ObjectiveTo investigate the effect of physical interventions (subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies) on days to recovery and symptom scores in the management of concussion.DesignA systematic review and meta-analysis.Data sourcesMedline, CINAHL, Embase, SportDiscus, Cochrane library, Scopus and PEDro.Eligibility criteriaRandomised controlled trials of participants with concussion that evaluated the effect of subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies on days to recovery/return to activity, symptom scores, balance, gait and/or exercise capacity.ResultsTwelve trials met the inclusion criteria: 7 on subthreshold aerobic exercise, 1 on vestibular therapy, 1 on cervical therapy and 3 on individually tailored multimodal interventions. The trials were of fair to excellent quality on the PEDro scale. Eight trials were included in the quantitative analysis. Subthreshold aerobic exercise had a significant small to moderate effect in improving symptom scores (standardised mean difference (SMD)=0.43, 95% CI 0.18 to 0.67, p=0.001, I2=0%) but not in reducing days to symptom recovery in both acutely concussed individuals and those with persistent symptoms (SMD=0.19, 95% CI −0.54 to 0.93, p=0.61, I2=52%). There was limited evidence for stand-alone cervical, vestibular and oculomotor therapies. Concussed individuals with persistent symptoms (>2 weeks) were approximately 3 times more likely to have returned to sport by 8 weeks (relative risk=3.29, 95% CI 0.30 to 35.69, p=0.33, I2=83%) if they received individually tailored, presentation-specific multimodal interventions (cervical, vestibular and oculo-motor therapy). In addition, the multimodal interventions had a moderate effect in improving symptom scores (SMD=0.63, 95% CI 0.11 to 1.15, p=0.02, I2=0%) when compared with control.ConclusionsSubthreshold aerobic exercise appears to lower symptom scores but not time to recovery in concussed individuals. Individually tailored multimodal interventions have a worthwhile effect in providing faster return to sport and clinical improvement, specifically in those with persistent symptoms.PROSPERO registration numberCRD42020108117.
Introduction: Patients in ventricular fibrillation (VF) who do not respond to standard Advanced Cardiac Life Support treatments are deemed to be in refractory VF (rVF). The ideal prehospital treatment for patients with rVF remains unknown. Double sequential external defibrillation (DSED) has been proposed as a viable option for patients in rVF. Although the mechanism by which DSED terminates rVF remains unknown, one theory is that the change in defibrillation vector that occurs may contribute. The objective of this study was to describe clinical outcomes for patients presenting in rVF during out-of-hospital cardiac arrest (OOHCA) for those who underwent vector change defibrillation, compared to those who received standard treatment. Methods: This was a retrospective chart review of adult (18 years) patients presenting in rVF during OOHCA over 15 months beginning in March 2016. Patients who underwent vector change defibrillation had a change in pad position (anterior-anterior to anterior-posterior) after 3 or more consecutive shocks. Termination of rVF was defined as the absence of VF after a vector change or standard shock during the next rhythm analysis. Results: There were 372 OOHCA, with 25 (6.7%) patients meeting our definition of rVF. Of these, 16 (64.0%) patients (median age 62 years, 81.3% male) had vector change after a median (IQR) of 3 (3.0-4.0) paramedic defibrillation attempts. Median (IQR) time to vector change defibrillation was 8.8 (7.1-11.1) minutes. Eight (50%) patients had termination of rVF after the first vector change shock, 6 (37.5%) had prehospital return of spontaneous circulation (ROSC) and 5 (31.3%) patients survived to hospital discharge. Of the 9 rVF patients who did not have vector change, median age was 63 years and 88.9% were male. The median (IQR) number of defibrillations within this group was 5 (4.5-7.0). No patients converted after the 4th defibrillation. Prehospital ROSC was achieved in 3 (33.3%) patients and 5 (55.5%) patients were transported while in rVF . Three patients (33.3%) survived to hospital discharge. Conclusion: This is preliminary evidence that vector change defibrillation in patients with rVF may result in VF termination. A randomized controlled trial is warranted to test whether or not vector change has a role in the termination of rVF.
ObjectiveThe tackle is the most injurious event in rugby league and carries the greatest risk of concussion. This study aims to replicate previous research conducted in professional men's rugby league by examining the association between selected tackle characteristics and head impact events (HIEs) in women's professional rugby league.MethodsWe reviewed and coded 83 tackles resulting in an HIE and every tackle (6,318 tackles) that did not result in an HIE for three seasons (2018–2020) of the National Rugby League Women's (NRLW) competition. Tackle height, body position of the tackler and ball carrier, as well as the location of head contact with the other player's body were evaluated. Propensity of each situation that caused an HIE was calculated as HIEs per 1,000 tackles.ResultsThe propensity for tacklers to sustain an HIE was 6.60 per 1,000 tackles (95% CI: 4.87–8.92), similar to that of the ball carrier (6.13 per 1,000 tackles, 95% CI: 4.48–8.38). The greatest risk of an HIE to either the tackler or ball carrier occurred when head proximity was above the sternum (21.66 per 1,000 tackles, 95% CI: 16.55–28.35). HIEs were most common following impacts between two heads (287.23 HIEs per 1,000 tackles, 95% CI: 196.98–418.84). The lowest propensity for both tackler (2.65 per 1,000 tackles, 95% CI: 0.85–8.20) and ball carrier HIEs (1.77 per 1,000 tackles, 95% CI: 0.44–7.06) occurred when the head was in proximity to the opponent's shoulder and arm. No body position (upright, bent or unbalanced/off feet) was associated with an increased propensity of HIE to either tackler or ball carrier.ConclusionsIn the NRLW competition, tacklers and ball carriers have a similar risk of sustaining an HIE during a tackle, differing from men's NRL players, where tacklers have a higher risk of HIEs. Further studies involving larger samples need to validate these findings. However, our results indicate that injury prevention initiatives in women's rugby league should focus on how the ball carrier engages in contact during the tackle as well as how the tackler executes the tackle.
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