A Comparison of Generalized and Individualized Vestibular Rehabilitation Therapy in a Military TBI Sample.

OBJECTIVE: To compare clinical outcomes between active duty service members receiving generalized versus individualized vestibular rehabilitation treatment (GVRT and IVRT, respectively) for persistent vestibular-related symptoms following mild traumatic brain injury (mTBI). SETTING: An outpatient TBI rehabilitation clinic. PARTICIPANTS: Fifty-seven participants with persistent vestibular-related symptoms following mTBI were randomly assigned to the GVRT ( n = 28) or IVRT ( n = 29) group, stratified by dizziness-related impairment severity. Forty-two participants ( n = 21 per group) completed the posttreatment evaluation and were included in analyses. DESIGN: We employed a single-site, randomized, pre-/posttest experimental design. The GVRT program consisted of eight 45-minute group-based treatment sessions and IVRT consisted of three 30-minute one-on-one treatment sessions both to be completed within 8 weeks. Group assignment was not blinded to study personnel or participants. Research evaluations were completed approximately 2 weeks prior to treatment initiation and following treatment completion. MAIN MEASURES: Outcome measures included Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC) total scores, Sensory Organization Test (SOT) composite equilibrium and sensory input ratio scores, Head Shake SOT (HS-SOT) conditions 2 and 5, and horizontal and vertical Dynamic Visual Acuity. Separate mixed-effects models were used to compare clinical outcomes between the GVRT and IVRT groups. RESULTS: Both groups demonstrated significant improvement from pre- to posttreatment on self-reported dizziness-related impairment (DHI [ F(1,41) = 16.28, P < .001]) and balance performance with and without head movement (composite equilibrium score [ F(1,41) = 16.58, P < .001, effect size [ES] = 0.43], somatosensory [ F(1,41) = 6.79, P = .013, ES = 0.26], visual [ F(1,41) = 6.49, P = .015, ES = 0.29], vestibular [ F(1,41) = 22.31, P < .001, ES = 0.55], and HS-SOT condition 5 [ F(1,38) = 23.98, P < .001, ES = 0.64]). Treatment effects did not differ between groups on any of the outcome measures. CONCLUSIONS: We provide preliminary evidence that differences in clinical outcomes do not exist between participants receiving generalized versus individualized VR. Further research is needed to determine comparative effectiveness between these 2 treatment approaches for persistent vestibular-related symptoms following mTBI.

Progressive Visual Occlusion and Postural Control Responses in Individuals With and Without Chronic Ankle Instability.

CONTEXT: Prophylactic and rehabilitative balance training is needed to maximize postural control and develop appropriate sensory organization strategies. Partially occluding vision during functional exercise may promote appropriate sensory organization strategies, but little is known about the influence of partially occluded vision on postural control in those with and without a history of musculoskeletal injury. OBJECTIVE: To determine the effect of increasing levels of visual occlusion on postural control in a heterogeneous sample of those with and without chronic ankle instability (CAI). The secondary objective was to explore postural control responses to increasing levels of visual occlusion among those with unilateral and bilateral CAI relative to uninjured controls. DESIGN: Cross-sectional. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-five participants with unilateral CAI, 10 with bilateral CAI, and 16 participants with no history of lower extremity injury. MAIN OUTCOME MEASURES: All participants completed four 3-minute postural control assessments in double-limb stance under the following 4 visual conditions: (1) eyes open, (2) low occlusion, (3) high occlusion, and (4) eyes closed. Low- and high-occlusion conditions were produced using stroboscopic eyewear. Postural control outcomes included time-to-boundary minima means in the anteroposterior (TTB-AP) and mediolateral directions (TTB-ML). Repeated-measures analysis of variances tested the effects of visual condition on TTB-AP and TTB-ML. RESULTS: Postural control under the eyes-open condition was significantly better (ie, higher) than the limited visual occlusion and eyes-closed conditions (P < .001) for TTB-AP and TTB-ML. For TTB-AP only, partially occluded vision resulted in better postural control than the eyes-closed condition (P ≤ .003). CONCLUSIONS: Partial and complete visual occlusion impaired postural control during dual-limb stance in a heterogeneous sample of those with and without CAI. Stroboscopic eyewear appears to induce postural control impairments to the same extent as complete visual occlusion in the mediolateral direction.

Considerations for Athletic Trainers: A Review of Guidance on Mild Traumatic Brain Injury Among Children From the Centers for Disease Control and Prevention and the National Athletic Trainers' Association.

The Centers for Disease Control and Prevention recently published an evidence-based guideline, "Diagnosis and Management of Mild Traumatic Brain Injury (mTBI) Among Children." The guideline has many applications for athletic trainers. The following commentary provides considerations for athletic trainers regarding the guideline in conjunction with the current National Athletic Trainers' Association position statement "Management of Sport Concussion" and the "Consensus Statement on Concussion in Sport-The 5th International Conference on Concussion in Sport Held in Berlin, October 2016."

The Effect of Body Checking Policy Changes on Concussion Incidence in Canadian Male Youth Ice Hockey Players: A Critically Appraised Topic.

Clinical Scenario: Current studies have identified body checking as the most common cause of sports-related concussion in ice hockey across all divisions and levels. As a result, many hockey organizations, particularly in youth sports, have implemented rules making body checking to the head, face, and/or neck illegal. Such a rule, in Canada, makes age 13 the first age in which individuals can engage in body checking. Despite these changes, effectiveness of their implementation on the incidence of concussion in Canadian male youth ice hockey players remains unclear. Clinical Question: What is the effect of body checking policy changes on concussion incidence in male youth ice hockey players? Summary of Key Findings: Of the 3 included studies, 2 studies reported a decrease in the incidence of concussion once a body checking policy change was implemented. The third study showed an increase; however, it is important to note that this may be due, in part, to increased awareness leading to better reporting of injuries. Clinical Bottom Line: Current evidence supports a relationship between body checking policy implementation and decreased concussion incidence; however, more research is needed to understand the long-term implications of policy change and the effects in other leagues. In addition, further data are needed to differentiate between increased concussion incidence resulting from concussion education efforts that may improve disclosure and increased concussion incidence as a direct result of policy changes. Strength of Recommendation: Grade B evidence exists that policy changes regarding body checking decrease concussion incidence in male youth ice hockey players.

Baseline Concussion Clinical Measures Are Related to Sensory Organization and Balance.

PURPOSE: This study aimed to examine relationships among baseline demographics, symptom severity, computerized neurocognitive outcomes, and balance performance in collegiate athletes. METHODS: Collegiate varsity athletes (N = 207, age = 19.3 ± 1.0 yr) participating in an ongoing clinical research program who completed concussion baseline assessments including a demographic questionnaire, a graded symptom checklist, a neurocognitive assessment, and the Sensory Organization Test (SOT) were included in this study. The SOT composite equilibrium score (COMP) and three sensory ratio scores-vestibular (VEST), visual (VIS), and somatosensory (SOM)-were used to describe athletes' overall sensory organization and ability to use input from each sensory system to maintain balance. Separate stepwise multiple linear regression models were performed for each SOT outcome. Total symptom severity level and CNS Vital Signs domain scores served as predictor variables. RESULTS: Stepwise regression models for COMP (R = 0.18, F4,201 = 11.29, P < 0.001), VEST (R = 0.14, F4,201 = 8.16, P < 0.001), and VIS (R = 0.10, F4,201 = 5.52, P < 0.001) were all significant. Faster reaction times and higher executive function scores were associated with higher COMP and VEST scores in separate models. Those with faster reaction times also had significantly higher VIS scores. CONCLUSION: Reaction time and executive function demonstrated significant relationships with SOT balance performance. These cognitive processes may influence athletes' ability to organize and process higher-order information and generate appropriate responses to changes in their environment, with respect to balance and injury risk. Future investigations should consider these relationships after injury, and clinicians should be mindful of this relationship when considering concussion management strategies.

Factors Associated with Sport-Related Post-concussion Headache and Opportunities for Treatment.

PURPOSE OF REVIEW: The purpose of this review is to (1) describe factors both pre- and post-injury that are associated with post-concussion headache, (2) describe the influence of post-concussion headache on recovery following concussion, and (3) provide potential post-concussion treatment options that may reduce the burden of headache, as well as other symptoms to facilitate recovery. RECENT FINDINGS: Various factors may be associated with post-concussion headache presentation. These may include pre-injury or historical factors such as sex, family and self-history of headache and migraine, concussion history, and mood disorders. In addition, post-injury presentation factors for consideration may include injury mechanism, symptom clusters, cervicogenic dysfunction, and post-concussion physiologic dysfunction. Despite this complex interplay of factors, many treatment options may improve headache symptoms and recovery post-concussion including rehabilitation programs focusing on deficits such as visual-vestibular dysfunction, sub-symptom threshold exercise, and potential pharmacological interventions. Concussion is a complex injury that results in a variety of sequelae with headache being one of the most common. Understanding factors related to post-concussion headache presentation and the available options for treatment may improve patient care and outcomes post-concussion.

Factors associated with post-concussion syndrome in high school student-athletes.

OBJECTIVES: To identify factors associated with post-concussion syndrome (PCS) among a national sample of high school student-athletes from the 2011/12-2013/14 academic years. DESIGN: Ambispective cohort study from sports injury surveillance data. METHODS: Sport-related concussion data originated from the National Athletic Treatment, Injury and Outcomes Network (NATION) surveillance program, consisting of 27 sports from a convenience sample of 196 high schools across 26 states. All SRCs were reported by certified athletic trainers. The PCS and non-PCS groups consisted of concussed individuals with symptoms resolution time of >4 weeks and ≤2 weeks, respectively. Logistic regression estimated the association of athlete and concussion characteristics on the odds of PCS, and calculated adjusted odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Overall, 1334 concussed high school athletes met inclusion criteria: 215 in the PCS group and 1119 in the non-PCS group. In the multivariable analysis, concussion symptoms associated with increased odds of PCS included: retrograde amnesia (OR=3.01, 95%CI: 1.31-6.91), difficulty concentrating (OR=2.72, 95%CI: 1.56-4.77), disorientation (OR=1.86; 95%CI: 1.04-3.33), insomnia (OR=2.79; 95%CI: 1.62-4.80), loss of balance (OR=1.76; 95%CI: 1.00-3.10), sensitivity to noise (OR=1.80; 95%CI: 1.02-3.17), and visual disturbance (OR=2.21; 95%CI: 1.23-3.97). Sex and recurrent concussion were not associated with PCS. CONCLUSIONS: As in previous research, somatic and cognitive symptoms were associated with PCS. The identification of factors associated with PCS may assist clinicians in identifying concussed athletes at greater risk of having longer symptom resolution time.