Exercise Parameters for Postconcussion Symptom Rehabilitation: A Systematic Review.

CONTEXT: Exercise rehabilitation for postconcussion symptoms (PCS) has shown some benefits in adolescent athletes; but a synthesis of evidence on exercise per se has been lacking. OBJECTIVE: This systematic review aimed to determine if unimodal exercise interventions are useful to treat PCS and if so, to identify a set of clearly defined and effective exercise parameters for further research. EVIDENCE ACQUISITION: Relevant health databases and clinical trial registries were searched from inception to June 2022. The searches used a combination of subject headings and keywords related to mild traumatic brain injury (mTBI), PCSs, and exercise. Two independent reviewers screened and appraised the literature. The Cochrane Collaboration's Risk of Bias-2 tool for randomized controlled trials was used to assess methodological quality of studies. EVIDENCE SYNTHESIS: Seven studies were included in the review. Four studies were assessed to have a low overall risk of bias, 2 with low risk and 1 with some concerns. Participants in the studies comprised mostly adolescents with sports-related concussion. The review found exercise to be more beneficial than control conditions in 2 studies investigating acute PCS and 2 studies investigating persistent PCS. Within-group differences showing symptom improvement over time were observed in all 7 studies. In general, the review found support for programmatic exercise that commences after an initial period of rest for 24 to 48 hours. Recommendations for exercise parameters that can be explored in subsequent research include progressive aerobic exercise starting from 10 to 15 minutes at least 4 times a week, at a starting intensity of 50% HR of the subsymptom threshold, with length of program depending on recovery. CONCLUSION: The evidence in support of exercise rehabilitation for PCSs is moderate based on the small pool of eligible studies. Further research can be guided by the exercise parameters identified in this review.

Widespread Introduction of a High-Sensitivity Troponin Assay: Assessing the Impact on Patients and Health Services.

Adoption of High-sensitivity troponin (hs-cTn) assays by hospitals worldwide is increasing. We sought to determine the effects of a simultaneous state-wide hs-cTn assay introduction on the implementing health service. A quasi-experimental pre-post design was used. Participants included all adult patients presenting to 21 Australian hospitals who had troponin testing commenced within the Emergency Department (ED). Data were collected for 124,357 episodes of care between 30 April 2018 and 23 April 2019; six months pre- and six months post-implementation of the assay. The primary outcome was hospital length of stay (LOS). Secondary outcomes included ED LOS, 90-day cardiovascular mortality, elevated troponin, diagnosis of acute myocardial infarction (AMI), admission to a cardiology ward, invasive cardiac procedures, and total hospital costs. Following hs-cTn implementation, there was a 1.9-h (95% CI: -2.9 to -1.0 h) reduction in overall LOS. This equated to a cost saving of over 9 million Australian dollars per year. There was no increase in diagnosis of AMI, invasive cardiac procedures or ward admissions. The use of hs-cTn assays facilitates important benefits for health services by enabling more rapid evaluation protocols within the ED. This benefit may be considerable given the large cohort of emergency patients with possible ACS.

Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research.

BACKGROUND: Guideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians' perceptions of facilitators and barriers to the use of the IMPACT protocol. METHODS: Guided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use. RESULTS: Domains most often reported as fundamental to the use of the IMPACT protocol included 'social/professional role and identity', 'environmental context and resources' and 'social influences'. These factors seemingly influenced professional confidence, with participants noting 'goals' that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain 'environmental context and resources' also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education - both formal and informal. CONCLUSIONS: A range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.

Effects of Dance on Gait, Cognition, and Dual-Tasking in Parkinson's Disease: A Systematic Review and Meta-Analysis.

Dance-based interventions have been proposed for the management of Parkinson's disease (PD) symptoms. This review critically appraises and synthesises the research on the effects of dance interventions on gait, cognition and dual-tasking in PD, through a meta-analysis of peer-reviewed literature from seven databases. Eligible studies included people with PD, used a parallel-group or cohort design with a dance-based intervention, reported outcome measures of gait, cognition or dual-tasking, and were published in English up until September 2017. Of the initial 1079 articles, 677 articles were reviewed for eligibility, and 25 articles were retained. Only 12 articles had sufficient common assessment items for meta-analysis. Two independent reviewers extracted the data and assessed the risk of bias of each study using the Cochrane risk-of-bias tool. Based on pre-post change scores, gait speed, Timed Up and Go (TUG) test performance, freezing of gait questionnaire, and six-minute walk test times significantly improved after a dance intervention compared to controls. Global cognition assessed with Montreal Cognitive Assessment, and cognitive dual-tasking measured using dual-task TUG, also exhibited greater improvement in dance groups. There was limited evidence to determine the most effective intensity, frequency, duration of dance interventions or the most beneficial music. Findings must be interpreted cautiously because of the lack of randomised control trials, and the moderate to high risk of bias of studies. However, the results of papers with level-I and level-II.1 evidence suggest that dance may have the potential to ameliorate PD symptoms, particularly gait, global cognition and cognitive dual-tasking.

Agreement Between Patient-reported and Cardiology-adjudicated Medical History in Patients With Possible Ischemic Chest Pain: An Observational Study.

OBJECTIVE: Obtaining an accurate medical history is essential in the assessment of patients, particularly in emergency department (ED) patients with acute chest pain, as there can be a time imperative for diagnosis and commencement of treatment. We aimed to evaluate reliability of patient-reported compared with physician-adjudicated medical history by assessing patient's recall and communication of personal events and its influence on the accuracy of the medical history. METHODS: A total of 776 patients presenting at ED with suspected cardiac chest pain were recruited. Data collection included self-reported patient history, electrocardiogram testing, and troponin I measurements. Independent assessment of risk factors and medical history was adjudicated by cardiologists. Diagnosis of acute coronary syndrome (ACS) at 30 days after presentation was assessed. Cohen's kappa measured patient-cardiologist agreement. Cardiologist adjudicated events were taken as true to assess accuracy. RESULTS: A total of 83 participants (10.7%) were diagnosed with ACS at 30 days after presentation. "Previous coronary artery bypass grafting" showed highest agreement (K = 1.00) between patient-reported and cardiologist-adjudicated events. Lowest agreement between patient-reported and cardiologist-adjudicated events was found for "prior ventricular dysrhythmia" (K = 0.33). Accuracy of reported "prior congestive heart failure" differed significantly between patients with and without diagnosed ACS at 30 days (92.8% and 97.5%, respectively). CONCLUSIONS: Accuracy of patient's recall and communication of medical history and risk factors was substantial but not perfect in the assessment of patients with ACS in the ED context. Our study reinforces the importance in the utilization of medical records and collateral information to address possible discrepancies in the medical history and improve patient care.

Poor sleep predicts subacute postconcussion symptoms following mild traumatic brain injury.

The primary objective was to determine if poor sleep predicts postconcussion symptoms in the subacute period after mild traumatic brain injury (TBI). The impact of poor sleep pre- and post-injury was examined. The research design was cross-sectional. After screening to detect response invalidity, 61 individuals with a self-reported history of mild TBI 1-to-6 months prior answered an online fixed order battery of standardized questionnaires assessing their sleep (current and preinjury) and persistent postconcussion symptoms (Neurobehavioral Symptom Inventory, minus sleep, and fatigue items). The sleep measures were the Insomnia Severity Index, Epworth Sleepiness Scale, a single Likert-scale pre-injury sleep quality rating, and two PROMIS™ measures (sleep-related impairment and sleep disturbance). After controlling for the effects of preinjury sleep quality and demographics, the combination of the sleep measures made a significant contribution to the outcome (F[8,58] = 4.013, p = .001, [Formula: see text]). Only current sleep-related impairment (ß = .60, p < .05) made a significant and unique contribution to neurobehavioral symptoms. Preinjury sleep was not a predictor (ß = -.19, p > .05), although it contributed 3% of the variance in NSI scores after controlling for demographics. Sleep-related impairment is a modifiable factor. As a significant contributor to neurobehavioral symptoms, treatment for post-injury sleep-related impairment warrants further attention.

Sex-specific versus overall cut points for a high sensitivity troponin I assay in predicting 1-year outcomes in emergency patients presenting with chest pain.

OBJECTIVE: To evaluate the incidence of major adverse cardiac events (MACE) at 1 year in emergency department (ED) patients with possible acute coronary syndromes, stratified by high sensitivity troponin (hs-cTnI) concentrations using sex-specific cut points compared with overall cut points. METHODS: In a multicentre observational study of 2841 patients, presentation hs-cTnI concentrations were categorised using sex-specific (women 16 ng/L; men 34 ng/L) and overall (26 ng/L) cut points. The primary outcome was MACE occurring within 1 year of presentation. Patients with hs-cTnI values concentrations within these categories were reported by sex and 1-year MACE. Net reclassification improvement (NRI) was computed to measure the change in prediction after altering the hs-cTnI cut points, and was calculated separately for events and non-events. RESULTS: Application of sex-specific 99th percentile cut points rather than the overall cut point of 26 ng/L, reclassified 25 females from having a non-elevated troponin to having an elevated troponin, and 29 males from having an elevated troponin value to having a non-elevated troponin value on presentation. Of these, 7 (28.0%) females and 12 (41.4%) males had a 1-year MACE. There was no reclassification improvement for those with or without 1-year MACE (NRIevents=-1.5%, 95% CI -4.0% to 1.1%; NRInon-events -0.04%, 95% CI -0.5% to 0.4%). CONCLUSIONS: Sex-specific cut points improve the identification of women but not men at risk for 1-year MACE. The net-effect across the whole ED population with possible cardiac chest pain is minimal. Lowering the clinical cut point for both sexes may be appropriate for prognostic purposes. TRIAL REGISTRATION NUMBER: ISRCTN No. 21109279, ACTRN12609000283279.