may be modifiable. Once a concussion is suspected, the player should be removed from play and further assessed by a qualified health care professional (FIGURE 2). Junge A, Engebretsen L, Alonso JM, Renström P, Mountjoy M, Aubry M, Dvorak J. Br J Sports Med. The duration of a dizziness episode can also provide a clue as to the source of dizziness following concussion. In this paper, the authors build on Meeuwisse’s dynamic, recursive model but argue a complex system approach is necessary to understand the nature of injury aetiology. 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. In other cases, findings suggest that central vestibular involvement may be present. 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. The Concussion Recognition Tool Fifth Edition (CRT5) is a sideline tool that can be used by parents, coaches, officials, and players to recognize when a concussion may have occurred.28 In some sports, a “spotter” watches for potential signs of concussion and identifies individuals who may require screening for concussion. 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. Other screening tools, such as the Vestibular/Ocular Motor Screening and a combination of optokinetic stimulation, gaze stabilization testing, and near point of convergence, may have clinical utility as screening tools for concussion in the subacute period (2–10 days) following concussion.85,89 The SCAT5 and Vestibular/Ocular Motor Screening tools can be used as part of the clinical assessment but should not replace other aspects of the clinical exam that may be warranted, based on the individual circumstances of the injury.21,29,84. 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