Clin J Sport Med. Steffen K, Myklebust G, Andersen TE, Holme I, Bahr R. Am J Sports Med. 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. Understanding the impact that these factors may have on assessment, management, and return to activity/sport helps to ensure a well-balanced and evidence-informed approach to care. Regardless of the type of injury, it is often preceded by a chain of shifting circumstances that, when they come together, constitute sufficient cause to result in an injury. Evidence has shown that physical factors such as over-training, equipment and playing conditions are the major contributors towards an athlete’s injuries. When the 2 injuries occur concurrently, they must be treated appropriately. 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. The questions - how do I get better and how do I stay healthy - are part a dynamic and constantly changing system. 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. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. USA.gov. Cognitive behavioral therapy may be beneficial for insomnia.36 Melatonin may have benefits for sleep following concussion, but is not currently recommended for sleep onset or maintenance problems.100 In the presence of ongoing sleep difficulties, refer to a sleep specialist to further investigate potential underlying causes. Journal of Orthopaedic & Sports Physical Therapy, 21 April 2020 | Brain Injury, Vol. 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. During sport, athletes are exposed to different events in which no concussion or injury occurs. ELECTRONIC The extent of the sports injury problem is often described by injury incidence and by indicators of the severity of sports injuries. Pessimistic Inter-pretation. 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? 2020 Sep 1;55(9):967-976. doi: 10.4085/1062-6050-477-19. 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. Clin Sports Med. This site needs JavaScript to work properly. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Injury surveillance in multi-sport events: the International Olympic Committee approach. 16.2. 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. In this section, we summarize the key intrinsic and extrinsic risk factors for concussion. Regardless of the type of injury, it is often preceded by a chain of shifting circumstances that, when they come together, constitute sufficient cause to result in an injury. Every step, competition or practice is an exposure that impacts the body. the context of sport (both in the presence and absence of injury) that alter risk and affect etiology in a dynamic, recursive fashion. Following concussion, it is necessary to recognize and remove the player from additional risk and refer the player to appropriate medical management as early as possible.28,84 Trauma followed by observable signs or symptoms of concussion should trigger an assessment to screen for concussion.28,84 A multifaceted assessment can inform appropriate management.37,78,84,102 Once the player has recovered and received clearance to return to play, the player may re-enter the dynamic process of adapting through recurrent participation. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Treatment may be more effective when initiated early in the recovery process.104 However, further research is warranted to identify the ideal timing and type of intervention. How Do We Meet the Challenges of Assessing and Managing Concussion? Use case 1: Survival analysis a. 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. Previous history of concussion is a risk factor for future concussion.1 The exact mechanism by which this occurs is not yet well understood and may be related to genetics, epigenetics, sensorimotor or neuromuscular control, and other factors. The article then focuses on the dynamic core of the integrated response to sport injury and rehabilitation model. Immediate removal from activity may improve outcomes.4, At the time of injury, screening for more severe injury (eg, intracranial bleeding, cervical spine fracture) is imperative. eCollection 2020. 16.4.1. 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. As concussions differ so widely, an awareness of risk factors and individual clinical characteristics can facilitate an individualized approach. Epub 2008 Apr 7. Epub 2008 Jan 28. Such a rehabilitation strategy, tailored to the individual, can facilitate high-quality, evidence-informed care and injury prevention. 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. 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. Of the children with convergence insufficiency, 46% had their symptoms resolve in the initial 4.5 weeks following injury, and another 41% reported recovery following vestibular rehabilitation that included convergence training.110 Deficits in smooth pursuit, saccades, near point of convergence, and accommodation also have been reported following concussion, often in the presence of vestibulo-ocular reflex deficits and altered balance.81 Thus, visual assessment should include smooth pursuit, saccades, near point of convergence, and accommodation, in combination with a vestibular and balance examination. A dynamic, recursive model of etiology in sport injury. Whether its recreational or professional, injury is a common occurrence at all levels of sport and exercise. cancer mortality). 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