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PubMed2006

Repeat mild traumatic brain injury: how to adjust return to play guidelines.

Determining when it is safe for an athlete to return to play (RTP) after concussion is one of the most difficult decisions facing the team physician. There is significant variability in the evaluation and management of mild traumatic brain injury (mTBI). In the past decade, a tremendous amount of sport-specific research has improved our understanding of mTBI. The advent of neuro-psychologic (NP) testing batteries designed to assess concussive injury has improved the assessment of cognitive dysfunction that occurs in the absence of structural brain abnormalities. The severity of injury is determined by the nature, burden, and duration of symptoms. Athletes must be asymptomatic and have a normal neurologic and cognitive evaluation prior to RTP. Several factors aid in making the RTP decision, including age, the severity of injury, and history of prior mTBIs. Given the potential complications of mTBI, the RTP decision must be made using a thoughtful, individualized process.

Age Factors↗
PubMed2007

Correlates to traumatic brain injury in nonhuman primates.

BACKGROUND: Traumatic brain injury (TBI) is a major health problem, both in terms of the economic cost to society and the survivor's quality of life. The development of devices to protect against TBI requires criteria that relate observed injury to measurements of head kinematics. The objective of this study is to find the best statistical correlates to impact-induced TBI in nonhuman primates using a qualified, self-consistent set of historical kinematic and TBI data from impact tests on nonhuman primates. METHODS: A database was constructed and qualified from historical head impact tests on nonhuman primates. Multivariate logistic regression analysis with backwards stepwise elimination was performed. Variables considered are the peak rotational acceleration (Omegamax), the peak linear acceleration (Amax), and the number of impacts (N). RESULTS: Bivariate combinations of angular acceleration and the number of impacts are the best correlates to all modes of TBI considered, i.e., concussion, subarachnoid hemorrhage, brain contusion, and subdural hematoma. For a nonhuman primate with 100-g brain mass, the criteria that the probability of TBI is less than 10% by injury mode are:Concussion: OmegamaxN(0.84) < 70 krad/s/s SAH: OmegamaxN(0.70) < 160 krad/s/s Contusion: Omegamax N(0.35) < 160 krad/s/s SDH: Omegamax N(0.60) < 280 krad/s/s CONCLUSIONS: Based on this dataset, the best statistically based risk factor for all modes of TBI in nonhuman primates is the bivariate combination of rotational acceleration and number of impacts.

Acceleration↗
PubMed1987

Prediction of post-concussional sequelae by reaction time test.

The aim of this study was to examine whether it was possible by a reaction time (RT) test to predict if a patient was to complain of sequelae after a cerebral concussion. 55 patients had an RT test performed 1-5 days after concussion. The test showed a significant (P less than 0.02) prolongated RT in patients having postconcussional sequelae (median 186 ms) after 1 month (27 patients, 49%) compared to the patients without sequelae (median 168 ms). Patients with sequelae after 3 months (12 patients, 22%) also had a prolongation of RT (median 183 ms) although non-significant. These results supports a structural organic etiology for postconcussional sequelae.

Adolescent↗
PubMed2006

Cervical spinal injury in children's community rugby football.

OBJECTIVE: To examine the characteristics of cervical spinal injury (CSI) in school aged children injured in community based rugby football who presented to the emergency department for assessment. METHODS: This is a retrospective descriptive case series study reviewing the medical records of all children younger than 15 years of age who presented to the emergency department at the Children's Hospital at Westmead, Sydney, Australia for assessment of injury to the cervical spine between 2000 and 2003. RESULTS: There were 125 children with CSI; most (97%) were boys of mean age 12.7 years. Injuries occurred throughout the season, with an unexpected peak in June. Neck pain was the main presenting complaint (98%). Neurological symptoms were reported in 43%, half having concussion. Hyperextension of the neck accounted for a third of all cases and was usually the result of a spear tackle. Appropriate treatment of the cervical spine on the field of play before transport to hospital was inconsistently performed. Half of the players with CSI suffered secondary injuries, consisting of concussive head injury, faciomaxillary injury, eye injury, or limb fracture. Admission to hospital was common, with all children admitted undergoing further radiological assessment. Two minor fractures were reported and no permanent neurological disability. Overall, no adverse events were reported and the clinical outcome was good. CONCLUSION: CSI in children playing rugby football is rarely catastrophic although often associated with other injuries. Continued efforts are needed to educate players and referees to prevent injury.

Adolescent↗
PubMed2005

Value of neuropsychological testing after head injuries in football.

This paper reviews the pros and cons of the traditional paper and pencil and the newer computerised neuropsychological tests in the management of sports concussion. The differences between diagnosing concussion on the field and neuropsychological assessment at follow up and decision making with regard to return to play are described. The authors also discuss the issues involved in interpreting the results of neuropsychological testing (comparison with population norms versus player's own baseline test results) and potential problems of such testing in football. Finally, suggested recommendations for neuropsychological testing in football are given.

Brain Concussion↗
PubMed2003

Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video.

OBJECTIVE: The ThinkFirst Canada Smart Hockey program is an educational injury prevention video that teaches the mechanisms, consequences, and prevention of brain and spinal cord injury in ice hockey. This study evaluates knowledge transfer and behavioural outcomes in 11-12 year old hockey players who viewed the video. DESIGN: Randomized controlled design. SETTING: Greater Toronto Minor Hockey League, Toronto Ontario. SUBJECTS: Minor, competitive 11-12 year old male ice hockey players and hockey team coaches. INTERVENTIONS: The Smart Hockey video was shown to experimental teams at mid-season. An interview was conducted with coaches to understand reasons to accept or refuse the injury prevention video. MAIN OUTCOME MEASURES: A test of concussion knowledge was administered before, immediately after, and three months after exposure to the video. The incidence of aggressive penalties was measured before and after viewing the video. RESULTS: The number of causes and mechanisms of concussion named by players increased from 1.13 to 2.47 and from 0.67 to 1.22 respectively. This effect was maintained at three months. There was no significant change in control teams. There was no significant change in total penalties after video exposure; however, specific body checking related penalties were significantly reduced in the experimental group. CONCLUSION: This study showed some improvements in knowledge and behaviours after a single viewing of a video; however, these findings require confirmation with a larger sample to understand the sociobehavioural aspects of sport that determine the effectiveness and acceptance of injury prevention interventions.

Attitude to Health↗
PubMed1992

Recovery from visual and acoustic hyperaesthesia after mild head injury in relation to patterns of behavioural dysfunction.

Patients with head injuries frequently complain of a decreased ability to endure intense light and sound stimuli. The few psychophysical studies that have objectively studied this type of hyperaesthesia have not assessed to what extent patients recover from this hyperaesthesia after mild head injury (MHI). A computerised rating technique was used to assess tolerance to intense sound (95 dB) and light (1500 lux) stimuli in patients with an uncomplicated MHI. Patients were tested 10 days and five weeks after the injury. Although most patients substantially recovered from both visual and acoustic hyperaesthesia, 25% of the patients were still not able to endure intense stimuli by five weeks. Analysis of data obtained with two behavioural rating scales (one with post-concussive/cognitive complaints and a second with emotional/vegetative complaints) indicated that visual hyperaesthesia was specifically related to the post-concussive/cognitive complaints scale.

Adult↗
PubMed2001

Suicide after traumatic brain injury: a population study.

OBJECTIVES: To determine the rates of suicide among patients who have had a traumatic brain injury. METHODS: From a Danish population register of admissions to hospital covering the years 1979-93 patients were selected who had had either a concussion (n=126 114), a cranial fracture (n=7560), or a cerebral contusion or traumatic intracranial haemorrhage (n=11 766). All cases of deaths by the end of the study period were identified. RESULTS: In the three diagnostic groups there had been 750 (0.59%), 46 (0.61%), and 99 (0.84%) cases of suicide respectively. Standardised mortality ratios, stratified by sex and age, showed that the incidence of suicide among the three diagnostic groups was increased relative to the general population (3.0, 2.7, and 4.1 respectively). In all diagnosis groups the ratios were higher for females than for males, and lower for patients injured before the age of 21 or after the age of 60. The presence of a codiagnosis relating to substance misuse was associated with increased suicide rates in all diagnosis groups. There was a tendency, among patients with cerebral contusions or traumatic intracranial haemorrhages, for suicide risk to increase with duration of stay in hospital. Cox regression analyses for proportional hazards confirmed that there was a significantly greater risk of suicide among patients with cerebral contusions or traumatic intracranial haemorrhages than among patients with concussion or cranial fractures (hazard ratios=1.42 and 1.50 respectively). There was, however, no evidence of a specific risk period for suicide after injury. CONCLUSION: The increased risk of suicide among patients who had a mild traumatic brain injury may result from concomitant risk factors such as psychiatric conditions and psychosocial disadvantage. The greater risk among the more serious cases implicates additionally the physical, psychological, and social consequences of the injuries as directly contributing to the suicides.

Adolescent↗
PubMed1991

Fetal cortical transplants in adult rats subjected to experimental brain injury.

Fetal cortical tissue was injected into injured adult rat brains following concussive fluid percussion (FP) brain injury. Rats subjected to moderate FP injury received E16 cortex transplant injections into lesioned motor cortex 2 days, 1 week, 2 weeks, and 4 weeks post injury. Histological assessment of transplant survival and integration was based upon Nissl staining, glial fibrillary acidic protein (GFAP) immunocytochemistry, and staining for acetylcholinesterase. In addition to histological analysis, the ability of the transplants to attenuate neurological motor deficits associated with concussive FP brain injury was also tested. Three subgroups of rats receiving transplant 1 week, 2 weeks, and 4 weeks post injury were chosen for evaluation of neurological motor function. Fetal cortical tissue injected into the injury site 4 weeks post injury failed to incorporate with injured host brain, did not affect glial scar formation, and exhibited extensive GFAP immunoreactivity. No improvement in neurological motor function was observed in animals receiving transplants 4 weeks post injury. Conversely, transplants injected 2 days, 1 week, or 2 weeks post injury survived, incorporated with host brain, exhibited little GFAP immunoreactivity, and successfully attenuated glial scarring. However, no significant improvement in motor function was observed at the one week or two week time points. The inability of the transplants to attenuate motor function may indicate inappropriate host/transplant interaction. Our results demonstrate that there exists a temporal window in which fetal cortical transplants can attenuate glial scarring as well as be successfully incorporated into host brains following FP injury.

Animals↗
PubMed1976

Effect of cerebral injury on cerebrospinal fluid cyclic AMP concentration.

Cerbrospinal fluid (CSF) cyclic adenosine-3', 5'-monophosphate (cAMP) was measured in rabbits after experimental brain injury as well as in patients with cerebral contusion and cerebral concussion. In rabbits a marked elevation lasting for two weeks was observed. From the third week onwards after the injury the CSF cAMP concentration was lower than the basal level before the injury. Dexamethasone partly inhibited the elevation. Ethanol treatment decreased the CSF cAMP values. In man, the CSF cAMP concentration was significantly higher in patients with cerebral contusion than in those with cerebral concussion. Also in the latter group the cAMP values were higher than in control patients. Due to the clear differences between the various groups, measurement of cAMP concentration in CSF might have diagnostic value in evaluation of the severity of cerebral lesion in the acute phase. Also the activities of some enzymes were measured, and the results were parallel with cAMP changes but less striking.

Adolescent↗
PubMed2005

American collegiate men's ice hockey: an analysis of injuries.

BACKGROUND: Reported rates and types of ice hockey injuries have been variable. Ice hockey combines tremendous speeds with aggressive physical play and therefore has great inherent potential for injury. PURPOSE: To identify rates and determinants of injury in American men's collegiate ice hockey. STUDY DESIGN: Prospective cohort study. METHODS: Data were collected from 8 teams in a Division I athletic conference for 1 season using an injury reporting form specific for ice hockey. RESULTS: There were a total of 113 injuries in 23,096 athlete exposures. Sixty-five percent of injuries occurred during games, although games accounted for only 23% of all exposures. The overall injury rate was 4.9 per 1000 athlete exposures (13.8 per 1000 game athlete exposures and 2.2 per 1000 practice athlete exposures). Collision with an opponent (32.8%) or the boards (18.6%) caused more than half of all injuries. Concussion (18.6%) was the most common injury, followed by knee medial collateral ligament sprains, acromioclavicular joint injuries, and ankle sprains. CONCLUSIONS: The risk of injury in men's collegiate ice hockey is much greater during games than during practices. Concussions are a main cause for time lost and remain an area of major concern.

Adult↗
PubMed2004

Injuries at the Canadian National Tae Kwon Do Championships: a prospective study.

BACKGROUND: The purpose of this prospective study was to assess the injury rates in male and female adult Canadian Taekwondo athletes relative to total number of injuries, type and body part injured. METHODS: Subjects (219 males, 99 females) participated in the 1997 Canadian National Taekwondo Championships in Toronto, Canada. Injuries were recorded on an injury form to documents any injury seen and treatment provided by the health care team. These data were later used for this study. The injury form describes the athlete and nature, site, severity and mechanism of the injury. RESULTS: The overall rate of injuries was 62.9/1,000 athlete-exposures (A-E). The males (79.9/1,000 A-E) sustained significantly more injuries than the females (25.3/1,000 A-E). The lower extremities were the most commonly injured body region in the men (32.0 /1,000 A-E), followed by the head and neck (18.3/1,000 A-E). Injuries to the spine (neck, upper back, low back and coccyx) were the third most often injured body region in males (13.8/1,000 A-E). All injuries to the women were sustained to the lower extremities. The most common type of injury in women was the contusion (15.2/1,000 A-E). However, men's most common type of injury was the sprain (22.8/1,000 A-E) followed by joint dysfunction (13.7/1,000 A-E). Concussions were only reported in males (6.9/1,000 A-E). Compared to international counterparts, the Canadian men and women recorded lower total injury rates. However, the males incurred more cerebral concussions than their American colleagues (4.7/1,000 A-E). CONCLUSIONS: Similar to what was found in previous studies, the current investigation seems to suggest that areas of particular concern for preventive measures involve the head and neck as well as the lower extremities. This is the first paper to identify spinal joint dysfunction.

Adolescent↗
PubMed2000

Postconcussional symptoms in chronic back pain.

Checklist measures of persisting postconcussional and control symptom change (postinjury-preinjury self-ratings on 5-point scales) were compared among selected groups of consecutive referrals with traumatic back pain and concussion. Mean symptom change was not significantly different between the 2 groups. Positive correlations were found between postconcussional symptom change and psychometric measures of emotional distress for participants with valid Minnesota Multiphasic Personality Inventory profiles in the 2 groups combined. Results suggested that persisting postconcussional symptoms were not specific to concussion but were associated with increased emotional distress.

Adolescent↗
PubMed2006

Alteration of postural responses to visual field motion in mild traumatic brain injury.

OBJECTIVE: Balance deficits in individuals experiencing mild traumatic brain injury have been documented in numerous recent studies. However, long-lasting balance deficits and specific mechanisms causing these deficits have not been systematically examined. This article aimed to present empirical evidence showing destabilizing effects of visual field motion in concussed individuals up to 30 days postinjury. METHODS: Sixty student athletes participated in the pilot (n = 12) and major experiments (n = 48) before injury. Eight of these 48 subjects who experienced mild traumatic brain injury in athletic events were tested again on Days 3, 10, and 30 after the incident. Postural responses to visual field motion were recorded using a virtual reality environment in conjunction with balance (AMTI force plate) and motion tracking (Flock of Birds) technologies. RESULTS: The area of the center of pressure during upright stance did not change from Day 3 to 30 postinjury with respect to pre-injury status (P > .05). However, balance deficits induced by visual field motion were present up to 30 days postinjury. Destabilizing effect of visual field motion was observed via significant increase of the center of pressure data (P < .05) and reduced coherence value. CONCLUSION: Our data suggest the presence of residual sensory integration dysfunction in concussed individuals at least 30 days postinjury and may indicate a lower threshold for brain reinjury.

Adult↗
PubMed2002

The relevance of neuropsychologic testing for sports-related head injuries.

The utilization of neuropsychologic testing following sports-related concussion has dramatically increased over the past 5 years. The inclusion of neuropsychologic test results in the diagnosis of concussion has resulted in increasing questions into the specific role of these procedures in the return-to-play decision-making process. This article reviews the relevance of neuropsychologic testing for the sports medicine physician.

Athletic Injuries↗
PubMed2003

Epidemiology and pathophysiology of minor traumatic brain injury.

This review article presents evidence from the current literature on the epidemiology and pathophysiology of concussion. The recent epidemiologic data for a variety of sports are presented relevant to the general population, and professional, college, and high school athletics. The evidence for the pathophysiology of head injury is presented using a mixture of current animal and human studies. A brief discussion on the benefits and limitations of the evidence is offered for the both the epidemiology and pathophysiology of concussion, and how it relates to current treatment options.

Animals↗
PubMed2005

Gender differences in head-neck segment dynamic stabilization during head acceleration.

PURPOSE: Recent epidemiological research has revealed that gender differences exist in concussion incidence but no study has investigated why females may be at greater risk of concussion. Our purpose was to determine whether gender differences existed in head-neck segment kinematic and neuromuscular control variables responses to an external force application with and without neck muscle preactivation. METHODS: Forty (20 females and 20 males) physically active volunteers participated in the study. The independent variables were gender, force application (known vs unknown), and force direction (forced flexion vs forced extension). The dependent variables were kinematic and EMG variables, head-neck segment stiffness, and head-neck segment flexor and extensor isometric strength. Statistical analyses consisted of multiple multivariate and univariate analyses of variance, follow-up univariate analyses of variance, and t-tests (P < or = 0.05). RESULTS: Gender differences existed in head-neck segment dynamic stabilization during head angular acceleration. Females exhibited significantly greater head-neck segment peak angular acceleration (50%) and displacement (39%) than males despite initiating muscle activity significantly earlier (SCM only) and using a greater percentage of their maximum head-neck segment muscle activity (79% peak activity and 117% muscle activity area). The head-neck segment angular acceleration differences may be because females exhibited significantly less isometric strength (49%), neck girth (30%), and head mass (43%), resulting in lower levels of head-neck segment stiffness (29%). CONCLUSION: For our subject demographic, the results revealed gender differences in head-neck segment dynamic stabilization during head acceleration in response to an external force application. Females exhibited significantly greater head-neck segment peak angular acceleration and displacement than males despite initiating muscle activity earlier (SCM only) and using a greater percentage of their maximum head-neck segment muscle activity.

Acceleration↗
PubMed2006

Reflections on 40 years as a sideline physician.

OBJECT: In this study the author presents his personal observations concerning football injuries in a historical perspective with additional literature citations. METHODS: Aspects of brachial plexus and cervical spine injuries, neurapraxia, face mask infractions, concussion, acute subdural hematoma (SDH), and the so-called second-impact syndrome are addressed. CONCLUSIONS: The list of conclusions presented in this paper is as follows: there is more than one kind of brachial plexus injury; wedging of cervical vertebrae may be normal; neurapraxia presents a problem for return to play; face mask injuries are rarely serious; definitions of concussion vary; acute SDH requires immediate transfer to a hospital; and the second-impact syndrome may be a myth to some.

Athletic Injuries↗