478 Final Exam PDF

⌛ 478 Final Exam Course KPE478 Date @December 17, 2024 Status In progress Type Exam Module 7 - Return to Sport, Neuropsychological Tests, Exertion Tests 7.1 Des...

⌛ 478 Final Exam Course KPE478 Date @December 17, 2024 Status In progress Type Exam Module 7 - Return to Sport, Neuropsychological Tests, Exertion Tests 7.1 Describe of the impact of concussions on return to school 7.2 Understand the purpose of return to school/learn strategies Return to School Return to Physical Education Return to Play (RTP) vs Return to Physical Education (RTPE) 7.3 Describe the resources needed to support students to return to school 7.4 Apply class learnings to a case study 7.5 Increase awareness to return to school research 7.6 Describe the steps involved for the return-to-learn strategy Return to Learning (RTL) 7.7 Describe the steps involved for the return-to-sport strategy Return to Sport (RTS) 7.8 Understand the role of neuropsychological testing in return-to-sport 7.9 Differentiate between comparison with normative data vs. baseline/individualized approach in neuropsychological tests 7.10 Understand the evolution of exertional testing for return-to-sport 7.11 Understand the different exertional tests and their potential benefit for assisting clinicians Module 8 - Biomarkers, Micro RNA, Neuroimaging, Technology 8.1 Describe what a biomarker is Issues with Traditional Approaches to Diagnose Concussions 8.2 Understand the disruption caused to the blood brain barrier (BBB) following concussion and the role of the glympathic system Glymphatic clearance pathway Acute and subacute pathophysiology post-concussion 8.3 Understand common biomarkers released following TBI and what they are markers for Micro-RNA (miRNA) miRNA in Concussion Key Considerations for Biomarker Research in Concussion Inflammatory Response Following TBI and Concussion Common Biomarkers following TBI 8.4 Identify the overlap in fluid biomarkers that have and have not been found to discriminate between SRC and controls as well as during recovery trajectories 478 Final Exam 1  Blood Biomarkers for Concussion Study Summaries Advantages and Disadvantages of Peripheral Blood Biomerakers 8.5 Describe the various neuroimaging techniques and key findings identified Advantages and Disadvantages of Neuroimaging 8.6 Identify various emerging technologies that have been used in research 8.7 Understand key considerations for all biomarker research following concussion Module 10 - Clinical Recovery, Prolonged and Decreased Recovery 10.1 Overall for this course: identify the hierarchy for scientific evidence 10.2 Understand the different components of clinical recovery and what is used to help inform clinical recovery 10.3 Understand the timeline patterns for returning to play/sport and learn/school for different age groups 10.4 Identify all preand post-injury modifiers and describe which have been associated with prolonged recovery 10.5 Understand what variables have been identified to decrease recovery time Module 11 - Additional Treatment Strategies, Risky Calculation, Risks of Injury following Concussion 11.1 Be Familiar with More Detailed Symptom Clusters: 11.2 Understand and Describe the Various Treatment Strategies for the Six Symptom Clusters: 11.3 Be Able to Calculate Odds Ratio, Relative Risk, and Absolute Relative Risk: 11.4 Describe the Different Theories for Risk of Musculoskeletal Injuries Following Concussion: 11.5 Understand the Various Findings Identified for Risk of Musculoskeletal Injuries Following Concussion: Module 12 - Chronic Traumatic Encephalopathy, Repetitive Head Impacts, Traumatic Encephalopahty Syndrome, Modifiable Risk Factors 12.1 Describe the Progression of CTE Understanding from the 1900s to Current: 12.2 Understand Why Dr. Omalu’s Findings Were Significant in Professional Sports (Specifically Football): Tau Protein: Neurofibrillary Tangles (NFTs): Astrocytic Tangles: Amyloid Plaques: Criticism from the NFL 12.3 Describe the Various Neuropathological Features for CTE (Diagnosis) and the Advancement of Them: 12.4 Understand the Progression of Dr. McKee’s CTE Findings: History of NFL and Concussions Emerging Literature CTE vs Alzheimer’s Disease CTE Findings in Football Players CTE in Former NHL Enforcer controversial results 12.5 Differentiate Between Concussions and Repetitive Head Impacts and Current Repetitive Head Impact Findings Another cause of abnormal tau 12.6 Define Traumatic Encephalopathy Syndrome (TES) and the Most Recent TES Criteria (2021): 2014 TES Criteria: 2021 TES Criteria: 12.7 Understand the Flaws of the TES 2014 Criteria: 12.8 Describe the Different Modifiable Risk Factors for Cognitive Impairment: The Football Players Health Study at Harvard (funded by NFL) 12.9 Understand the Associations of Medical Conditions and TES: 12.10 Understand the Concussion in Sport Group (Consensus Statement) Stance and Findings: Supporters of CTE Critics of CTE 478 Final Exam 2  Module 7 - Return to Sport, Neuropsychological Tests, Exertion Tests 7.1 Describe of the impact of concussions on return to school Academic Challenges: Research indicates that up to 64% of students experience academic difficulties following a concussion. This includes challenges in processing information, maintaining focus, and completing assignments, leading to a significant impact on their overall educational experience. However, a systematic review and meta-analysis showed that there is no impact on school attendance, academic performance, and perceptions of academic difficulties for students returning to learn after concussion. Decline in Grades: Approximately 31% of students report a drop in their grades post-concussion, which can have lasting effects on their academic trajectory and self-esteem. Such declines can lead to increased anxiety about academic performance and future opportunities. Cognitive and Emotional Symptoms: Students may present with a range of cognitive symptoms such as impaired attention, memory deficits, and difficulties with executive functioning (planning, organizing, and decision-making). Emotional challenges, including frustration, anxiety, and social withdrawal, can further complicate their reintegration into the school environment. Impact on Social Interactions: Missing school can isolate students from their peers, affecting their social skills and relationships. This social withdrawal can exacerbate feelings of loneliness and anxiety, making the transition back to school even more difficult. 7.2 Understand the purpose of return to school/learn strategies Facilitating Safe Reintegration: Help students transition back into academic settings in a manner that minimizes symptom recurrence. Emphasize a cautious approach that allows for gradual increases in academic demands. Tailored Accommodations: Each student’s unique symptoms necessitate customized accommodations. 478 Final Exam 3  Strategies might include reduced homework loads, extended time for tests, and modified classroom environments (e.g., reduced noise and light). Educational Recovery Framework: Create an educational framework that supports recovery while fostering academic engagement. This includes frequent communication between educators and healthcare professionals to monitor progress and make adjustments as needed. Notes: After an initial rest period of 24-48 hours post-injury (Stage 1), students can begin increasing cognitive load incrementally. Progress should be slowed if symptoms exceed mild and brief exacerbation (no more than 2 points on a 0-10 scale for less than one hour compared to baseline). Return to School Stage 1 (At home) Physical and cognitive rest Basic board games, craft, talk on phone Activities that don’t increase heart rate or break a sweat Limit/Avoid: Computer, TV, texting, video games, reading No: School work, sports, work, driving until cleared by a health care professional Rest When symptoms start to improve or after resting for 2 days max, then begin stage 2 Stage 2 (At home) Start with light cognitive activity (Part 1) Gradually increase cognitive activity up to 30 min Take frequent breaks Prior activities plus: Reading, TV, drawing Limited peer contact and social networking Contact school to create Return to School plan Gradually add cognitive activity including school work at home 478 Final Exam 4  Tolerates 30 min of cognitive activity, introduce school work at home When light cognitive activity is tolerated (Part 2) Introduce school work Prior activities plus: School work as per Return to School plan Communicate with school on student’s progression Gradually add cognitive activity including school work at home Tolerates 60 min of school work in two 30 min intervals, then begin stage 3 No: School attendance, sports, work Stage 3 (At school) Back to school part-time Part time school with maximum accommodations Prior activities plus: School work at school as per Return to School plan No: PE, PA at lunch/recess, homework, testing, sports, assemblies, field trips Communicate with school on student’s progression School work only at school Tolerates 120 min of cognitive activity in 30-45 min intervals, then begin stage 4 Stage 4 (At school) Part-time school Increase school time with moderate accommodations Prior activities plus: Increase time at school Decrease accommodations Homework up to 30 min/day Classroom testing adaptations No: PE, PA at lunch/recess, homework, sports, standardized testing 478 Final Exam 5  Communicate with school on student’s progression Increase school work, introduce homework, decrease learning accommodations Tolerates 240 min of cognitive activity in 45-60 min intervals, then begin stage 5 Stage 5 (At school) Full-time school Full days at school, minimal accommodations Prior activities plus: Start to eliminate accommodations Increase homework to 60 min/day Limit routine testing to one test per day with adaptations No: PE, PA at lunch/recess, sports, standardized testing Work up to full days at school, minimal learning accommodations Tolerates school full-time with no learning accommodations, then begin stage 6 Stage 6 (At school) Full-time school Full days at school, no learning accommodations Attend all classes All homework Full extracurricular involvement Full testing No: Full participation in PE or sports until Return to School protocol completed and written medical clearance provided Full academic load Return to School protocol completed; focus on Return to sport Return to Physical Education Phase I - Prepare Step 1: Obtain Permission Confirm approval to begin RTPE through discussion with the nurse or physician. 478 Final Exam 6  Reach out to the student’s healthcare provider if needed. Gather Feedback from Parents/Guardians Discuss concerns with parents/guardians. Review signs/symptoms checklist and visual analogue scale (VAS). Engage with the Student Discuss possible symptoms and concerns about RTPE. Review VAS usage and tolerance to physical activity (PA). Consider environmental factors (e.g., noise, light). No Activities During This Phase Phase II - Progress Step 2: Low-Impact Activity Engage in non-strenuous light aerobic activities in a safe environment (e.g., walking, stationary bike, light yoga). Avoid resistance training and activities with risk of contact or rapid heart rate increase. Step 3: Medium-Impact Activity Introduce moderate aerobic activities (e.g., jogging, yoga, elliptical). Continue to avoid resistance training and high-risk activities. Step 4: Unit-Specific Non-Contact Activity Focus on individual skill work relevant to the unit (e.g., locomotor skills for elementary, low-resistance weight training with a spotter for middle/high school). Ensure safety; no contact or collision activities. Step 5: Modified Partner Skill Work Engage in individual or partner skill activities (e.g., throwing/catching, rhythm activities for elementary; higher-resistance weight training with supervision for middle/high school). Avoid contact/collision activities. Step 6: Small-Group Skill Work Conduct small-group activities (e.g., station work, small-sided games). For middle/high school, include intense aerobic activities. Ensure safety; no contact/collision activities. Phase III: Exit Step 7: Full Activity Return 478 Final Exam 7  Return to all unit activities without restrictions. Return to Play (RTP) vs Return to Physical Education (RTPE) Initiation Criteria: RTP: Begins when the student is symptom-free at rest and during maximal exertion. RTPE: Starts when the student can tolerate part-time school attendance, even with lingering symptoms. Goals: RTP: Aims to verify full recovery before returning to sports. RTPE: Focuses on enabling participation in normal school activities and exercise during recovery. Protocol Differences: RTP: Follows a uniform protocol applicable to all student-athletes. RTPE: Requires individualized accommodations, as each student's situation and needs differ. Awareness and Guidelines: RTP: Well-known protocols among athletes, parents, and coaches. RTPE: Many schools and teachers lack clarity, with no standardized guidelines. Oversight: RTP: Primarily managed by athletic trainers and/or school nurses. RTPE: Involves close collaboration between teachers, administrators, and the medical team, along with the student and family. 7.3 Describe the resources needed to support students to return to school Collaborative Support Teams: Form a multidisciplinary team including teachers, school counselors, healthcare providers, and parents/guardians. Work together to create and implement a tailored return-to-learn plan for each student. Access to Educational Resources: Utilize tools like the Concussion Toolkit for School Professionals for guidelines on supporting students post-concussion. Offer workshops for staff on concussion management and effective support strategies. Physical and Emotional Support Resources: Provide quiet spaces for rest and access to counselling services for emotional support. Implement peer support programs to encourage social interaction and reduce anxiety. 478 Final Exam 8  Return to School Team Members: Include teachers, guidance counsellors, the principal, parents/guardians, and coaches/athletic directors. Return to Life Team Members: Involve school team members, parents/guardians, coaches, extracurricular leaders, and family members in the support process. Return to School Flow: Inform all team members about the concussion. Develop a collaborative plan with the team. Gradually increase academic demands and monitor progress. Provide ongoing support and communication. Academic Accommodations: Physical: Position students away from windows; provide sunglasses or earplugs as needed. Cognitive: Offer a quiet workspace and provide class notes. Emotional: Increase support services, conduct regular check-ins, and facilitate socialization. Classroom Considerations: Address safety-sensitive subjects (e.g., chemistry, biology) carefully. Manage noise levels in the classroom (e.g., instrumental music, drama). Ensure the school environment is conducive to learning, considering factors like lighting. Take into account the student’s pre-existing history and individual needs. Tailored Supports: 478 Final Exam 9  Provide individualized supports to meet each student's unique needs for a successful return to school. 7.4 Apply class learnings to a case study 🥍 AA is a 16-year-old student in grade 11. They are enrolled in academic courses this semester including Phys Ed-3M, Math-3U, English-3U, and Chemistry-4U. AA sustained a concussion last night during a lacrosse game. They were diagnosed with a concussion at the hospital, but no other injuries. AA reports the following symptoms: difficulty concentrating, difficulty planning, headaches, balance concerns, and is frustrated that they are missing a tournament this weekend because of their concussion. What is your role in supporting AA? Facilitate AA's safe return to school and academic activities while ensuring appropriate accommodations are in place to support their recovery. This includes collaborating with AA, their family, and school staff to create an effective return-to-learn plan. What steps would you take to support AA to return to school? Initial Communication: Inform all team members (teachers, counselors, healthcare providers) about AA's concussion and current symptoms. Develop a Return-to-Learn Plan: Collaborate to create a personalized plan that outlines specific accommodations based on AA's symptoms (e.g., reduced workload, extended time for assignments). Gradual Reintegration: Start with light cognitive activities at home, progressing to part-time school attendance before moving to full-time as tolerated. Ongoing Monitoring: Regularly check in with AA to assess their progress and adjust the plan as needed. Who would you involve and why? Teachers: To implement academic accommodations and monitor AA’s progress in class. School Counselor: To provide emotional support and help AA cope with frustration and anxiety related to missing activities. Parents/Guardians: To keep them informed and involved in decision-making regarding AA’s return to school. Healthcare Provider: To offer insights into AA's recovery status and ensure that accommodations align with medical advice. What course-specific concerns can you identify, if any? Physical Education (Phys Ed-3M): AA may struggle with balance and coordination, impacting participation in physical activities. 478 Final Exam 10  Math and Chemistry (3U and 4U): Difficulty concentrating and planning could hinder performance in these subjects, especially with complex problem-solving and lab work. English (3U): Reading and writing assignments may be challenging if AA experiences headaches or cognitive fatigue. What other considerations would you have for AA? Rest Periods: Ensure AA has access to quiet areas for breaks during the school day to manage headaches and fatigue. Environmental Adjustments: Consider minimizing sensory distractions in the classroom (e.g., reducing noise, adjusting lighting). Social Support: Encourage peer interactions to alleviate feelings of isolation while being mindful of AA’s current emotional state. Monitor Emotional Well-being: Regular check-ins to address any frustration or anxiety regarding missed activities, especially the upcoming tournament. 🥍 AA is now five weeks post-concussion. They are attending school for half days, alternating between attending mornings one day, and afternoons the next. AA has taken a few quizzes, but no major or assignments. AA continues to experience headaches that worsen with extended time reading and difficulty concentrating. They also expressed concerns with falling behind in classes, anxiousness surrounding their exams, difficulty remembering new information, and mixing up numbers in math class. AA's school has not permitted them to return to PE class, but AA has returned to playing lacrosse full-time. What other steps would you take to support AA in their return to school? Review and Adjust Accommodations: Reassess AA’s current accommodations to better address ongoing symptoms, such as: Allowing for extended time on quizzes and assignments. Providing alternative methods for assessments (e.g., oral presentations or projects instead of written tests). Giving AA access to recorded lectures or class notes to reduce the need for extensive reading. Implement Regular Check-Ins: Schedule frequent meetings with AA to monitor their progress, address any concerns, and adjust the return-to-learn plan as needed. Coordinate with Teachers: Work closely with AA’s teachers to ensure they are aware of AA’s challenges and can provide tailored support in their classes. Enhance Study Strategies: Introduce study techniques designed for students with concentration difficulties, such as: 478 Final Exam 11  Breaking tasks into smaller, manageable parts. Using visual aids and mnemonic devices to help with memory retention. Encourage Rest Periods: Ensure AA has scheduled breaks during their school day to manage headaches and fatigue, especially after intensive concentration. What else should you consider? Emotional Support: Address AA’s anxiety about falling behind and upcoming exams by providing resources such as counselling or peer support groups to help them cope with stress. Address Physical Activity Concerns: Re-evaluate the decision regarding AA's participation in PE class, considering their full return to lacrosse. Collaborate with healthcare providers to ensure safe participation in physical education. Monitor Headache Triggers: Identify specific activities or environments that exacerbate AA’s headaches and adjust their schedule or workload accordingly. Prepare for Exams: Develop a study plan that allows AA to prepare for exams without overwhelming them. This could include creating a revision schedule with shorter study sessions and frequent breaks. Parental Involvement: Keep parents/guardians informed about AA’s academic progress and emotional well-being, encouraging them to provide support at home. Long-Term Recovery Plan: Consider that AA may need continued support beyond the initial return-to- learn phase, including gradual reintroduction to full academic and physical activities as their symptoms improve. 7.5 Increase awareness to return to school research Public Health Implications of Concussions: Emphasize that concussions are a significant public health issue, particularly in youth sports, and that their impact extends beyond immediate symptoms to long-term academic and social consequences. Need for Comprehensive Policies: Highlight the gap in existing policies and support systems in Canada for students returning to school after a concussion. Advocacy for better policies at the provincial and national levels is critical to ensure that all students receive adequate support. Current Research Initiatives: Encourage awareness of ongoing studies that aim to validate and improve return-to-school strategies, addressing the need for evidence-based practices that can be implemented in educational settings. 7.6 Describe the steps involved for the return-to-learn strategy Initial Communication and Education: Start by informing all members of the school team about the student’s concussion, the expected symptoms, and the rationale behind the return-to-learn strategies. This ensures everyone is aligned in their approach. 478 Final Exam 12  Creating a Personalized Return Plan: Develop a detailed plan that outlines specific accommodations based on the student’s symptoms and academic requirements. This might include flexible scheduling, reduced course loads, or alternative forms of assessment (oral presentations vs. written tests). Ongoing Monitoring and Feedback: Implement a system for regularly checking in on the student’s progress, adjusting the plan as necessary based on their recovery and feedback from teachers and the student themselves. This iterative process helps to ensure that the support remains relevant and effective. Return to Learning (RTL) Stage 1: Initial Activities Engage in daily activities that cause only mild symptoms related to the concussion. Limit screen time; start with 5-15 minutes of activities like reading, gradually increasing duration. Goal: Gradual return to typical daily activities. Stage 2: Cognitive Activities Introduce school-related tasks, including homework and reading outside the classroom. Focus on increasing tolerance for cognitive work. Goal: Enhance cognitive endurance. Stage 3: Part-Time School Return to school on a part-time basis with gradual introduction of schoolwork. Allow for rest breaks throughout the school day as needed. Goal: Increase engagement in academic activities. Stage 4: Full-Time School Progress to full-time school attendance, gradually increasing school activities until a complete day is tolerated without significant symptom exacerbation. Goal: Achieve full academic participation and catch up on missed assignments. 7.7 Describe the steps involved for the return-to-sport strategy Initial Symptom-Limited Activity: Begin with light, non-strenuous activities that do not provoke symptoms. Activities such as walking or light stretching should be encouraged to gauge the student’s tolerance to exertion. Structured Staged Progression: Follow a systematic approach that includes 6 clear stages. Ensure students remain symptom-free for 24 hours before advancing to the next stage. If symptoms return, the student should revert to the previous stage and rest. Readiness Confirmation: Before allowing a return to full sport participation, confirm that the student has resolved all symptoms during both cognitive and physical activities, ensuring comprehensive recovery. 478 Final Exam 13  Return to Learn and Sport: Full return to play cannot occur until the student has fully returned to learn. Symptoms should be resolved at rest and after cognitive and physical exertion, allowing progression through the stages. Physicians may not physically observe patients during each stage; students often report their experiences based on memory, which can lead to inaccuracies. Varsity athletes have follow-ups at the McIntosh clinic or with an athletic therapist for ongoing assessment. Return to Sport (RTS) Stage 1: Symptom-Limited Activity Engage in daily activities that do not worsen symptoms (e.g., walking) for first 24-48 hours. Goal: Gradual reintroduction to work and school. Stage 2: Aerobic Exercise - Physical 2A: Light aerobic exercise (up to 55% HRmax). 2B: Moderate aerobic exercise (up to 70% HRmax). Activities include stationary cycling or walking at a slow to medium pace. Light resistance training may be introduced without causing more than mild, brief symptom exacerbation. Goal: Increase heart rate, increase physical capacity. Stage 3: Individual Sport-Specific Exercise - Physical Perform sport-specific training away from the team (e.g., running, directional changes, hand-eye coordination). Avoid activities that risk head impact. 478 Final Exam 14  Goal: Incorporate movement and change of direction. Stage 4: Non-Contact Training Drills - Physical & Cognitive Engage in high-intensity exercises, including challenging drills (e.g., passing drills, multiplayer training) in a team environment. Goal: Resume usual exercise intensity, enhance coordination, and improve cognitive processing. Stage 5: Full Contact Practice - Physical, Cognitive, & Sensory Participate in normal training activities with the team (use a pinny to make others aware) Goal: Restore confidence and assess functional skills with coaching staff. Stage 6: Return to Sport Engage in normal game play - travel with team but may start with less playing time then gradually increase. Medical clearance for full return to sports. 7.8 Understand the role of neuropsychological testing in return-to-sport Comprehensive Cognitive Evaluation: Neuropsychological testing assesses various cognitive domains, including memory, attention, and processing speed, which may be affected by a concussion. This testing provides a detailed profile of the student's cognitive abilities. Identification of Persistent Cognitive Issues: These evaluations can help identify cognitive deficits that persist beyond the acute phase of injury, allowing for targeted interventions and support strategies. Informing Medical Clearance Decisions: Results from neuropsychological assessments can be crucial for healthcare providers in determining whether a student is medically cleared to return to sport. They provide objective data that supports clinical decision-making. Role of the Neuropsychologist: A licensed psychologist who assesses cognitive, behavioural, and socio-emotional domains. Provides treatments such as supportive therapies and cognitive behavioural therapy. Availability of Neuropsychological Testing: Often not available in most clinical settings; primarily accessible for high-performance athletes. Neuropsychological Assessment: Involves a full assessment, including medical history, interviews, and clinical findings, which may take several days to complete. Conducted by a trained clinical neuropsychologist, typically for patients with persistent symptoms (> 4 weeks). Neuropsychological Testing (the focus): 478 Final Exam 15  Measures functioning in cognitive domains (e.g., reaction time, processing speed) but does not directly assess brain function. Not designed to diagnose brain injury or concussion. Testing can be administered using paper and pencil or computerized methods by trained technicians. Pros of Neuropsychological Testing: Enables comparison of cognitive results before and after injury. Identifies cognitive disturbances that may last longer than physical symptoms. Provides objective data to assist physicians in making medical clearance decisions. Cons of Neuropsychological Testing: Requires clinical expertise for result interpretation; trained technicians can administer tests but may lack training in interpretation. Results can be influenced by non-concussion factors (e.g., sleep, mood, test anxiety, caffeine intake). Variability in what is considered normal or abnormal; larger clinics may have more data than smaller ones, complicating assessments for adolescents. No standardized test battery exists; many companies offer different tests. Cannot prevent athletes from performing poorly on baseline tests. 7.9 Differentiate between comparison with normative data vs. baseline/individualized approach in neuropsychological tests Normative Approach: Measuring the student’s test scores against a normative database that reflects the average performance of similar-aged peers. This comparison helps to identify significant deviations from expected performance levels and is increasingly used. Baseline/Individualized Approach: Uses the student’s baseline test results (obtained prior to injury) for comparison. This method allows for a more personalized assessment of recovery and acknowledges the student’s unique cognitive profile, offering insights into their specific recovery trajectory, but is less beneficial compared to normative approach. 7.10 Understand the evolution of exertional testing for return-to-sport Advancements in Testing Protocols: Over time, the development of exertional testing has moved towards more comprehensive evaluations that assess both physical exertion and cognitive function simultaneously. This holistic approach provides a better understanding of an athlete’s readiness to return to sport. Integration of Symptom Monitoring: Modern exertional tests are designed to monitor symptoms that may arise during physical activity, ensuring that athletes can safely progress through recovery stages without exacerbating their condition. This focus on symptomatology helps prevent premature returns to play. 478 Final Exam 16  7.11 Understand the different exertional tests and their potential benefit for assisting clinicians Gapski-Goodman Test (GGT; NHL Chicago Blackhawks): This test assesses an athlete’s physical readiness through a combination of stationary cycling and plyometric exercises (lateral hurdle jumps, burpees, lateral box jumps, 180-degrees rotation). It evaluates how well the athlete can handle physical exertion while monitoring for any symptoms that may arise. At RTP, 14.6% of participants failed the test (i.e., symptom exacerbation). Dynamic Exertion Test (EXiT Protocol): 30-minute assessment with aerobic (slow and fast treadmill running) and dynamic (2 functional movement tasks and 5 change of direction tasks) components. It measures the athlete's ability to perform sport-specific movements under controlled conditions. At RTP, 6.6% of participants failed the test. UofT Test Wish List: Minimal resources required Any physician can administer Captures key elements of sport/exercise. 4 components Cardiovascular load - increase physical capacity and heart rate Head acceleration - move head vertically and horizontally Cognitive Tasks Balance/coordination Multimodal Exertion Test (MET): Duration: 20-25 minutes. Preparation: 3 trials of Hopkins Verbal Learning Test (HVLT) - 12 word recall test Pre-MET Post-Concussion Symptom Scale (PCSS) Heart rate monitor put on and worn throughout MET Stage 1: Focus on aerobic exercise and head acceleration in randomized order. 20 repetitions of squats , alternating reverse lunges, hip hinges (good morning) - randomized order 478 Final Exam 17  Stage 2: Continue targeting aerobic exercise and head acceleration sped up in randomized order. 10 repetitions within 15 seconds of squats, alternating reverse lunges, hip hinges (good morning) Stage 3: Introduce cognitive load in randomized order. 20 repetitions with cognitive task (Controlled Oral Word Association Test [COWAD]) of squats , alternating reverse lunges, hip hinges (good morning) Stage 4: Achieve 80-90% of age-predicted HRmax in a specific order. 12 step-downs (10” box) and lateral jump with decision Box jump-overs (6” box) with 180-degree twist (as many as possible in 20 seconds) Box jump-overs (6” box) with 180-degree twist and delayed HVLT (as many as possible in 20 seconds) Measurements: Monitor heart rate, symptoms, and performance metrics. Results: No increase in symptom severity score observed when progressing through the stages. Benefits for Clinical Decision-Making: These tests provide valuable data on cardiovascular performance, symptom responses, and overall physical readiness, enabling clinicians to make informed decisions about an athlete’s return to sport. They help ensure that athletes do not return too soon, thereby reducing the risk of re- injury or prolonged recovery. Module 8 - Biomarkers, Micro RNA, Neuroimaging, Technology 8.1 Describe what a biomarker is A biomarker is defined as a measurable characteristic that indicates normal biological processes, pathogenic processes, or responses to interventions. Biomarkers can be biological molecules present in blood, other body fluids, or tissues, serving as indicators of a normal or abnormal process, condition, or disease. A biomarker may be used to see how well the body responses to a treatment of a disease or condition. 478 Final Exam 18  They are critical for diagnosing and monitoring diseases, as well as predicting disease risk, by providing objective data rather than relying on subjective patient reports. Examples include proteins, genes, and metabolites that reflect physiological states or disease processes. Examples of biomarker collection include MRI, blood pressure, heart variability, spinal drain, and blood draw. Issues with Traditional Approaches to Diagnose Concussions Self-Reporting Symptom Scales: Prone to under-reporting of symptoms. Responses can be variable and inconsistent. Reliance on Clinical Judgment: Heavily dependent on the judgment of physicians and physiotherapists. Validity and Reliability Concerns: Tests may lack validity and reliability in concussion populations. Risk of Misdiagnosis: Misdiagnosis or premature return to sport can increase the risk of sustaining another sports-related concussion (SRC). 8.2 Understand the disruption caused to the blood brain barrier (BBB) following concussion and the role of the glympathic system The BBB consists of: Capillary endothelial cells Basal lamina (basement membrane as barrier between astrocytes and capillaries) Astrocytes Pericytes 478 Final Exam 19  The BBB regulates the movement of ions, solutes, and nutrients between peripheral circulation and the CNS and blocks pathogens and toxins from entering the CNS. Following a concussion, the integrity of the BBB can be compromised, leading to increased permeability and allowing potentially harmful substances and biomarkers to enter the peripheral circulation. The disruption of the BBB can result in an inflammatory response, involving the release of various cytokines and recruitment of immune cells to the site of injury. The glymphatic system plays a crucial role in clearing waste from the CNS, which includes the elimination of metabolites and proteins through a network that utilizes cerebrospinal fluid (CSF). Glymphatic clearance pathway 1. Para-Arterial Influx: The process starts with the para-arterial influx of cerebrospinal fluid (CSF) from the subarachnoid space into the brain's interstitial space. This influx allows CSF to flow through the brain tissue, facilitating nutrient delivery and waste removal. 2. Interstitial Fluid Movement: As CSF enters the interstitial space, it mixes with interstitial fluid, helping to wash away metabolic waste generated by neurons and glial cells. 3. Paravenous Efflux: Following this, the waste-laden interstitial fluid exits the brain through the paravenous efflux, moving from the interstitial spaces into the venous system. 4. Dural Venous Sinuses: During this process, neural factors are transported through the dural venous sinuses, which play a crucial role in draining waste products from the brain. 5. Drainage into the Lymphatics: Finally, the waste is drained into the cervical lymphatics via the meningeal lymphatic system, allowing it to re-enter the peripheral bloodstream through the subclavian vein. 478 Final Exam 20  Acute and subacute pathophysiology post-concussion Initial phase Release of inflammatory markers - damage leads to inflammatory response Recruitment of white blood cells - increase inflammation Remove damaged cells Subacute phase Release to anti-inflammatory markers - decrease inflammatory response Stimulate repair processes - decrease cell death and regenerate normal cells Restore normal function 478 Final Exam 21  8.3 Understand common biomarkers released following TBI and what they are markers for Micro-RNA (miRNA) miRNAs are small non-coding RNAs (~22 nucleotides) that can easily cross the blood-brain barrier (BBB) for measurement. They control mRNA expression and protein concentration post-transcriptionally through mRNA degradation and translation repression via ribosome inhibition. Methods of Analysis: Samples are taken from blood, cerebrospinal fluid (CSF), and saliva. Analysis Techniques: RT-PCR: Amplifies and detects specific RNA sequences using primers. Microarray: Simultaneously measures thousands of RNA transcripts for gene expression or genomic DNA fragments for copy number variation analysis; requires a reference transcript. RNA Sequencing: Analyzes the whole transcriptome, better suited for miRNA, and detects both known and unknown transcripts. miRNA in Concussion Expression Differences: Variations in miRNA expression observed between concussed participants and healthy controls, as well as baseline and post-concussion measurements. 478 Final Exam 22  Differences noted at various recovery time points post-injury. Dysregulation: miRNA dysregulation correlates with symptom severity and symptom clusters. Exploratory Study: Participants: 27 collegiate athletes with baseline and 7 hours post-sports-related concussion (SRC) blood samples. Findings: Significant up-regulation in 3 out of 5 evaluated miRNAs associated with CNS dysfunction; however, no significant correlation with clinical test scores. Conclusion: Further research is needed to explore biological mechanisms, functional implications, and clinical relevance. Key Considerations for Biomarker Research in Concussion Sex Differences: Females show a higher incidence of concussion and longer recovery times, with more severe symptoms and differing biological responses in blood flow and inflammation. The X chromosome codes for more miRNAs compared to the Y chromosome, leading to greater miRNA expression in females. Sex hormones can influence immune responses, and anatomical differences in brain structure may also play a role. Physical Activity: Physical activity induces a stress response that influences inflammatory markers and gene expression. 478 Final Exam 23  Acute high-intensity interval training can produce changes in peripheral protein levels similar to those seen in concussive injuries. Repeated exercise may mitigate these responses, with genes related to neural plasticity and repair returning to baseline values more quickly. Inter-Individual Genetic Variation: Baseline differences in miRNA expression exist due to genetic variation; comparing baseline and post- concussion data is more informative than comparing healthy vs. concussed populations. Utility and Future Directions: There is no consensus on a specific set of miRNAs/mRNAs for clinical use, necessitating further research. Understanding miRNAs offers greater insight into the pathophysiology of concussion, potential drug therapies, and guided rehabilitation strategies. Inflammatory Response Following TBI and Concussion 1. Release of DAMPs: Following TBI, damaged cells release damage associated molecular patterns (DAMPs), which are endogenous molecules that signal tissue injury. DAMPs alert the immune system to the presence of injury, initiating an inflammatory response. 2. Activation of Microglia: DAMPs activate microglia, the resident immune cells of the central nervous system (CNS). Once activated, microglia change shape, proliferate, and migrate to the site of injury. They release pro-inflammatory cytokines and chemokines, amplifying the immune response. 3. Cytokine and Chemokine Release: Activated microglia secrete various inflammatory cytokines and chemokines, including: Interleukin-6 (IL-6): Promotes inflammation and plays a role in the acute phase response. Interleukin-1 beta (IL-1β): Enhances inflammatory responses and promotes neuronal apoptosis. Tumor Necrosis Factor-alpha (TNF-α): Induces inflammation and can lead to cell death. Matrix Metalloproteinase-2 (MMP-2): Involved in the degradation of extracellular matrix components, contributing to BBB disruption. Matrix Metalloproteinase-9 (MMP-9): Facilitates the breakdown of the BBB and promotes the infiltration of immune cells. These signalling molecules propagate the inflammatory response and recruit additional immune cells. 4. Inflammatory Response and Blood-Brain Barrier (BBB) Breakdown: 478 Final Exam 24  The inflammatory cytokines lead to disruption of the blood-brain barrier (BBB), which normally protects the CNS from harmful substances. Increased BBB permeability allows for the infiltration of immune cells and plasma proteins into the brain, exacerbating inflammation and potentially causing secondary injury. 5. Immune Cell Infiltration: Following BBB breakdown, peripheral immune cells, such as neutrophils and macrophages, infiltrate the injured brain tissue. These cells contribute to the inflammatory environment, releasing additional cytokines and reactive oxygen species (ROS), which can lead to further neuronal damage. 6. Neuroinflammation: The accumulation of activated microglia and infiltrating immune cells leads to a sustained state of neuroinflammation. While this response is initially protective and aims to clear debris and promote repair, chronic neuroinflammation can result in neuronal injury, synaptic dysfunction, and contribute to long-term neurodegenerative processes. Common Biomarkers following TBI 478 Final Exam 25  Axonal Injury: Tau Protein: Associated with neurodegeneration and is released following axonal damage. Neurofilament Light (NFL) and Neurofilament Heavy (NFH): Markers indicating neuronal injury; elevated levels often correlate with the severity of brain injury. Spectrin Breakdown Products (SBDPs): Provide insights into the extent of axonal damage. White Matter Integrity: Myelin Basic Protein (MBP): Indicates myelin sheath damage, crucial for neuronal signal transmission. Neuronal Injury Markers (enrichment/accumulation in neuronal soma): Neuron-Specific Enolase (NSE): Elevated levels suggest neuronal damage and are often used in TBI assessments. Ubiquitin C-Terminal Hydrolase-L1 (UCH-L1): A marker for neuronal cell injury, correlating with the degree of brain injury. Activated Astrocytes and Microglia Markers: S100-B: Indicates astrocytic activation and is linked to brain injury severity. Glial Fibrillary Acidic Protein (GFAP): A marker for astrocytic activation and neuroinflammation. 478 Final Exam 26  Interleukins and Cytokines: These are inflammatory mediators released following injury, reflecting the immune response. Matrix Metalloproteinases (MMPs): Involved in extracellular matrix remodelling and can indicate BBB disruption. 8.4 Identify the overlap in fluid biomarkers that have and have not been found to discriminate between SRC and controls as well as during recovery trajectories Biomarker Distinction: Some biomarkers can differentiate between sport-related concussions (SRC) and healthy controls, while others show no significant differences. miRNA Variability: Commonly studied miRNAs may be dysregulated in concussed individuals; however, variability is influenced by factors like sample collection timing and individual differences. GFAP and UCH-L1: These biomarkers correlate with symptom severity and recovery trajectories, although findings are inconsistent across studies. Lack of Standardization: The absence of a standardized biomarker panel complicates clinical assessments, as specific biomarkers may be relevant for some individuals but not others. Blood Biomarkers for Concussion Study Summaries 478 Final Exam 27  Concussion: Sub-Acute Phase and Medical Clearance: Participants: 19 athletes with concussion and 19 matched healthy controls, average age 19. Biomarkers measured at 3-7 days post-injury (sub-acute phase) and at medical clearance (symptom resolution). Significant increases in T-tau at medical clearance and PRDX-6 during both sub-acute and medical clearance phases when comparing SRC to healthy controls. Sex Differences: Significant differences in inflammatory biomarkers for 4 out of 10 measured; many biomarkers show opposing trends between males and females. FDA-Approved Biomarkers: GFAP and UCH-L1 are authorized by the FDA to evaluate concussions, aiding in determining the need for CT scans and preventing unnecessary neuroimaging and radiation exposure. Blood tests indicate which patients should receive neuroimaging but are not used for diagnosing concussions. A study on healthy males showed GFAP decreases and UCH-L1 increases after exercise. Impact of Physical Exertion: Physical exertion influences biomarker levels, potentially complicating accurate SRC diagnoses in athletes. Advantages and Disadvantages of Peripheral Blood Biomerakers 478 Final Exam 28  Advantages: Relatively cheap. Familiarity with blood draws (majority of people). Disadvantages: No blood biomarker currently exists that can definitively diagnose a concussion. Biomarkers can be affected by exercise and various factors, including stress, biological sex, chemical exposure, diet, medication, and caffeine/sugar intake. 8.5 Describe the various neuroimaging techniques and key findings identified CT Scans and Structural MRI: Limited utility for diagnosing concussion unless there are signs of traumatic structural damage (e.g., brain bleed, skull fracture). Most concussions do not show macrostructural changes on traditional MRIs used in clinical settings. Advanced Neuroimaging Techniques: Diffusion MRI (dMRI) and Diffusion Tensor Imaging (DTI): 478 Final Exam 29  These techniques measure the translation motion of water molecules within different parts of the brain, providing insights into tissue microstructure. On average, water molecules move over distances of approximately 10µm. Within a voxel (take multiple images and layer them), the displacement distribution of water molecules in the direction of the gradient are measured. These imaging methods typically focus on white matter tracts to assess white matter microstructure. Two common measures: Fractional Anisotropy (FA): Indicates the directionality of water diffusion, reflecting the integrity of white matter. A higher FA implies more water diffusion directinoality and lower FA implies less water diffusion directionality (diffusion in different directions). Mean Diffusivity (MD): Represents the total amount of water diffusion, independent of directionality. Findings: Chronic effects in retired athletes show decreased fractional anisotropy (FA) and increased mean diffusivity (MD), indicating white matter damage or tissue loss (similar to moderate or severe TBI). Athletes with a history of concussion (~21 years old) showed an increase in FA and decreased MD. Acutely after concussion, FA decreases and MD increases. Arterial Spin Labelling (ASL): 478 Final Exam 30  A differential MRI technique that measures/quantifies brain perfusion and tracks cerebral blood flow (CBF). Findings: Significant increase in CBF 24 hours post-injury, followed by a decrease below normal levels by 8 days post-injury. Resting State and Task Functional MRI (fMRI): Examines brain connectivity with blood oxygenation levels Resting state fMRI: Conducted at rest without focusing on anything. Task fMRI: Involves performing cognitive tasks. Measures (functional connectivity): Blood oxygenation level depenedent (BOLD): Changes in blood oxygenation levels. When a brain region becomes active, it consumes more oxygen. This increase in activity leads to a localized increase in blood flow, delivering more oxygen to that area. The BOLD signal detects the differences in magnetic properties between oxygenated and deoxygenated blood, allowing researchers to infer brain activity. Global functional connectivity (Gconn): Refers to the overall connectivity patterns between different brain regions over time. This is typically quantified by analyzing the correlation between the BOLD signals of different brain regions, revealing how regions communicate with each other. 478 Final Exam 31  Global functional connectivity provides insights into the organization of the brain's functional architecture, helping to identify intrinsic networks (e.g., the default mode network) and how they may change in various conditions, such as neurological disorders or during cognitive tasks. Findings: Changes in functional connectivity patterns may indicate altered brain function following concussion. Magnetic resonance spectroscopy (MRS): Non-invasive imaging technique that provides information about the biochemical composition of tissues in the body, particularly the brain. Advantages and Disadvantages of Neuroimaging Advantages: Provides extensive information about brain microstructure and damage post-concussion. Disadvantages: High cost associated with advanced MRI techniques. Limited availability in many healthcare settings. Requires specialized training to interpret results, which not all doctors possess. 8.6 Identify various emerging technologies that have been used in research 478 Final Exam 32  Electroencephalograms (EEGs): Measure electrical activity in the brain; studies show lower power in specific frequency bands following concussion, suggesting changes in neural function. Heart Rate Variability (HRV): Assesses autonomic nervous system function; decreased HRV (especially in high frequency bands) has been observed after physical or cognitive exertion, indicating stress responses as there is no difference at rest. Blood Pressure and Heart Rate: Conflicting evidence; differences identified following tasks that cause physiological stress. Emerging Biomarker Technologies: Used for identifying physioloigcal and autonomic nervous system perturbations following concussion. 8.7 Understand key considerations for all biomarker research following concussion Inter-Individual Variability: Differences in responses to concussion can be influenced by factors such as age, sex, genetic predisposition, and baseline health status. Sex Differences: Females may exhibit different biomarker expressions and recovery patterns compared to males, necessitating gender-specific research considerations. Recovery Trajectories: Biomarkers may change over time; understanding the timing and context of biomarker assessments is crucial for accurate interpretation. Standardization of Biomarkers: The absence of consensus on which biomarkers to use complicates clinical application and necessitates further research to establish reliable panels. Biological Mechanisms: Ongoing studies are needed to elucidate the underlying biological mechanisms linking specific biomarkers to concussion outcomes, which could inform therapeutic strategies and rehabilitation. Module 10 - Clinical Recovery, Prolonged and Decreased Recovery 10.1 Overall for this course: identify the hierarchy for scientific evidence 478 Final Exam 33  Levels of Evidence: Systematic Reviews and Meta-Analyses: Considered the highest level of evidence, summarizing findings from multiple studies to provide comprehensive conclusions. Randomized Controlled Trials (RCTs): Provide robust data through controlled conditions, allowing for causative conclusions. Cohort Studies and Case-Control Studies: Offer insights into outcomes based on population data but with less control over variables than RCTs. Cross-Sectional Studies: Examine data at a specific point in time, useful for identifying associations but limited in establishing causality. Animal Trials and In Vitro Studies: Important for preliminary research and understanding mechanisms but may not fully translate to human outcomes. Case Reports and Case Series: Document individual patient experiences, providing insights but lacking generalizability. Expert Opinion Papers and Letters: Represent the lowest level of evidence, offering anecdotal insights without rigorous methodology or empirical support. 10.2 Understand the different components of clinical recovery and what is used to help inform clinical recovery 478 Final Exam 34  Full return to learn plus full return to sport doesn’t equal clinical recovery, must have medicial doctor declare full medical clearance. Symptom Evaluation: Continuous monitoring of symptoms is essential, focusing on physical (e.g., headaches, dizziness), cognitive (e.g., difficulty concentrating), and sensory (e.g., noise, light, music) aspects. No symptoms related to concucission without parmacological aids. Must be symptom free without medication (e.g., Tylenol or Advil). Neuropsychological Testing: Utilization of standardized tests to assess cognitive function, memory, and processing speed, guiding decisions on return-to-learn and return-to-play. Balance/Motor Tests: Assessments such as the Balance Error Scoring System (BESS) to evaluate physical stability and coordination post-injury. Vestibular/Ocular Measures: Testing for visual disturbances and balance issues that often accompany concussions, important for a comprehensive recovery plan. Physical Examination: Conducted by healthcare professionals to rule out other injuries and assess overall health, ensuring readiness to return to activities. Additional Considerations: Factors influencing recovery include: Fear of Re-Injury: Assess the athlete's readiness to return without fear; a referral to a sports psychologist may be necessary. Mental and Physical Preparedness: Consider both physical (e.g., cardiovascular fitness) and mental factors (e.g., reaction time, decision-making skills) affected by missing practices and games. External Pressures: Be aware of pressures from teammates and coaches that may impact the athlete's decision to return. Homelife Factors: Consider responsibilities and pressures from parents, especially for youth athletes. History of Concussions: 478 Final Exam 35  Evaluate the number of previous concussions, length of recovery, and frequency of occurrences. Desire to Return to Sport: Determine if the athlete wants to return, weighing benefits against risks, personal goals, and the nature of the sport (collision vs. contact vs. non-contact), as well as the time of season (regular season vs playoffs) and level of play (house league vs varsity vs professional). 10.3 Understand the timeline patterns for returning to play/sport and learn/school for different age groups Youth (5-12 years old): Return to Play/Sports: Longest recovery timeline between 7 days to 8 weeks (2 months), but usually within 4 weeks (1 month). 478 Final Exam 36  Return to Full Learn/School: Usually around 5 days to 4 weeks, but may be as long as 8 weeks (2 months). Adolescents and Young Adults (15-20 years old): Return to Play/Sports: Similar to youth, take longer to recover between 7 days to 6 weeks (42 days). Return to Full Learn/School: Usually around 4 days to 3.5 weeks, but may be as long as 9 weeks (2 months). Athletes (> 18 years old) Return to Play/Sports: Recovery length between 1 to 21 days (3 weeks), with 80-90% returing to sports by 2-3 weeks. Return to Full Learn/School: Mean of 8 days, range of 0 to 23 days. 93% of athletes had full return to learn by day 10 with no acadmic support. Professional Athletes: Return to Play/Sports: Generally exhibit quickest recovery timelines within 14 days, reflecting their higher level of physical conditioning and access to immediate medical care. 10.4 Identify all preand post-injury modifiers and describe which have been associated with prolonged recovery Prevalence of Persistent Symptoms: About 15-20% of adults and 20-30% of children experience symptoms lasting beyond 4 weeks. Long-Term Symptoms: Approximately 5% of individuals may have symptoms lasting longer than 6 months. At this stage, injury factors (e.g., neurometabolic cascade) are less influential; non-injury factors (biological, social, psychological) become more significant. Recovery Uncertainty: It is challenging to predict who will recover within typical timelines versus those who may experience prolonged recovery. Pre-Injury Modifiers: Sex: Some studies indicate that females may be at a higher risk for prolonged symptoms, although findings are mixed. Age: Younger athletes tend to recover more slowly, with recovery order typically being professional athletes, collegiate, high school, then youth. History of Concussion: Mixed results; many studies suggest an association between previous concussions and longer recovery, but some do not. 478 Final Exam 37  Mental Health History: Those with a history of anxiety, depression, or other mental health disorders often experience longer recovery times. History of Migraines: Evidence is inconclusive; most studies show no significant association with prolonged recovery. Learning Disabilities: Majority of studies report no significant link between learning disabilities and prolonged recovery. Initial Symptom Severity: Strong evidence supports that a higher initial symptom severity score correlates with a longer recovery period. Loss of Consciousness: Mixed findings; not a clear association established regarding its impact on recovery. Amnesia: No clear association identified with recovery duration. Post-Injury Modifiers: Timely Medical Intervention: Individuals who see a medical professional quickly after injury tend to have better outcomes, highlighting the importance of prompt diagnosis and care. Follow-Up Care: Early and ongoing care, including education and treatment, is crucial for optimal recovery. Physical Activity Post-Injury: Engaging in appropriate aerobic exercise may positively influence recovery and reduce symptoms. 10.5 Understand what variables have been identified to decrease recovery time Aerobic Exercise: Considered the most effective for reducing recovery time. Research shows that starting aerobic exercise within 1 day post-sport-related concussion (SRC) leads to faster recovery. By day 25, 100% of those who began exercise early recovered, compared to only 10% of those who started after 20 days. Early Medical Assessment: Early assessment may improve outcomes through timely diagnosis, education, treatment, and an active recovery approach. Individuals seeking their first clinic visit 8-20 days post-injury have an odds ratio of 4.7 for longer recovery compared to those who visit within 7 days. Module 11 - Additional Treatment Strategies, Risky Calculation, Risks of Injury following Concussion 478 Final Exam 38  11.1 Be Familiar with More Detailed Symptom Clusters: Visual Disturbances: Affecting 50-80% of individuals; includes blurred vision, double vision, light sensitivity, headache, dizziness, and screen intolerance. Vestibular/Balance Disturbances: Vestibular and vision systems are often working together. Common issues include balance problems, rining in ears, nausea, and potentially vertigo. Cervical Spine Issues: May manifest as neck pain or restricted movement, necessitating specific rehabilitation. Emotional/Mood Disturbances: Symptoms such as nervous or anxiety, irritability, more emotional, feeling down or sad, and anxiety and depression frequently occur. Sleep Disturbances: Affecting 30-70% of individuals; symptoms include fatigue, low energy, irregular sleep patterns, and difficulty sleeping soundly. Headaches/Migraines: One of the most common for acute concussion and persistent symptoms. 11.2 Understand and Describe the Various Treatment Strategies for the Six Symptom Clusters: Visual Disturbances: Smooth pursuits (horizontal and vertical). Saccades (horizontal and vertical). Convergence. Gaze stabilization (look at thumb then look away and head turn). Peripheral visition exercise. Referral to an optometrist for specialized care. Vestibular/Balance Disturbances: Balance exercisese both eyes open and closed (double legged, single leged, tandem). Balancing on different surfaces (on foam, on a Bosu/balance ball or board). Dual-tasks: walking or on a Bosu/balance ball while throwing/catching ball, object, etc. Physical therapists. Potential referral to audiologists - help with vertigo. 478 Final Exam 39  Cervical Spine Issues: Cervical spine manual therapy. Neck exercises. Range of motion exercises. Physical therapists. Potential referral to massage therapists. Emotional/Mood Disturbances: Social engagement throughout recovery (eg. have athlete on stationary bike during team practice). Clinical neuropyschologist: Cognitive behavioral therapy (CBT) and counseling Potential pharmacological treatments: Antidepressants typically in combindaiton with conselling therapy (depends on recovery duration, severity, past mental health history) Identifying and changing negative thought patterns and behaviors to improve emotional well-being Sleep Disturbances: Mindfulness and/or mediation. Restricting screens 2 hours before bed. Melatonin (natural to body). Pharmacological: Relatively safe and assist in keeping individual awake, prescription required by medical doctor *Napping may be recommened for 1st week by should start to limit and decrease after week 1 Headaches/Migraines: Nutrition intake and lifestyle (limit caffeine, stay hydrated, avoid alcohol and drugs). Limiting headache provoking activities. Manual therapy. Masssage therapy. 478 Final Exam 40  Pharmacological: Over-the counter medication: Ibuprofen (eg. Tylenol, Advil). Injections/Botox (injected to the face, back of head, and/or around neck region). 11.3 Be Able to Calculate Odds Ratio, Relative Risk, and Absolute Relative Risk: Odd Ratio (OR): Probability that an event will occur divided by the probability that it won’t occur. OR = Probability event will occur / Probability even won’t occur Risk: Probability of an event (or disease or injury) occuring in a group/condition Relative Risk or Risk Ratio (RR): The risk of disease/injury in one group divided by the risk in another group. RR = Risk in Group A / Risk in Group B Absolute Risk (AR) or Absolute Risk Reduction (ARR): Calculated by subtracting the risk of disease/injury in one group from the risk in another group. AR = Risk in Group A - Risk in Group B ⭐ Example Calculation: For rugby players: 5 concussions out of 20 players = 25% risk. For swimmers: 1 concussion out of 50 swimmers = 2% risk. Relative Risk Example: RR = 25% / 2% = 12.5 (indicating 12.5 times higher risk in rugby). Absolute Risk Example: AR = 25% - 2% = 23% (indicating a 23% higher absolute risk in rugby players). 11.4 Describe the Different Theories for Risk of Musculoskeletal Injuries Following Concussion: Definition and Prevalence: Musculoskeletal injuries involve damage to the muscular or skeletal systems (muscles, tendons, ligaments, bones). Increased risk of such injuries follows a concussion, with lower extremity injuries being the most common; upper extremity injuries are less studied. Neuromuscular Deficits: Perception-Action Coupling: 478 Final Exam 41  Involves coordination between visual and motor systems, affecting balance, coordination, visual perception, response/reaction, physical and mental capabilities. Post-Concussion Effects: Concussion can disturb neuromuscular control and delay visual processing or depth perception. Common deficits include difficulties in single- and dual-task activities (e.g., gait, jumps, step- downs). Research Findings: Studies show slower speed, greater sway, decreased stability, and smaller stride lengths post-injury. Performance declines with cognitive task complexity. Perturbations can be identified within 48 hours and at various points up to 2 months post-injury. History of concussion (>1 year) = inconclusive results Inconsistencies exist in research methods and findings, particularly for individuals with a history of multiple concussions. Physical Deconditioning: Skeletal Muscle Atrophy: Muscle mass and strength can decrease within 1-4 weeks of disuse, with some studies noting effects as early as 5 days. Cardiovascular Fitness: Decreases may begin as soon as 2 weeks post-injury, depending on prior fitness levels. Acute to Chronic Workload Ratio: Acute workload refers to current weekly exercise, while chronic workload is a rolling average over time (typically 6-9 weeks). A sudden stop in training after a concussion can lead to a decreased chronic workload. Returning to sport at pre-injury levels without gradually increasing acute workload risks further injury. 478 Final Exam 42  Psychological Issues: Mental readiness to return to sport is crucial; fear of re-injury, anxiety/depression, and lack of confidence can contribute to higher injury risk. 11.5 Understand the Various Findings Identified for Risk of Musculoskeletal Injuries Following Concussion: Increased Risk: Athletes with concussions have a 2.11 times greater odds of sustaining a musculoskeletal injury compared to a control group. The incidence rate ratio is 1.67, implying that athletes with concussion are 1.67 times more likely to sustain MSK injury comapred to control. Recent Studies: Increased risk of lower extremity musculoskeletal injuries within 90 days post-concussion, with odds ratios ranging from 1.4 to 4.6. Within one year, odds ratios for lower extremity injuries range from 1.6 to 3.1. Multiple Concussions: Increased Odds Ratio: The risk of lower extremity musculoskeletal (LE MSK) injuries rises with the number of prior concussions (1, >2, >3) compared to individuals with no concussions. Comparison Findings: 478 Final Exam 43  Greater risk is associated with multiple concussions compared to no concussions; however, the risk does not significantly increase with just one prior concussion. Risk of future MSK injury following concussion. Risk of future MSK injury based on type of sport. 478 Final Exam 44  Risk of future MSK injury based on sex. Module 12 - Chronic Traumatic Encephalopathy, Repetitive Head Impacts, Traumatic Encephalopahty Syndrome, Modifiable Risk Factors 12.1 Describe the Progression of CTE Understanding from the 1900s to Current: 1928: Martland introduces "punch-drunk" as a clinical condition to describe symptoms in boxers (confusion, gait issues, speech abnormalities, and slow response) from repeated blows to the head. 1934: Parker documents "traumatic encephalopathy of pugilists," noting behavioral changes in boxers (unsteady gait, slurred speech, and tremors) after repeated hits to the head. 1937: Millspaugh identifies "dementia pugilistica," a neurological deterioration and clinical observation in boxers. 1973: Coursellis finds neurofibrillary tangles (NFTs) in the brains of 15 deceased boxers but no plaques. 1990: Roberts reexamines Coursellis’ samples and 6 additional brains and discovers diffuse beta-amyloid plaques. 2005: Dr. Bennet Omalu confirms the first case of CTE in an NFL player (Mike Webster) post-mortem, identifying diffuse amyloid plaques and sparse neurfibrillary tangles (NFTs) and Tau-positive neuropil threads (NT) in neocortical areas. 2009-2013: Dr. Ann McKee publishes significant findings on CTE, presenting clinical and pathological features, and distinguishing CTE from other neurodegenerative diseases. 478 Final Exam 45  12.2 Understand Why Dr. Omalu’s Findings Were Significant in Professional Sports (Specifically Football): First Link to CTE: Omalu's 2005 paper was the first to neuropathologically connect chronic traumatic encephalopathy (CTE) to football, emphasizing the risks of repetitive head impacts. Case Report of Mike Webster: 50-year-old male, drafted into the NFL at age 22, played for 17 seasons. Died 12 years post-retirement from myocardial infarction (heart attack). Autopsy revealed a macroscopically normal-looking brain despite a damaged body. Post-Mortem Findings: Identified diffuse amyloid plaques, sparse neurofibrillary tangles (NFTs) in neocortical areas, and tau- positive neuropil threads (NTs) in neocortical areas. Impact on Awareness and Protocols: Omalu’s findings raised awareness of long-term neurological risks in football and challenged the NFL’s concussion management policies. This discovery led to further investigations into player safety and prompted changes in concussion protocols within the NFL. Tau Protein: A microtubule-associated protein primarily found in neurons. Binds and stabilizes microtubules in healthy brains, facilitating communication between neurons. Serves as a common marker for neurodegenerative diseases (e.g., Alzheimer’s, Dementia) where tau proteins detach from microtubules, forming threads that lead to tangles. Accumulation of tau disrupts the neuron's transport system, impairing neurotransmission. Neurofibrillary Tangles (NFTs): Formed by the accumulation of tau proteins inside neurons. Astrocytic Tangles: Result from the accumulation of tau proteins inside astrocytes. 478 Final Exam 46  Amyloid Plaques: Formed when amyloid precursor proteins break down into beta-amyloid proteins. The toxic beta-amyloid 42 form clusters around neurons, creating amyloid plaques. 478 Final Exam 47  Criticism from the NFL The NFL disagreed with Dr. Omalu’s findings and sought to retract his paper from Neurosurgery, despite a lack of neuropathologists on the MTBI committee. The NFL questioned Dr. Omalu’s expertise, partly due to his Nigerian background. Dr. Omalu faced significant backlash from the NFL and the public. In 2006, Dr. Omalu examined the brain of another NFL player, Terry Long, and identified CTE: No amyloid plaques were found (unlike Webster’s case). Tau-positive neurofibrillary tangles (NFTs) and tau-positive neuropil threads (NTs) were identified. 478 Final Exam