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1.  Summary of evidence-based guideline update: Evaluation and management of concussion in sports 
Neurology  2013;80(24):2250-2257.
Objective:
To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article.
Methods:
We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations.
Results:
Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.
doi:10.1212/WNL.0b013e31828d57dd
PMCID: PMC3721093  PMID: 23508730
2.  Mild Traumatic Brain Injury: Lessons Learned from Clinical, Sports, and Combat Concussions 
Over the past forty years, a tremendous amount of information has been gained on the mechanisms and consequences of mild traumatic brain injuries. Using sports as a laboratory to study this phenomenon, a natural recovery curve emerged, along with standards for managing concussions and returning athletes back to play. Although advances have been made in this area, investigation into recovery and return to play continues. With the increase in combat-related traumatic brain injuries in the military setting, lessons learned from sports concussion research are being applied by the Department of Defense to the assessment of blast concussions and return to duty decision making. Concussion management and treatment for military personnel can be complicated by additional combat related stressors not present in the civilian environment. Cognitive behavioral therapy is one of the interventions that has been successful in treating symptoms of postconcussion syndrome. While we are beginning to have an understanding of the impact of multiple concussions and subconcussive blows in the sports world, much is still unknown about the impact of multiple blast injuries.
doi:10.1155/2012/371970
PMCID: PMC3328165  PMID: 22550591
3.  Neuropsychological dysfunction in patients with end-stage pulmonary disease: lung transplant evaluation 
There has been a relative absence of studies that have examined the neuropsychological profiles of potential lung transplant candidates. Neuropsychological data are presented for 134 patients with end-stage pulmonary disease who were being evaluated as potential candidates for lung transplantation. Neuropsychological test results indicated that a significantly greater proportion of the patients exhibited impaired performances on a number of Selective Reminding Test (SRT) tasks as compared to the expected population frequency distributions for these measures. The highest frequencies of impairment were observed on the SRT’s Immediate Free Recall (46.43%), Long-term Retrieval (41.67%), and Consistent Long-term Retrieval (51.19%) variables. On the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)/Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), patients’ mean clinical profile revealed elevations on Scales 1 (Hypochondriasis) and 3 (Conversion Hysteria). This profile indicated that they were experiencing an array of symptomatology ranging from somatic complaints to lethargy and fatigue, and that they may have been functioning at a reduced level of efficiency. Findings are discussed in light of patients’ end-stage pulmonary disease and factors possibly contributing to their neuropsychological test performances. Implications for clinical practice and future research are also provided.
PMCID: PMC3219058  PMID: 14591451
Neuropsychology; Neurocognitive; Pulmonary disease; End-stage; Lung transplant
4.  Neuropsychological dysfunction in patients suffering from end-stage chronic obstructive pulmonary disease 
Few studies have examined the neuropsychological sequelae associated with end-stage pulmonary disease. Neuropsychological data are presented for 47 patients with end-stage chronic obstructive pulmonary disease (COPD) who were being evaluated as potential candidates for lung transplantation. Although patients exhibited a diversity of neurocognitive deficits, their highest frequencies of impairment were found on the Selective Reminding Test (SRT). Specifically, over 50% of the patients completing the SRT exhibited impaired immediate free recall and consistent long-term retrieval deficits, while more than 44% of these individuals displayed deficient long-term retrieval. Deficient SRT long-term storage strategies, cued recall, and delayed recall were exhibited by between 26% and 35% of these patients, while more than 32% of this sample displayed elevated numbers of intrusion errors. Over 31% of the patients completing the Wisconsin Card Sorting Test (WCST) failed to achieve the expected number of categories on this measure, while more than 23% of these individuals demonstrated elevated numbers of perseverative errors and total errors. Clinically notable frequencies of impairment (greater than 20% of the sample) were also found on the Trail Making Test (TMT): Part B and the Wechsler Memory Scale-R (WMS-R) Visual Reproduction II subtest. Minnesota Multiphasic Personality Inventory-2 (MMPI-2) personality assessments indicated that patients were experiencing a diversity of somatic complaints and that they may have been functioning at a reduced level of efficiency. These findings are discussed in light of patients’ end-stage COPD and factors possibly contributing to their neuropsychological test performances. Implications for clinical practice and future research are also included.
PMCID: PMC2714268  PMID: 14589783
Neuropsychological dysfunction; Chronic obstructive pulmonary disease; Lung transplantation
5.  Multiple Concussions and Neuropsychological Functioning in Collegiate Football Players 
Journal of Athletic Training  2001;36(3):303-306.
Objective:
To document neurocognitive and neurobehavioral consequences of 1 versus 2 concussions.
Design and Setting:
Nonequivalent, pretest-posttest cohort design with multiple dependent measures. Participants were selected from a large sample of athletes who participated in a comprehensive, multiuniversity study of football-related concussion.
Subjects:
College football players who sustained 1 and 2 grade 1 concussive injuries were matched for age, education, and duration of competitive football.
Measurements:
Neuropsychological tests and symptoms checklists.
Results:
Multivariate analysis of variance did not show a statistically significant difference in test performance between players with 1 or 2 concussions. Chi square analyses revealed that concussions significantly increased the number of symptom complaints, but symptoms returned to baseline by 10 days postinjury. The effects of 2 injuries did not appear to be significantly greater than that of a single injury. Differences in response to concussion were observed.
Conclusions:
Neurocognitive and neurobehavioral consequences of 2 concussions did not appear to be significantly different from those of 1 concussion, but methodologic issues place limitations on data interpretation. Additional studies are needed to clarify the neuropsychological consequences of multiple concussions.
PMCID: PMC155422  PMID: 12937500
sports injuries; neuropsychological tests; symptoms
6.  Monitoring Resolution of Postconcussion Symptoms in Athletes: Preliminary Results of a Web-Based Neuropsychological Test Protocol 
Journal of Athletic Training  2001;36(3):280-287.
Objective:
A new Web-based neuropsychological test was field tested to determine usefulness in detecting and monitoring resolution of symptoms after sport-related concussions and in providing objective information for return-to-play decisions.
Design and Setting:
We obtained neuropsychological baseline data on all subjects. After concussion, subjects were administered alternate, equivalent follow-up tests until symptoms resolved. Follow-up testing typically occurred at 1- to 2-day intervals after the concussion.
Subjects:
Baseline testing was obtained for 834 athletes as part of ongoing field trials. Subsequently, 26 athletes sustained concussions and were studied.
Measurements:
We administered The Concussion Resolution Index (CRI) at baseline and alternate forms posttrauma. Follow-up tests included a self-report inventory of neurophysiologic symptoms.
Results:
A total of 88% of patients were identified as symptomatic on initial postconcussion testing. The CRI appeared relatively resistant to retest effects, and multiple administrations tracked resolution of symptoms over short and extended time periods.
Conclusions:
Although the CRI is still in field trials, preliminary data indicate that the CRI may be a useful method for athletic trainers and other professionals to expeditiously track resolution of symptoms after sport-related concussion.
PMCID: PMC155419  PMID: 12937497
brain injury; return-to-play guidelines; computerized testing; Internet testing
7.  Acceleration-Deceleration Sport-Related Concussion: The Gravity of It All 
Journal of Athletic Training  2001;36(3):253-256.
Objective:
To discuss a newtonian physics model for understanding and calculating acceleration-deceleration forces found in sport-related cerebral concussions and to describe potential applications of this formula, including (1) an attempt to measure the forces applied to the brain during acceleration-deceleration injuries, (2) a method of accruing objective data regarding these forces, and (3) use of these data to predict functional outcome, such as neurocognitive status, recovery curves, and return to play.
Background:
Mild concussion in sports has gained considerable attention in the last decade. Athletic trainers and team physicians have attempted to limit negative outcomes by gaining a better understanding of the mechanisms and severity of mild head injuries and by developing meaningful return-to-play criteria. Mild head injury in sports has become an even greater area of focus and concern, given the negative neurobehavioral outcomes experienced by several recent high-profile professional athletes who sustained repeated concussions. Applying the principles of physics to characterize injury types, injury severity, and outcomes may further our development of better concussion management techniques and prevention strategies.
Description:
We describe the search for models to explain neuronal injury secondary to concussion and provide an exploratory method for quantifying acceleration-deceleration forces and their relationship to severity of mild head injury. Implications for injury prevention and reduction of morbidity are also considered.
PMCID: PMC155415  PMID: 12937493
mild head injury; physics; athletic injury; axonal injury; whiplash

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