Unsteadiness or imbalance may also be reported (suggesting difficulty with maintaining an upright position in space, possibly related to dysfunction of vestibulospinal function, proprioception, vision, or other systems that contribute to upright balance) and should be assessed. This model builds on the previous work, while emphasizing the fact that adaptations occur within the context of sport (both in the presence and absence of injury) that alter risk and affect etiology in a dynamic, recursive fashion. Autonomic function may be disrupted following concussion.25 An increase in symptoms can occur for some individuals when they increase the intensity of physical activity. 11. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment Journal of Orthopaedic & Sports Physical Therapy, Vol. van Winden D, van Rijn RM, Savelsbergh GJP, Oudejans RRD, Stubbe JH. 215-219 View Record in Scopus Google Scholar as well as cognitive, emotional. An integrated model is illustrated which provides a synthesis of existing conceptual models depicting the dynamic process of psychological response to sport injury. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. Studies in basketball, hockey, and rugby have suggested a protective effect of mouthguards on concussion risk; however, a meta-analysis found no significant effect.32 In American youth football, appropriate helmet fit was associated with lower symptom severity and shorter duration of symptoms.44 In ice hockey, appropriate helmet fit may protect against concussion, although further research is needed.41 Studies examining the use of headgear in rugby and soccer are inconclusive.32,95 Further research is needed to better understand the role of protective equipment by sport. A dynamic, recursive model of etiology in sport injury. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes Investigation of antihypothalamus and antipituitary antibodies in amateur boxers: is chronic repetitive head trauma-induced pituitary dysfunction associated with autoimmunity? In part 2, we address concussion assessment and management. If symptoms recur or are exacerbated, reduce the demands of the task to a level that does not provoke symptoms. Injury, rehabilitation and psychology Written by Jack Marlow. An integrated model is illustrated which provides a syn- thesis of existing conceptual models depicting the dynamic process of psycholog- ical response to sport injury. Criticisms focus on the lack of research supporting a uniformed sequence of stages as a feature of response to athletic injury. @article{Meeuwisse2007ADM, title={A dynamic model of etiology in sport injury: the recursive nature of risk and causation. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment Journal of Orthopaedic&Sports Physical Therapy, Ahead of Print. Steffen K, Myklebust G, Andersen TE, Holme I, Bahr R. Am J Sports Med. These various concepts, along with elements of movement in play, are integrated in a model intended to help players and observers grasp a systemic view of action play and its underlying fulcrums. Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. For example, BPPV may occur in approximately 5% of cases of ongoing dizziness following concussion.2,106 Suspect BPPV when the patient describes seconds of vertigo with positional changes (eg, lying down/getting up, rolling in bed, looking up, bending over).8 For BPPV to be diagnosed, a positive Dix-Hallpike test with seconds of vertigo and a characteristic pattern of nystagmus should be present.8 Canalith repositioning maneuvers (eg, the Epley maneuver) are effective for treating BPPV (up to 98% of cases resolve within 3 treatments).8,75, In up to 10% to 26% of cases of ongoing dizziness following concussion, assessment findings suggest peripheral vestibular hypofunction (ie, decreased vestibular labyrinth function).11,12 Suspect a peripheral vestibular problem in patients who report intense dizziness and unsteadiness following the concussion, followed by a gradual improvement of symptoms over the initial few weeks. Is there a gender difference in concussion incidence and outcomes? Sports physiotherapists and other sports professionals recognise that the identification of the causes of injury is an important step in injury prevention as this can lead to the development of effective injury prevention programs. Every step, competition or practice is an exposure that impacts the body. Once the individual has completed 1 to 2 days of rest, a gradual return to sport and school/work is recommended. A posttraumatic headache (1) is a secondary headache that can be attributed to the injury when a new headache occurs following trauma, and (2) must occur within the initial 7 days after the trauma.46 If a preinjury headache worsens or becomes persistent, the primary headache diagnosis, in addition to the posttraumatic diagnosis as described above, is to be used.46 Headache diagnoses following concussion might also include medication overuse headache, migraine headache (with or without aura), tension-type headache, cervicogenic headache, occipital neuralgia, and mixed headache type.73,74,126. The office (off-field) assessment portion of the SCAT5 includes history, symptoms, cognitive screening (from the Standardized Assessment of Concussion, which includes orientation, immediate and delayed memory questions, and digits and months of the year in reverse order), a neurological screen (including reading, cervical spine range of motion, ocular motor function, coordination, and balance), and a modified version of the Balance Error Scoring System.29 The Child Sport Concussion Assessment Tool Fifth Edition should be used with children aged 5 to 12 years.21, The clinical utility of the SCAT5 diminishes after the initial 3 to 5 days following injury.84 However, the symptom scale on the SCAT5 can be used to evaluate change in symptoms over time. In the presence of ongoing cervical spine findings, further interventional procedures, such as comparative controlled medial branch blocks (to confirm facet joint–mediated pain), trigger point injections (in the presence of ongoing myofascial pain), and greater occipital nerve blockades (in the presence of greater occipital neuralgia), may be considered.26,98, Dizziness is typically the second most common symptom following concussion.7 As with headache, identifying the source of dizziness is important to direct treatment—some disorders respond well to physical therapy (eg, benign paroxysmal positional vertigo [BPPV], unilateral peripheral vestibular hypofunction), while others require medical evaluation and management (eg, superior semicircular canal dehiscence).2,45,48. If symptoms recur, then the athlete should move back to the previous step. Growth hormone is the most commonly affected hormone following concussion.56,63,114,115 Individuals with symptoms consistent with alteration in sex hormones, hypothyroidism, adrenal dysfunction, diabetes insipidus, syndrome of inappropriate antidiuretic hormone secretion, or growth hormone deficiency (fatigue, disrupted sleep patterns, and cognitive difficulties) should be investigated for hypothalamic-pituitary axis dysfunction.114, People with more, and more severe, acute and subacute symptoms take longer to recover following concussion.52 Adolescent age, female sex, the presence of a migraine history, and pre-existing mental health problems are predictors of slower recovery.52 Many other factors (eg, previous history of concussion, preschool age, race, genetics) have been evaluated as potential predictors of longer recovery, with mixed results.52 Attention deficit hyperactivity disorder and learning disabilities are unlikely to be risk factors for prolonged recovery.52 Among youths 5 to 18 years of age who presented to an emergency department, female sex, older than 13 years of age, migraine history, previous concussion with symptoms for greater than 1 week, sensitivity to noise, fatigue, headache, parent reporting that the child answers questions slowly, and more than 3 errors on the Balance Error Scoring System-tandem stance were predictors of longer recovery.127 Children with visual, vestibular, and cervical spine findings also recover more slowly.30,81, After an initial 24 to 48 hours of cognitive and physical rest,84,103 initiate a strategy of gradual return to school and sport.84 If symptoms persist beyond 7 to 10 days following injury, targeted treatment may be warranted.84,103 Rehabilitation following concussion should be informed by a multifaceted, interdisciplinary assessment aimed at identifying underlying sources of ongoing symptoms.78,103, In the presence of headache, differential diagnosis of headache type is imperative to inform management. A special edition from JOSPT, focusing on concussion, has published Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment (Schneider et al) In some cases, targeted rehabilitation (eg, vestibular rehabilitation, cervical spine rehabilitation, subsymptom threshold aerobic exercise) is warranted.106 In other cases, further medical investigations, referral to additional interdisciplinary health care professionals, or referral for interdisciplinary care may be required (FIGURE 4). Once a concussion is suspected, the player should be removed from play and further assessed by a qualified health care professional (FIGURE 2). Regardless of the type of injury, it is often preceded by a chain of shifting circumstances that, when they come together, constitute sufficient cause to result in an injury. In youth athletes, growth and development may result in changes in performance and adaptations. For instance, the skills required of a volleyball player will differ from those expected of an ice hockey player. In part 1 of this commentary, we address etiology, risk factors, and detection of concussion. Epidemiology of injury in child and adolescent sports: injury rates, risk factors, and prevention. It is important for sports professionals to know why certain athletes may be at risk of injury risk factors and how injuries occur (i… There may be alterations in gait, reduced gait velocity, and increased sway when dividing attention following concussion.38,59 Further research to better understand changes in the ability to divide attention while accounting for growth and development is warranted. Many individuals who have suffered a concussion may report difficulty with reading at school, work, or during screen time (eg, computers, smartphones, tablets). Get the latest research from NIH: https://www.nih.gov/coronavirus. In this section, we outline 9 common persistent symptoms following concussion,7,58,106 describe differential diagnoses, and offer an overview of evidence-based rehabilitation approaches. 11 ERAIQ. Curr Sports Med Rep. 2008 Nov-Dec;7(6):359-66. doi: 10.1249/JSR.0b013e31818f0bed. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial, Sport-related concussion induces transient cardiovascular autonomic dysfunction, Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey, What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? Return to participation in sport should occur along a continuum, with respect to the individual's risk of concussion and the characteristics of the environment to which the person is returning. A model originally described by Meeuwisse (1994) and adapted and expanded upon by Barr and Krosshaug (2005)may guide sports professionals. Junge A, Engebretsen L, Alonso JM, Renström P, Mountjoy M, Aubry M, Dvorak J. Br J Sports Med. The literature is inconsistent regarding sex as a risk factor for concussion. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Headaches are the most frequent symptom following concussion. This integrated model encompasses personal and situational moderating factors. Whether its recreational or professional, injury is a common occurrence at all levels of sport and exercise. A special edition from JOSPT, focusing on concussion, has published Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment (Schneider et al) ELECTRONIC This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. Clin J Sport Med. Statistical metrics c. Machine learning model validation 5. Lower limb MSK injuries among school-aged rugby and football players: a systematic review. Diagnosis directs appropriate management. If we are to truly understand the etiology of injury and target appropriate prevention strategies, we must look beyond the initial set of risk factors that are thought to precede an injury and take into consideration how those risk factors may have changed through preceding cycles of participation, whether associated with prior injury or not. The best way to decrease the burden of concussion is to prevent the injury before it occurs (ie, through primary prevention). 49, No. Understanding the impact that these factors may have on assessment, management, and return to activity/sport helps to ensure a well-balanced and evidence-informed approach to care. A DYNAMIC, RECURSIVE MODEL OF SPORT INJURY In a real life sporting environment, a participant’s risks are dynamic and can change frequently.  |  Epub 2008 Jan 28. A quick introduction to R b. Findings of convergence insufficiency have been identified in children following concussion; however, further research is needed to identify whether these deficits are pre-existing or have their onset following trauma. Keywords: Dynamic systems in team sports , prototypical configuration of play , matrix of play , team sport … Address correspondence to Dr Kathryn J. Schneider, Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada T2N 1N4. J Athl Train. Increasing knowledge regarding concussion burden and identifying factors contributing to multifaceted and recursive risk for concussion will inform the development and evaluation of effective concussion prevention strategies. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. Less common diagnoses may include temporal bone fracture (with resultant damage to the eighth cranial nerve), labyrinthine concussion, peri-lymphatic fistula, and semicircular canal dehiscence.12,35, Vestibular rehabilitation may be of benefit for individuals with peripheral vestibular disorders (including BPPV) and stable central vestibular disorders.8,45,75 Positive effects on recovery following vestibular rehabilitation after concussion have been reported in the literature.2,106 Typically, vestibular rehabilitation includes canalith repositioning maneuvers (for BPPV) and individually targeted exercises aimed at facilitating sensorimotor compensation (including adaptation, habituation, substitution, and standing and dynamic balance exercises).3,8,106. response to sport injury. A dynamic model of etiology in sport injury: the recursive nature of risk and causation Clin J Sport Med, 17 (3) (2007), pp. For individuals with ongoing dizziness, neck pain, and headaches, cervicovestibular physical therapy can be beneficial.103,104,106 Sport-specific training, related to the context in which the individual would be participating, should form an integral part of the rehabilitation program.106 For children and adolescents with visual and vestibular findings, vestibular rehabilitation may be of benefit.111 In addition, low-level aerobic exercise may promote recovery following concussion.40,62,67, Collaborative care, including cognitive-behavioral therapy, care management, and psychopharmacological evaluation, has positive effects on symptom reduction after 6 months.83 An active approach to rehabilitation, including aerobic exercise, visualization, and coordination, has positive effects on symptoms and function.39,40 Future research to best understand timing, order, frequency, and other parameters of combination treatments is warranted.103. These factors may change over time. ↑ Alonso JM, Junge A, Renstrom P, Engebretsen L, Mountjoy M, Dvorak J. Immediate removal from activity may improve outcomes.4, At the time of injury, screening for more severe injury (eg, intracranial bleeding, cervical spine fracture) is imperative. A preliminary study, Predictors of clinical recovery from concussion: a systematic review, Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients, A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache, Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test, GH and pituitary hormone alterations after traumatic brain injury, Epidemiology of football injuries in the National Collegiate Athletic Association, 2004–2005 to 2008–2009, Concussion symptoms and return to play time in youth, high school, and college American football athletes, Dual-task assessment protocols in concussion assessment: a systematic literature review, Noninvasive brain stimulation for persistent postconcussion symptoms in mild traumatic brain injury, Sensorimotor function and dizziness in neck pain: implications for assessment and management, Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: an exploratory randomized clinical trial, Neuroendocrine dysfunction in a young athlete with concussion: a case report, Pain and sleep in post-concussion/mild traumatic brain injury, Brain or strain? Neuroendocrine dysfunction, caused by injury to the hypothalamic-pituitary axis following mild to severe traumatic brain injury5,6,90,114 and sport-related concussion,72,113,114,116 has been reported. However, while protective equipment, such as helmets, headgear, and mouthguards, may mitigate the risk of concussion, the literature is inconclusive. Ericsson, K. A. Neurological examination, assessment of vestibulo-ocular reflex function, static balance, dynamic balance, assessment of nystagmus with and without fixation, positional testing, and vestibular function testing can inform diagnosis and management. 2020 Sep 1;55(9):967-976. doi: 10.4085/1062-6050-477-19. In addition to a thorough history, targeted assessment tests help clinicians to understand the source of dizziness. 2008 Mar;40(3):444-50. doi: 10.1249/MSS.0b013e31815ce61a. Pituitary dysfunction after traumatic brain injury: a clinical and pathophysiological approach, Hypopituitarism due to sports related head trauma and the effects of growth hormone replacement in retired amateur boxers, Pituitary function in subjects with mild traumatic brain injury: a review of literature and proposal of a screening strategy, Gender differences in head–neck segment dynamic stabilization during head acceleration, Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain, Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma, Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: a prospective randomized study comparing three exercise programs, Comparison of psychological response between concussion and musculoskeletal injury in collegiate athletes, Incidence, severity, aetiology and prevention of sports injuries. This integrated model encompasses personal and situational moderating factors. How Do We Meet the Challenges of Assessing and Managing Concussion? 2008 Jan;27(1):19-50, vii. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Sport Med. per 1000 hours of sports participation) in order to facilitate the comparability of research results. Introduction. a dynamic model that accounts for the multifactorial nature of sports injuries, and in addition, takes the sequence of events eventually leading to an injury into account. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Activity brings benefits and risks. Evidence has shown that physical factors such as over-training, equipment and playing conditions are the major contributors towards an athlete’s injuries. Clin Sports Med. eCollection 2020. ELECTRONIC eCollection 2020. Integrated Model of Psychological Responses to Sport Injury. Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury, Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms, A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome, Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment, rTMS in alleviating mild TBI related headaches — a case series, Left dorsolateral prefrontal cortex rTMS in alleviating MTBI related headaches and depressive symptoms, Trends in concussion incidence in high school sports: a prospective 11-year study, Utility of serum IGF-1 for diagnosis of growth hormone deficiency following traumatic brain injury and sport-related concussion, Posttraumatic headache: clinical characterization and management, A prospective study of prevalence and characterization of headache following mild traumatic brain injury, Variables affecting treatment in benign paroxysmal positional vertigo, Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study, Factors affecting time to recovery from sports concussion [abstract], Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review, Epidemiology of concussions among United States high school athletes in 20 sports, Epidemiology of sports-related concussion in seven US high school and collegiate sports, Vision and vestibular system dysfunction predicts prolonged concussion recovery in children, Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis, Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial, Consensus statement on concussion in sport—the 5, Vestibular and oculomotor assessments may increase accuracy of subacute concussion assessment, Mild traumatic brain injury (mTBI) and chronic cognitive impairment: a scoping review, Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study, A dynamic model of etiology in sport injury: the recursive nature of risk and causation, A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings, Abnormalities of pituitary function after traumatic brain injury in children, Insomnia in patients with traumatic brain injury: frequency, characteristics, and risk factors, The incidence of concussion in youth sports: a systematic review and meta-analysis, What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? 16.4.1. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Symptoms may be reported by the player, such as headaches, dizziness, nausea, sensitivity to light or noise, fatigue, and feeling as though in a fog. Discussion among the health care team and with the individual and his or her family can facilitate appropriate return-to-sport and return-to-school decisions. A widely referenced model in the area of sport injury research has proposed that multiple factors influence the etiology of sport injury.88 Various etiological factors can vary over time and change the risk that is associated with injury.88 The literature in the area of concussion is evolving and, as such, enables adaptation of this model to better understand the etiology of concussion. A systematic review, Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York, Sleep quantity and quality during acute concussion: a pilot study, Cervicocephalic kinesthetic sensibility in patients with cervical pain, Trigger point injections for headache disorders: expert consensus methodology and narrative review, Association of returning to work with better health in working-aged adults: a systematic review, Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline, Are clinical measures of cervical spine strength and cervical flexor endurance risk factors for concussion in elite youth ice hockey players? A dynamic model of etiology in sports injury: the recursive nature of risk and causation . Consider occupation-specific activities (eg, cognitive and physical demands, safety requirements) in any return-to-work recommendations.15,91 Positive health outcomes have been reported with return to work or staying at work.99 However, reintroduction of risk and timing in the early recovery period must be carefully monitored.91. This site needs JavaScript to work properly. 16.3. This model considers the implications of repeated exposure, whether such exposure produces adaptation, maladaptation, injury or complete/incomplete recovery from injury. The relationship between physical fitness attributes and sports injury in female, team ball sport players: a systematic review. Recursive Preferences. Each individual who participates in an activity brings a specific set of intrinsic and extrinsic factors (FIGURE 1). Contact and collision sports, such as rugby, American football, and ice hockey, have the highest reported incidence of concussion.93 In youth ice hockey leagues where bodychecking is permitted, there is nearly a 4-fold increase in risk of concussion in the 11- to 12-year age group (Pee Wee).33 Game play has greater concussion risk than practice.1,22,57. Exercise may facilitate recovery following concussion.40,66,67 Two different paradigms of exercise have demonstrated benefit for symptoms and function: (1) subsymptom aerobic exercise training at 80% of the maximal heart rate that was achieved on the Buffalo Concussion Treadmill Test, 5 days per week67; and (2) exercising at 60% of maximal heart rate (calculated as 220 − age × 60%) for up to 15 minutes, combined with guided imagery and sport-specific coordination exercises.39,40 However, some studies have reported an increase in symptoms with exercise in children and youth, and others have reported no change.77,103 Given the known general positive benefits of exercise, consideration of aerobic exercise training following the initial return to activity after concussion is warranted in the absence of contraindications to exercise.103. Anderson DS, Cathcart J, Wilson I, Hides J, Leung F, Kerr D. BMJ Open Sport Exerc Med. The return-to-sport strategy includes 6 steps: (1) symptom-limited activity, (2) light aerobic exercise, (3) sport-specific exercise, (4) noncontact training drills, (5) full-contact practice, and (6) return to sport (FIGURE 3).29,84 Medical clearance to return to sport occurs once the individual is able to complete the return-to-sport protocol with no symptom exacerbation and when no other clinical assessment findings suggest ongoing problems that would preclude returning to sport.84, Return-to-work recommendations are based on similar principles as those of return to school and return to sport.91 Gradually and progressively increase activities, provided there is no increase in symptoms. Pessimistic Inter-pretation. To address this issue, Meeuwisse et al9 developed a dynamic, recursive model for risk and causes of sports injuries, considering that the injury has a non-linear behavior. J Orthop Sports Phys Ther 2019;49(11):799–810. doi: 10.1136/bmjsem-2020-000806. The Return to school and return-to-sport strategies can occur simultaneously.84 Each step of the return-to-school and return-to-sport protocols should take a minimum of 24 hours. Sport-specific and performance-related skills may be necessary to return to full participation. Other screening tools, such as the Vestibular/Ocular Motor Screening and a combination of optokinetic stimulation, gaze stabilization testing, and near point of convergence, may have clinical utility as screening tools for concussion in the subacute period (2–10 days) following concussion.85,89 The SCAT5 and Vestibular/Ocular Motor Screening tools can be used as part of the clinical assessment but should not replace other aspects of the clinical exam that may be warranted, based on the individual circumstances of the injury.21,29,84. Sports injury incidence should preferably be expressed as the number of sports injuries per exposure time (e.g. 34, No. The purpose of this manuscript is to outline a new model representing a dynamic approach that incorporates the consequences of repeated participation in sport, both with and without injury. Once again, literature on health and disease outcomes has a large influence as the source of the ‘web of determinants’ concept (Philippe and Mansi, 1998). Regardless of the type of injury, it is often preceded by a chain of shifting circumstances that, when they come together, constitute sufficient cause to result in an injury. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. J. If symptoms persist following the initial days to weeks following injury, a multifaceted assessment to identify areas that may require rehabilitation is warranted.37,65,78,103 Refer the patient for additional assessment and rehabilitation if the individual has not recovered in the 10 to 14 days following injury. Ericsson, K. A. The purpose of this clinical commentary was to summarize prevention, detection, assessment, and treatment factors that affect individuals across the continuum of concussion care, using the dynamic, recursive model of sport injury 88 framework. 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The article then focuses on the dynamic core of the integrated response to sport injury and rehabilitation model. 16. FIGURE 2. . 16.4. Evidence for cognitive remediation following concussion is very limited. A systematic review, Detecting gait abnormalities after concussion or mild traumatic brain injury: a systematic review of single-task, dual-task, and complex gait, Active rehabilitation for children who are slow to recover following sport-related concussion, A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion, Helmet fit assessment and concussion risk in youth ice hockey players ages 11–18 years [abstract], Attention problems as a risk factor for concussion in youth ice-hockey players [abstract], Concussions among United States high school and collegiate athletes, Inadequate helmet fit increases concussion severity in American high school football players, Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline, The International Classification of Headache Disorders, 3rd edition, Contact technique and concussions in the South African under-18 Coca-Cola Craven Week Rugby tournament, Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial, Mild traumatic brain injury among a cohort of rugby union players: predictors of time to injury, Is there a relationship between whiplash-associated disorders and concussion in hockey? As concussions differ so widely, an awareness of risk factors and individual clinical characteristics can facilitate an individualized approach. Cumulative, high-stress calls impacting adverse events among law enforcement and the public. Individuals with visual symptoms following concussion may benefit from accommodations to enable earlier return to school or work in a less visually provocative environment (eg, printed materials rather than electronic, change in contrast on a screen).94 Frequent breaks, pacing of activities, and working in a quieter environment may facilitate return to function. Jeffries AC, Wallace L, Coutts AJ, Cohen AM, McCall A, Impellizzeri FM. Cognitive symptoms can include difficulties remembering and concentrating, slowed processing, decreased attention, and difficulty with learning.58,86 Cognitive symptoms often resolve over the initial days to weeks following injury. Injury surveillance in multi-sport events: the International Olympic Committee approach. Combining specific exercises with manual therapy is effective for treating cervical spine pain.54 After concussion, include neuromotor control, sensorimotor control, manual therapy, and soft tissue techniques, in combination with vestibular rehabilitation.106 A sequential approach to addressing headaches and cervical spine findings (including neuromotor control) as an initial step of rehabilitation is appropriate, given the connections between the upper cervical spine and the vestibular and visual systems. In this section, we summarize the key intrinsic and extrinsic risk factors for concussion. 49, No. Symptom onset can be delayed, with the duration of the delay predicting a longer time to recovery following injury. A systematic review, Risk of injury associated with body checking among youth ice hockey players, Injury rates, risk factors, and mechanisms of injury in minor hockey, Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice, What domains of clinical function should be assessed after sport-related concussion? The stress-injury model also proposed a number of factors, such as personality, history of stress, and coping resources, that may moderate a stress response, but there was less clarity and exposition of mediating pathways, particularly those related to stress physiology, by which stress response may increase risk of injury. Interventions aimed at primary prevention have shown promise in decreasing the risk of concussion. doi:10.2519/jospt.2019.8926, Sport-related concussion is among the most frequently reported injuries in sport and recreation.80 A sport-related concussion is “a traumatic brain injury induced by biomechanical forces.”84 Symptoms and signs that occur following a concussion are believed to represent a functional rather than structural injury, as structural neuroimaging studies do not detect abnormalities.84 Recovery can occur in the initial days to weeks for most adults, but up to one third of children and youth may take longer than 4 weeks to recover.108,127. Sometimes, cognitive symptoms persist and may be associated with ongoing difficulties with school and with occupational, sport, and social activities.86 Cognitive symptoms often occur in the presence of other symptoms, such as pain, headaches, difficulties with vision, and sleep problems.87 Referral to a neuropsychologist may be warranted for a thorough assessment to clarify the etiology of the cognitive complaints and to assist in developing an individualized management plan. and behavioral responses of athletes to sport injury. A multifaceted assessment for each patient should include postconcussive symptom reports; a neurological screen; assessment of cervical spine, vestibular, visual, and exertion-related symptoms; plus sleep, mood, cognitive, and related domains. Incidence and by indicators of the return-to-school and return-to-sport protocols should take a minimum of 24 hours prevention ) of. The previous step c. Dataset i. 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