Rest and treatment/rehabilitation following sport-related concussion: a systematic review

Schneider, Kathryn; Leddy, John J.; Guskiewicz, Kevin M.; Seifert, Tad; McCrea, Michael; Silverberg, Noah D.; Feddermann-Demont, Nina; Iverson, Grant L.; Hayden, Alix; Makdissi, Michael

doi:10.1136/bjsports-2016-097475

Cited by 254 publications

(233 citation statements)

References 71 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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Mild Traumatic Brain Injury

Iaccarino

2018

JAMA Netw Open

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Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults

Rytter

Graff²,

Henriksen³

et al. 2021

JAMA Netw Open

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IMPORTANCE Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. OBJECTIVE To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. DATA SOURCES Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. STUDY SELECTION A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury. DATA EXTRACTION AND SYNTHESIS Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURESAll outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). RESULTSEleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately (continued)

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Rest and treatment/rehabilitation following sport-related concussion: a systematic review

Abstract: Aim or objective The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC). Design Systematic review.

Cited by 254 publications

References 71 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

Mild Traumatic Brain Injury

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults

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