Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups?

Makdissi, Michael; Davis, Gavin A; Jordan, Barry; Patricios, Jon; Purcell, Laura; Putukian, Margot

doi:10.1136/bjsports-2013-092256

Cited by 97 publications

(88 citation statements)

References 115 publications

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“…35 Additional factors that have been suggested to act as modifiers or potential predictors of prolonged recovery in broader populations of patients with concussion include the following: younger age; female sex; LOC; amnesia; and medical history of previous concussions, headaches, attention deficit hyperactivity disorder, and learning disorders. 27,30 Although these studies have identified several important clinical predictors of PCS among pediatric patients, limited attention has been paid to features of the physical examination that are associated with specific concussion symptoms and which together may provide important insight into the pathophysiological mechanisms mediating persistent symptoms. 13 The present study meets an urgent unmet need by introducing a novel clinical definition that uses a combination of subjective and objective clinical findings that can potentially identify patients at an elevated risk of developing PCS.…”

Section: Discussionmentioning

confidence: 99%

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley

Vis

et al. 2015

PED

145

130

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OBJECT The objective of this study was 2-fold: 1) to examine the prevalence of vestibulo-ocular dysfunction (VOD) among children and adolescents with acute sports-related concussion (SRC) and postconcussion syndrome (PCS) who were referred to a multidisciplinary pediatric concussion program; and 2) to determine if VOD is associated with the development of PCS in this cohort. METHODS The authors conducted a retrospective review of all patients with acute SRC (presenting 30 days or less postinjury) and PCS (3 or more symptoms for at least 1 month) referred to a multidisciplinary pediatric concussion program between September 2013 and July 2014. Initial assessment included clinical history, physical examination, and Post-Concussion Symptom Scale assessment. Patients were also assessed for VOD, which was defined as more than one subjective vestibular and oculomotor complaint (dizziness, blurred vision, and so on) and more than one objective physical examination finding (abnormal smooth pursuits, saccades, vestibulo-ocular reflex, and so on). This study was approved by the local institutional ethics review board. RESULTS A total of 101 patients (mean age 14.2 years, SD 2.3 years; 63 male and 38 female patients) participated, including 77 (76.2%) with acute SRC and 24 (23.8%) with PCS. Twenty-two of the 77 patients (28.6%) with acute SRC and 15 of the 24 (62.5%) with PCS met the clinical criteria for VOD. The median duration of symptoms was 40 days (interquartile range [IQR] 28.5–54 days) for patients with acute SRC who had VOD compared with 21 days (IQR 13–32 days) for those without VOD (p = 0.0001). There was a statistically significant increase in the adjusted odds of developing PCS among patients with acute SRC who had VOD compared with those without VOD (adjusted OR 4.10; 95% CI 1.04–16.16). CONCLUSIONS Evidence of VOD was detected in a significant proportion of children and adolescents with acute SRC and PCS who were referred to a multidisciplinary pediatric concussion program. This clinical feature was a significant risk factor for the subsequent development of PCS in this pediatric acute SRC cohort.

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Section: Discussionmentioning

confidence: 99%

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley

Vis

et al. 2015

PED

145

130

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“…13,17,34,40 Risk factors for prolonged recovery may include female sex, LOC, and a history of concussions, attention deficit hyperactivity disorder, migraine headaches, and learning disorders. 25,28,39 Physicians caring for pediatric patients with SRC must take into account all of these factors as well as the trajectory of concussion symptoms and physical examination findings when making the decision to order neuroimaging. These decisions are also impacted by the clinical experience and training of the treating physician as well as his or her familiarity with neurological conditions that can potentially mimic or can also co-occur in the setting of SRC.…”

Section: Discussionmentioning

confidence: 99%

Neuroimaging findings in pediatric sports-related concussion

Ellis

Leiter

Hall

et al. 2015

PED

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OBJECT The goal in this review was to summarize the results of clinical neuroimaging studies performed in patients with sports-related concussion (SRC) who were referred to a multidisciplinar ypediatric concussion program. METHODS The authors conducted a retrospective review of medical records and neuroimaging findings for all patients referred to a multidisciplinary pediatric concussion program between September 2013 and July 2014. Inclusion criteria were as follows: 1) age ≤ 19 years; and 2) physician-diagnosed SRC. All patients underwent evaluation and follow-up by the same neurosurgeon. The 2 outcomes examined in this review were the frequency of neuroimaging studies performed in this population (including CT and MRI) and the findings of those studies. Clinical indications for neuroimaging and the impact of neuroimaging findings on clinical decision making were summarized where available. This investigation was approved by the local institutional ethics review board. RESULTS A total of 151 patients (mean age 14 years, 59% female) were included this study. Overall, 36 patients (24%) underwent neuroimaging studies, the results of which were normal in 78% of cases. Sixteen percent of patients underwent CT imaging; results were normal in 79% of cases. Abnormal CT findings included the following: arachnoid cyst (1 patient), skull fracture (2 patients), suspected intracranial hemorrhage (1 patient), and suspected hemorrhage into an arachnoid cyst (1 patient). Eleven percent of patients underwent MRI; results were normal in 75% of cases. Abnormal MRI findings included the following: intraparenchymal hemorrhage and sylvian fissure arachnoid cyst (1 patient); nonhemorrhagic contusion (1 patient); demyelinating disease (1 patient); and posterior fossa arachnoid cyst, cerebellar volume loss, and nonspecific white matter changes (1 patient). CONCLUSIONS Results of clinical neuroimaging studies are normal in the majority of pediatric patients with SRC. However, in selected cases neuroimaging can provide information that impacts decision making about return to play and retirement from the sport.

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“…Standardized sideline tests are a useful framework for examination, however the sensitivity, specificity, validity and reliability of these tests among different age and cultural groups and settings have not been clarified yet (Makdissi, Cantu et al, 2013 After the sideline assessment, the (team) physician should examine the player in further detail apart from the field in a calm surrounding (emergency room or in the physicians office). This includes documentation of the specific medical history of the player (figure 1, 2.2) (Colvin et al, 2009;Makdissi, Davis et al, 2013) and completion of the neurological examination (2.3), described in detail by Casson et al (2009a and b).…”

Section: Sideline-evaluationmentioning

confidence: 99%

Return to play management after concussion in football: recommendations for team physicians

Feddermann-Demont

Straumann

Dvořák

2014

Journal of Sports Sciences

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A concussion is a rare but potentially serious injury of football players. Thus, an immediate and valid diagnosis, estimate of severity and therapeutic management is required. To summarise the published information on management of concussion with respect to a safe return to play (RTP), a literature search was conducted. Current guidelines on concussion in sports and significant studies on concussion in football were analysed. After concussion, management and RTP decision should remain in the area of clinical judgement on an individualised basis according to the current international guidelines. If a concussion is suspected, the player should not be allowed to RTP the same day. The RTP programme should follow a gradual step-wise procedure. A concussed player should not RTP unless he/she is asymptomatic and the neurological and neuropsychological examinations are normal. Untimely RTP bears an increased risk of sustaining another more severe brain injury and repetitive brain injury of long-term sequelae. In football, the management of concussion should primarily follow the recommendations proposed by the Concussion in Sports Group. Information and education of players and their medical and coaching team help to protect the players' health. Future studies on concussion should include validated and detailed information on RTP protocols. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58

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Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups?

Cited by 97 publications

References 115 publications

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Neuroimaging findings in pediatric sports-related concussion

Return to play management after concussion in football: recommendations for team physicians

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