Symptom presentation and evolution in the first 48 hours after injury are associated with return to play after concussion in elite Rugby Union

Background:Return to play(RTP)in elite rugby is managed using a 6-stage graduated RTP protocol,which can result in clearance to play within 1 week of injury.We aimed to explore how symptom,cognitive,and balance presentation and evolution during concussion screens 2 h(head injury assessment(HIA2)and 48 h(HIA3)after injury were associated with time to RTP)to identify whether a more conservative graduated RTP may be appropriate.Methods:A retrospective cohort study was conducted in 380 concussed rugby players from elite men’s rugby over 3 consecutive seasons.Players were classified as shorter or longer returns,depending on whether RTP occurred within 7 days(allowing them to be considered to play the match 1 week after injury)or longer than 8 days,respectively.Symptom,cognitive,and balance performance during screens was assessed relative to baseline(normal or abnormal)and to the preceding screen(improving or worsening).Associations between sub-test abnormalities and RTP time were explored using odds ratios(OR,longer vs.shorter).Median day absence was compared between players with abnormal or worsening results and those whose results were normal or improving.Results:Abnormal symptom results during screens 2 h and 48 h after concussion were associated with longer return time(HIA2:OR=2.21,95%confidence interval(95%CI):1.39-3.50;HIA3:OR=3.30,95%CI:1.89-5.75).Worsening symptom number or severity from the time of injury to 2 h and 48 h post-injury was associated with longer return(HIA2:OR=2.49,95%CI:1.36-4.58;HIA3:OR=3.34,95%CI:1.10-10.15).Median days absence was greater in players with abnormal symptom results at both HIA2 and HIA3.Cognitive and balance performance were not associated with longer return and did not affect median days absence.Conclusion:Symptom presentation and evolution within 48 h of concussion were associated with longer RTP times.This may guide a more conservative approach to RTP,while still adhering to individualized concussion management principles.

Are EPB41 and alpha-synuclein diagnostic biomarkers of sport-related concussion?Findings from the NCAA and Department of Defense CARE Consortium

Background:Current protein biomarkers are only moderately predictive at identifying individuals with mild traumatic brain injury or concussion.Therefore,more accurate diagnostic markers are needed for sport-related concussion.Methods:This was a multicenter,prospective,case-control study of athletes who provided blood samples and were diagnosed with a concussion or were a matched non-concussed control within the National Collegiate Athletic Association-Department of Defense Concussion Assessment,Research,and Education Consortium conducted between 2015 and 2019.The blood was collected within 48 h of injury to identify protein abnormalities at the acute and subacute timepoints.Athletes with concussion were divided into 6 h post-injury(0-6 h post-injury)and after 6 h postinjury(7-48 h post-injury)groups.We applied a highly multiplexed proteomic technique that used a DNA aptamers assay to target 1305proteins in plasma samples from athletes with and without sport-related concussion.Results:A total of 140 athletes with concussion(79.3%males;aged 18.71±1.10 years,mean±SD)and 21 non-concussed athletes(76.2%males;19.14±1.10 years)were included in this study.We identified 338 plasma proteins that significantly differed in abundance(319 upregulated and 19 downregulated)in concussed athletes compared to non-concussed athletes.The top 20 most differentially abundant proteins discriminated concussed athletes from non-concussed athletes with an area under the curve(AUC)of 0.954(95%confidence interval:0.922-0.986).Specifically,after 6 h of injury,the individual AUC of plasma erythrocyte membrane protein band 4.1(EPB41)and alpha-synuclein(SNCA)were 0.956 and 0.875,respectively.The combination of EPB41 and SNCA provided the best AUC(1.000),which suggests this combination of candidate plasma biomarkers is the best for diagnosing concussion in athletes after 6 h of injury.Conclusion:Our data suggest that proteomic profiling may provide novel diagnostic protein markers and that a combination of EPB41 and SNCA is the most predictive biomarker of concussion after 6 h of injury.

Diffusion tensor tractography characteristics of axonal injury in concussion/mild traumatic brain injury

The main advantage of diffusion tensor tractography is that it allows the entire neural tract to be evaluated.In addition,configurational analysis of reconstructed neural tracts can indicate abnormalities such as tearing,narrowing,or discontinuations,which have been used to identify axonal injury of neural tracts in concussion patients.This review focuses on the characteristic features of axonal injury in concussion or mild traumatic brain injury(m TBI)patients through the use of diffusion tensor tractography.Axonal injury in concussion(m TBI)patients is characterized by their occurrence in long neural tracts and multiple injuries,and these characteristics are common in patients with diffuse axonal injury and in concussion(m TBI)patients with axonal injury.However,the discontinuation of the corticospinal tract is mostly observed in diffuse axonal injury,and partial tearing and narrowing in the subcortical white matter are frequently observed in concussion(m TBI)patients with axonal injury.This difference appears to be attributed to the observation that axonal injury in concussion(m TBI)patients is the result of weaker forces than those producing diffuse axonal injuries.In addition,regarding the fornix,in diffuse axonal injury,discontinuation of the fornical crus has been frequently reported,but in concussion(m TBI)patients,many collateral branches form in the fornix in addition to these findings in many case studies.It is presumed that the impact on the brain in TBI is relatively weaker than that in diffuse axonal injury,and that the formation of collateral branches occurs during the fornix recovery process.Although the occurrence of axonal injury in multiple areas of the brain is an important feature of diffuse axonal injury,case studies in concussion(m TBI)have shown that axonal injury occurs in multiple neural tracts.Because axonal injury lesions in m TBI patients may persist for approximately 10 years after injury onset,the characteristics of axonal injury in concussion(m TBI)patients,which are reviewed and categorized in this review,are expected to serve as useful supplementary information in the diagnosis of axonal injury in concussion(m TBI)patients.

Quiet rest ameliorates biochemical metabolism in the brain in a simple concussion rabbit model Evaluation of hydrogen proton magnetic resonance spectroscopy

The present study analyzed changes in the biochemical metabolites N-acetyl aspartate, choline, and creatine in a simple concussion rabbit model following quiet rest, hyperbaric oxygen therapy, or interference stimulation through the use of hydrogen proton magnetic resonance spectroscopy detection. Experimental findings showed that brain N-acetyl aspartate and choline peak values significantly decreased, while creatine peak values significantly increased following simple concussion. Following treatments, N-acetyl aspartate and choline peaks returned to normal levels in the quiet rest and hyperbaric oxygen therapy groups, but no changes were observed in the interference stimulation group. Results demonstrated abnormal changes in the brain biochemical metabolism environment following simple concussion. Quiet rest was shown to play an important role in restoration of biochemical metabolism following simple concussion.

Post-Concussion Syndrome after a Mild Traumatic Brain Injury: A Minefield for Clinical Practice

In this clinical practice review, the controversies and difficulties managing post concussion symptoms following mild traumatic brain injury are discussed. Based on considerable clinical experience in a designated Concussion Clinic, the authors (a neuropsychologist, a psychiatrist, and a neurologist) review relevant literature and issues for clinical practice, particularly with respect to understanding risk factors for and vulnerability to, development of chronic post-concussion symptoms. We contend it is not just the kind of head that matters but also the kind of complications, the kind of outcomes and the kind of management that can influence injury recovery. Given these complexities, a bio-psychosocial conceptualization of chronic post-concussion syndrome is appropriate. Though understanding is still elusive, management should not be biased by physiogenic or psychogenic aetiological theories for management needs to address patient reported outcomes regardless of underpinning aetiology.

Strategies to avoid a missed diagnosis of co-occurring concussion in post-acute patients having a spinal cord injury

Research scientists and clinicians should be aware that missed diagnoses of mild-moderate traumatic brain injuries in post-acute patients having spinal cord injuries may approach 60-74% with certain risk factors, potentially causing clinical consequences for patients, and confounding the results of clinical research studies. Factors leading to a missed diagnosis may include acute trauma-related life-threatening issues, sedation/intubation, subtle neuropathology on neuroimaging, failure to collect Glasgow Coma Scale scores or duration of posttraumatic amnesia, or lack of validity of this information, and overlap in neuro-cognitive symptoms with emotional responses to spinal cord injuries. Strategies for avoiding a missed diagnosis of mild-moderate traumatic brain injuries in patients having a spinal cord injuries are highlighted in this perspective.

Microstructural changes in memory and reticular formation neural pathway after simple concussion

Patients with concussion often present with temporary disturbance of consciousness. The microstructural and functional changes in the brain associated with concussion, as well as the relationship with transient cognitive disorders, are currently unclear. In the present study, a rabbit model of simple concussion was established. Magnetic resonance-diffusion tensor imaging results revealed that the corona radiata and midbrain exhibited significantly decreased fractional anisotropy values in the neural pathways associated with memory and the reticular formation. In addition, the apparent diffusion coefficient values were significantly increased following injury compared with those before injury. Following a 1-hour period of quiet rest, the fractional anisotropy values significantly increased, and apparent diffusion coefficient values significantly decreased, returning to normal pre-injury levels. In contrast, the fractional anisotropy values and apparent diffusion coefficient values in the corpus callosum, thalamus and hippocampus showed no statistical significant alterations following injury. These findings indicate that the neural pathways associated with memory and the reticular formation pathway exhibit reversible microstructural white matter changes when concussion occurs, and these changes are exhibited to a different extent in different regions.

Concussion Practice Patterns among Speech-Language Pathologists

OBJECTIVE: To identify current SLP practice patterns in concussion care, clarify definitions of common cognitive retraining terminology, and establish areas of growth in clinical practice and research. METHOD: An online 10 question survey to collect data on assessment and practice components. Total 79 respondents from ASHA Special Interest Group 2 Neurogenic Communication Disorders website participated. Data were analyzed using descriptive statistics. RESULTS: Patient education and symptom management were regular components of cognitive retraining with concussion. Smaller percentage included cognitive endurance building. Further analysis identified variation in how clinicians defined terms: patient education, symptom management, and cognitive endurance building. Discrepancies noted with diagnostic tools, with one quarter using screening tools as primary assessment. CONCLUSION: Strong knowledge base to support differential diagnosis and therapeutic plan is critical to optimize outcomes in concussion care. Consistency with terminology use can reduce the risk of confusion but also support the value of what SLPs contribute to an interdisciplinary concussion team.

Nature-Based Therapy for People Suffering from Post-Concussion Syndrome—A Pilot Study

Background: Approximately 10% - 15% of people diagnosed with a concussion develop post-concussion syndrome (PCS), in which mental fatigue is a dominating symptom. PCS has major consequences for the individuals diagnosed, and society as a whole. Objective: The objective of the pilot study was to investigate whether a nature-based therapeutic (NBT) intervention would be suitable for ameliorating the symptoms experienced by people with PCS, especially mental fatigue. Method: Eight participants diagnosed with PCS took part in a NBT programme, which consisted of weekly two-hour sessions over the course of eight weeks. The participants’ level of mental fatigue was measured on the Mental Fatigue Scale (MFS) before and after the intervention. An analogue scale inspired by the EuroQol-visual analogue scales (EQ-VAS) was used to measure immediate self-perceived feeling of health/ well-being before and after individual sessions. A semi-structured interview was held with each participant after the intervention. The interviews and logbooks were analysed through content analysis, which entails several steps in a spiral-like process, from reading and re-reading the transcripts to forming units of meaning, which were then grouped into sub-categories and categories for further analysis. Result: The MFS showed a significant decrease in mental fatigue and large effect size. The participants’ self-assessed health/ well-being on the analogue scale showed an increase from the beginning to the end of each session. The analysis of the interviews revealed that the participants experienced the sensory stimuli and exercises in the natural environment as motivating and meaningful, even when they were challenging. Further, they found the psycho-educational aspects transferable to everyday life. Conclusion: The results support that NBT can have potential in the rehabilitation of PCS, by lowering mental fatigue and improving health and well-being. The NBT was further found to be experienced as enjoyable and motivating with good transferability to everyday life.

What do coaches want to know about sports-related concussion?A needs assessment study

Purpose: This study aims to identify the concussion-related training and education needs of Gaelic Athletic Association(GAA) coaches in Ireland,as well as the preferred method of concussion education delivery.Methods: We used a self-report questionnaire to collect data from a convenience sample of 108 GAA coaches in Ireland. Data were captured on(1) informational needs and desires,(2) preferred methods of delivery, and(3) concussion practices and procedures. Questionnaires were completed electronically from June 3 rd–September 29 th, 2015.Results: Coaches indicated that they were most interested in receiving information about the(1) signs and symptoms of concussion,(2) assessment of concussion, and(3) return-to-play guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population. Additionally, only 10% coaches reported that before the start of the season they talked to their athletes about concussion management and safety, and this was more common among coaches who reported being formally educated about concussion.Conclusion: Our findings reveal a disconnect between the concussion education needs and the education that is currently provided to GAA coaches, in terms of content and delivery modality. Our results suggest a need for a multifaceted approach to concussion education, tailored to the needs and learning preferences of the target population.

有限元方法在脑震荡领域的热点:脑损伤模型、测试方法与防护装备的改进

背景:由身体接触性运动或交通事故造成的脑震荡远比人们想象的更为严重与常见,近年来引起了媒体、医学界及体育界的广泛关注与高度重视。目的:采用文献计量学方法对有限元方法在脑震荡领域的研究热点与趋势进行可视化分析,从而为中国在该领域的研究提供一定的参考。方法:基于Web of Science核心集数据库进行文献检索,检索主题词策略为(TS=(Concussion)) AND TS=(Finite element),利用CiteSpace 6.2.R4可视化工具对纳入文献的作者、国家、机构、关键词及被引文献等进行可视化分析。结果与结论:(1)共计纳入215篇文献,发文量与被引量总体上呈上升趋势;学科分布涉及生物医学工程、生物物理学、运动科学、临床神经学及神经科学等学科,呈现多学科交叉融合的趋势;发文量最多的作者是来自爱尔兰都柏林大学的Gilchrist M,发文量最多的机构是渥太华大学,发文量最多的国家是美国。(2)通过关键词分析发现研究的热点聚焦于脑损伤模型的建立用来模拟和预测脑震荡的损伤;脑震荡损伤机制的解析;防护设备和装置的优化设计。(3)通过文献共被引分析发现脑损伤的预测与评估是该领域的知识基础亦是研究热点。(4)有限元方法运用在脑震荡领域的研究热点主要围绕头部损伤预测为主题展开,结合探索大脑损伤机制以及防护装备的设计与改进。(5)随着人工智能与材料学的进步,未来有限元方法在脑震荡损伤领域的研究热点将集中于脑损伤模型、测试方法与防护装备的改进。

脑创伤致脑震荡患者UCHL1水平和认知功能的相关性

目的 探讨脑创伤致脑震荡患者泛素羧基末端水解酶-1(UCHL1)水平和认知功能的相关性。方法 选取2018年1月至2019年11月该院收治的脑创伤所致脑震荡患者126例设为观察组,以认知功能评分中位数为界分为高分组(>65分)和低分组(≤6分),每组63例。选取同期在该院进行健康体检者100例设为对照组。记录观察组入院后临床资料,包括年龄、性别、体重指数、入院时间、临床体征等,并且根据韦氏智力测试记忆测试评判患者认知功能,比较与分析2组研究对象UCHL1水平。结果 观察组患者UCHL1水平明显高于对照组,高分组患者认知功能评分明显高于低分组,高分组患者UCHL1水平明显低于低分组,差异均有统计学意义(P<0.05);高分组患者年龄、性别、文化程度、UCHL1水平与低分组比较,差异均有统计学意义(P<0.05);年龄、性别、文化程度、UCHL1水平均为影响因素,其中年龄、UCHL1水平为独立危险因素,差异均有统计学意义(P<0.05)。结论 脑创伤致脑震荡患者UCHL1水平可作为认知功能独立危险因素,检测UCHL1水平可准确反映患者认知功能和预后情况。

脑CT灌注成像对轻型颅脑损伤预后的评估价值

目的探讨脑CT灌注成像技术对轻型颅脑损伤(mTBI)患者预后的评估价值。方法收集2020-01至2022-01联勤保障部队第908医院轻型颅脑损伤患者34例,行头颅64排CT平扫及脑CT灌注成像检查,脑创伤后1个月对患者进行随访及Rivermead脑震荡症状问卷评分(RPQ)作为预后评估指标。结果30例(88.2%)发现脑灌注异常,12例(35.3%)出现脑震荡后综合征(PCS)阳性(RPQ>14分),4例(11.8%)未见异常灌注改变。30例灌注异常患者中PCS阳性11例(36.7%),4例无灌注异常患者PCS阳性中仅1例(25.0%)。灌注异常区域主要表现为额叶或颞叶局灶性低灌注改变。结论脑CT灌注成像有助于了解mTBI患者血流动力学变化情况,对评价病情严重程度,及时纠正脑微循环异常具有重要意义。

Cognitive disorder in brain concussion

这份报纸有关流行和与大脑震动联系的认知缺陷的临床的特征论述了原来的学习结果。80 个连续病人的认知功能(吝啬的年龄 = 37.40 獩搠癥汥灯摥懌 ? 懌 ?

磁共振波谱成像、事件相关电位及脑震荡后综合征问卷评分在轻度创伤性脑损伤中的应用价值研究

背景轻度创伤性脑损伤(mTBI)较常见且其引发的脑震荡后综合征严重困扰着患者的生活,由于其临床表现相对主观,相关辅助检查阳性率不高,临床诊断尚存争议,因此探寻早期诊断、评估预后的有效检测手段尤为重要。目的探讨磁共振波谱成像(MRS)、事件相关电位(P300)及脑震荡后综合征问卷(RPQ)评分在mTBI中的应用价值。方法 2012年5月—2015年6月选取东莞东华医院符合纳入标准的mTBI患者30例为病例组,同期选取于本院体检健康的志愿者30例为对照组。两组分别进行MRI检查、P300检测和RPQ评分,分别测量其大脑的基底核、额叶白质、半卵圆中心、胼胝体膝部、胼胝体压部左侧及其右侧的代谢物[N-乙酰天冬氨酸(NAA)、肌酸(Cr)、胆碱(Cho)]水平,并记录病例组患侧、健侧NAA/Cr、Cho/Cr,对照组左侧、右侧NAA/Cr、Cho/Cr,记录两组P300波幅、P300潜伏期、RPQ评分。结果两组常规MRI检查均未见异常,病例组额叶白质、半卵圆中心患侧NAA峰较其健侧下降、Cho峰较其健侧升高。对照组基底核、额叶白质、半卵圆中心、胼胝体膝部、胼胝体压部左侧NAA/Cr、Cho/Cr与右侧比较,差异无统计学意义(P>0.05);病例组基底核、胼胝体膝部、胼胝体压部患侧NAA/Cr、Cho/Cr与健侧比较,差异无统计学意义(P>0.05);病例组额叶白质、半卵圆中心患侧NAA/Cr小于健侧,Cho/Cr大于健侧(P<0.05)。病例组P300波幅小于对照组,P300潜伏期、RPQ评分大于对照组(P<0.05)。病例组额叶白质、半卵圆中心患侧的NAA/Cr与P300波幅呈正相关(r=0.874,P<0.001;r=0.883,P<0.001),与P300潜伏期(r=-0.813,P<0.001;r=-0.850,P<0.001)、RPQ评分(r=-0.617,P<0.001;r=-0.627,P<0.001)均呈负相关;病例组额叶白质、半卵圆中心患侧的Cho/Cr与P300波幅均呈负相关(r=-0.862,P<0.001;r=-0.749,P<0.001),与P300潜伏期(r=0.607,P<0.001;r=0.552,P=0.002)、RPQ评分(r=0.786,P<0.001;r=0.558,P=0.001)均呈正相关。结论 MRS能从分子层面反映mTBI患者伤后脑组织的生化及组织代谢的变化情况,P300能客观地反映mTBI患者的认知功能受损情况,RPQ评分能较客观地反映mTBI患者脑震荡后综合征的严重程度,三者结合在mTBI的早期诊断、评估及预后中有着重要意义。

5-羟色胺在大鼠实验性脑震荡脑组织中的表达

目的 探讨5-羟色胺在大鼠实验性脑震荡脑组织中的表达及其意义。方法 采用Wistar雄性二级大鼠复制脑震荡动物模型,于伤后1、3、7、14及30 d取脑组织,经免疫组化等技术研究5-羟色胺在脑震荡发生发展中的变化规律。结果 100g组见典型脑震荡的临床表现,其病理改变为脑血管收缩与扩张,脑组织淤血、水肿,神经元变性、坏死,尼氏体减少甚至消失。5-羟色胺于伤后1d表达增强,3d达高峰,7d后开始减少,而于14d后逐渐恢复至正常水平。阳性染色见于大脑、海马、丘脑及小脑神经元胞浆内。结论 脑震荡以血液循环障碍和实质细胞变性、坏死为主要病理改变;5-羟色胺参与脑震荡发生时脑组织损伤的病理过程,可能是脑震荡时脑损伤的重要原因之一。

脑震荡前后大鼠听力及耳蜗形态变化

目的观察脑震荡前后Wistar大鼠畸变产物耳声发射(distortion product otoacoustic emissions,DPOAE)、听性脑干反应(auditory brainstemresponses,ABR)阈值及耳蜗形态的变化。方法40只健康雄性Wistar大鼠随机分成4组,分别为撞击前组,撞击后30分钟组,撞击后1小时组以及撞击后1天组,各组10只。选用0.5、0.7、1、1.4、2、3、4、6及8kHz共9个频率点进行DPOAE(f2/f1=1.2,L1=65dBSPL,L2=55dBSPL)幅值测试,同时进行ABR阈值检测。并进行耳蜗毛细胞及周围组织形态学观察。结果撞击前测得的ABR反应阈值分别与撞击后30分钟、撞击后1小时及撞击后1天比较,反应阈值升高,差异有显著性意义(P<0.05)。DPOAE测试显示,撞击前分别与撞击后30分钟、1小时和1天比较,在2kHz时其幅值均有显著性差异(P<0.05),即撞击后出现DPOAE幅值下降。这一结果与形态学结果相吻合。结论撞击后DPOAE幅值在频率2kHz时下降,ABR反应阈值和DPOAE检测幅值的改变说明脑震荡对耳蜗外毛细胞有一定的损害。

脑震荡对大鼠多巴胺能神经元及神经纤维的影响

目的：探讨脑震荡(BC)鼠多巴胺能神经元和神经纤维内酪氨酸羟化酶(TH)含量的变化。方法：用金属单摆打击装置复制 BC 模型。动物随机分为对照组和伤后1～24 d 损伤组；用免疫组织化学结合图像分析方法研究 BC 后中脑黑质致密区(SNC)和腹侧被盖区(VTA)多巴胺能神经元及基底节尾壳核多巴胺能神经纤维 TH 含量的变化。结果：在 SNC 和 VTA 及基底节,BC 后1、4、8及16 d 组的 TH 免疫反应阳性明显高于对照组,其中以4d 组反应最强,24 d 组在 SNC 和基底节与对照组比较无显著性差异,但在 VTA,TH 免疫反应阳性仍高于对照组。结论：BC 后 TH 早期增高可能是脑损伤神经元过度兴奋的反应,随后持续增高一段时间可能是多巴胺能神经元上调其合成能力的一种代偿反应。

实验性大鼠脑震荡后Bcl-2的表达

目的观察实验性大鼠脑震荡后Bcl-2表达的变化规律。方法应用免疫组织化学方法检测大鼠脑震荡后不同时间大脑皮层、脑干和小脑等脑区内Bcl-2表达的变化规律进行研究。结果对照组大鼠未见Bcl-2蛋白的表达。脑震荡组损伤后1h组可在神经细胞内观察到少量Bcl-2蛋白的表达,4d达到高峰,8d和16d,Bcl-2蛋白表达随后逐渐下降。结论Bcl-2的检测可能成为脑震荡的诊断和脑损伤时间推断的一个敏感指标。