Concussion and the Sleeping Brain.

BACKGROUND: Emerging research has suggested sleep to be a modifier of the trajectory of concussion recovery in adolescent and adult populations. Despite the growing recognition of the relationship between sleep and concussion, the mechanisms and physiological processes governing this association have yet to be established. MAIN BODY: Following a concussion, a pathophysiologic cascade of events occurs, characterized by numerous factors including microglia activation, ionic imbalance, and release of excitatory neurotransmitters. Importantly, each of these factors plays a role in the regulation of the sleep-wake cycle. Therefore, dysregulation of sleep following injury may be a function of the diffuse disruption of cerebral functioning in the wake of both axonal damage and secondary physiological events. As the onset of sleep-related symptoms is highly variable following a concussion, clinicians should be aware of when and how these symptoms present. Post-injury changes in sleep have been reported in the acute, sub-acute, and chronic phases of recovery and can prolong symptom resolution, affect neurocognitive performance, and influence mood state. Though these changes support sleep as a modifier of recovery, limited guidance exists for clinicians or their patients in the management of sleep after concussion. This may be attributed to the fact that research has correlated sleep with concussion recovery but has failed to explain why the correlation exists. Sleep is a complex, multifactorial process and the changes seen in sleep that are seen following concussion are the result of interactions amongst numerous processes that regulate the sleep-wake cycle. SHORT CONCLUSION: The assessment and management of sleep by identifying and considering the biological, sociological, and psychological interactions of this multifactorial process will allow for clinicians to address the dynamic nature of changes in sleep following concussion.

Influence of sleep symptoms on recovery from concussion in collegiate athletes: a LIMBIC MATARS consortium investigation.

OBJECTIVE: Changes in sleep quality and quantity are commonly endorsed by individuals following a concussion. Limited data exists examining the role of sleep disturbances within 72 hours, and throughout recovery, from concussion. The objective of this study was to determine if the number of days to symptom resolution varied between collegiate athletes with or without sleep-related symptoms following a concussion. DESIGN: Retrospective chart review. METHODS: Collegiate athletes (n = 539) who were diagnosed with a concussion between the 2015-2020 sport seasons participated in this retrospective chart review. Participants were divided into groups based on the presence or absence of sleep symptoms within 72 hours of a diagnosed concussion. A Mann-Whitney U test was used to compare days to symptom resolution between groups with α = 0.05. RESULTS: Of the 539 participants, 250 (46.3%) reported sleep-related symptoms. Participants with sleep-related symptoms took significantly longer (U = 30656, p = 0.002) to report symptom resolution at rest (median [full range] = 8.00[0-423]) as compared to participants who did not report sleep-related symptoms (6.00[0-243] days). CONCLUSION: Collegiate athletes that report sleep-related symptoms immediately following concussion (<72 hours) were observed to take, on median, two days longer to achieve symptom resolution at rest when compared to athletes who did not endorse the same symptoms.

The Influence of Race on Time to Symptom Resolution Following Sport Concussion in Collegiate Athletes.

CONTEXT: Race has been shown to influence computerized neurocognitive test scores, motor function test scores, and reported symptomology following sport-related concussion (SRC). However, the effect race may have on recovery time following SRC remains unknown. The objective of this study was to determine the influence of race on days until symptom free from SRC in NCAA Division 1 collegiate athletes. DESIGN: Prospective cohort study. METHODS: Participants were Black (n = 53 [28% female]) and White (n = 150 [43.3% female]) who were on average 19.0 (1.21) and 20.2 (1.3) years of age, respectively. Data were collected from the 2015-2016 to 2020-2021 collegiate sport seasons. Participants were evaluated before and after an SRC at empirically derived time points. The primary outcome measure was time until symptom free (days). Additional outcomes included baseline and postinjury Immediate Postconcussion Assessment and Cognitive Test and Sensory Organization Test (SOT) scores. A Mann-Whitney U test compared days to symptom free between groups. Immediate Postconcussion Assessment and Cognitive Test and SOT outcome scores were analyzed using a 2 (group) × 2 (time) analysis of variance. RESULTS: White participants had a longer median recovery time (9 d) to symptom free compared with Black participants (6 d [P = .04]). Statistically significant differences were observed between Black 87.3 (9.84) and White 90.4 (8.30) groups for Immediate Postconcussion Assessment and Cognitive Test's verbal memory composite score (P = .03). Postinjury, White participants scored significantly higher 44.5 (5.63) on visual motor speed compared with Black participants (42.4 (5.90) [P = .02]). Within-group SOT differences between baseline and postinjury testing were observed in both groups (all P < .001). CONCLUSIONS: Black collegiate athletes achieved symptom resolution sooner than White athletes. We did not explore underlying sociocultural factors such as socioeconomic status or previous concussion education, which may have influenced our results. Future studies should explore factors that may contextualize these findings.

False-Positive Rates, Risk Factors, and Interpretations of the Vestibular Ocular Motor Screen in Collegiate Athletes.

CONTEXT: Biological sex and history of motion sickness are known modifiers associated with a false-positive baseline Vestibular Ocular Motor Screen (VOMS). However, other factors may associate with a false-positive VOMS in collegiate athletes. OBJECTIVE: Identify contributing factors to false-positive VOMS assessments using population specific criteria. We also critically appraised previously reported interpretation criterion. DESIGN: Descriptive Laboratory. SETTING: Single site collegiate athletic training clinic. PATIENTS OR OTHER PARTICIPANTS: NCAA Division 1 athletes (n=462[41% female]) who were 18.8±1.4 years old. MAIN OUTCOME MEASURES: Participants completed the Athlete Sleep Behavior Questionnaire (ASBQ), Generalized Anxiety Index (GAD-7), the ImPACT battery, Patient Health Questionnaire (PHQ-9), Revised Head Injury Scale (HIS-r), the Sensory Organization Test (SOT), and the VOMS as part of a multidimensional baseline concussion assessment. Participants were classified into two groups based on whether they had a total symptom score of ≥8 following VOMS administration, excluding the baseline checklist. Chi-squared (χ2) and independent t-tests compared group demographics. A binary logistic regression with adjusted odds ratios (OR) evaluated the influence of sex, corrected vision, ADHD, ImPACT composite scores, concussion history, a history of treatment for headache and/or migraine, GAD-7, PHQ-9, ASBQ, and SOT Equilibrium Score, and Somatosensory, Visual, and Vestibular sensory ratios on false-positive rates. RESULTS: Approximately 9.1% (42/462 [30 females]) met criteria for a false-positive VOMS. A significantly greater proportion of females had false-positives (χ2(1) = 18.37, p < 0.001). Female sex (OR=2.79, 95% CI [1.17-6.65], p =.02) and history of treatment for headache (OR=4.99, 95% CI [1.21-20.59], p=0.026) were the only significant predictors of false-positive VOMS. Depending on cutoff interpretation, false-positive rates using our data ranged from 9.1%-22.5%. CONCLUSIONS: Our results support the most recent interpretation guidelines for the VOMS in collegiate athletes due to a low false-positive rate and ease of interpretation. Biological sex and history of headaches should be considered when administering the VOMS in the absence of a baseline.

Kinesiophobia Is Related to Acute Musculoskeletal Injury Incidence Following Concussion.

CONTEXT: Athletes with a history of sport concussion (SC) have an increased risk of musculoskeletal injury (MSK); however, the underlying mechanisms have yet to be determined. The purpose of our study was to evaluate kinesiophobia in college athletes with or without a time-loss MSK within 180 days of unrestricted return to play following a SC. DESIGN: This was a retrospective cohort study within a sports medicine facility. METHODS: Participants were eligible if they were diagnosed with a SC, completed the Tampa Scale of Kinesiophobia (TSK), and completed an unrestricted return to play. Fifty-six college athletes (40 men and 16 women) with an average age of 19.5 (1.25) years, height of 183.5 (10.45) cm, and mass of 94.72 (24.65) kg, were included in the study. MSK participants were matched to non-MSK participants 1:1. Demographic and TSK outcome scores were compared using independent t tests. The proportion of participants in each group who scored above the clinical threshold (TSK ≥ 37) was compared using a chi-square analysis. Alpha was set at α = .05. RESULTS: The MSK group (31.2 [6.30]) reported similar TSK scores to the matched group (28.9 [3.34]; t54 = 1.70, P = .10, d = 0.45 [-0.08 to 0.97]). A greater proportion of athletes who were diagnosed with an MSK-reported scores above the cutoff (χ2[1] = 6.49, P = .01). CONCLUSIONS: Athletes diagnosed with SC had similar kinesiophobia values regardless of MSK status. However, a higher proportion of athletes with a time-loss MSK injury reported a TSK score greater than the clinical cutoff. Our results suggest that factors such as kinesiophobia should be considered following a SC.

Neuropsychological and Balance Symptoms of Abused Women Who Have Experienced Intimate Partner Violence-Related Strangulation: A Feasibility and Acceptability Study.

Intimate partner violence (IPV) is a public health crisis that results in acute and long-term health consequences for women, including potential acquired brain injury from non-fatal strangulation. Despite existing evidence on the neuropsychological sequelae experienced by women after experiencing IPV-related assault, limited evidence-based treatment protocols exist for these women. This 14-month study sought to: 1) assess the feasibility and acceptability of recruiting women who experienced strangulation associated with IPV within 7 days of the event and retaining them throughout a 3-month follow-up period; and 2) examine preliminary data from neuropsychological, balance, and symptom assessments. Inclusion criteria were: reported strangulation by an intimate partner in the past 7 days, female, 18-60 years of age, English speaking, and able to consent. Neuropsychological, balance, and symptom assessments were administered at the first time point and again 3 months later. Participants also completed a standardized daily symptom inventory. Eight participants (73%) were recruited and completed daily inventories and the baseline assessment; 4 (36%) completed the baseline and 3-month assessments. Of the 4 participants who completed the 3-month assessment, none reported symptom resolution. Only balance returned to values consistent with normative values. Our results demonstrate the ability to recruit women who have experienced IPV-related strangulation during the post-acute phase of injury with less success retaining participants for a 90-day period for follow-up study. This pilot research protocol demonstrated the feasibility of recruitment from the emergency department and systematic evaluation of neuropsychological and functional symptoms in women who experienced strangulation in the context of IPV.