the context of sport (both in the presence and absence of injury) that alter risk and affect etiology in a dynamic, recursive fashion. 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) Stage of the return to sport models In order to explain the psychological stages of the rehabilitation, stage models provide a succession of emotions and attitudes occurring following 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. Introduction. Treatment may be more effective when initiated early in the recovery process.104 However, further research is warranted to identify the ideal timing and type of intervention. The Concussion Recognition Tool Fifth Edition (CRT5) is a sideline tool that can be used by parents, coaches, officials, and players to recognize when a concussion may have occurred.28 In some sports, a “spotter” watches for potential signs of concussion and identifies individuals who may require screening for concussion. In other cases, findings suggest that central vestibular involvement may be present. A quick introduction to R b. cancer mortality). Intrinsic Risk Factors for Concussion Intrinsic risk factors may be modifiable (such as neuromuscular or sensorimotor control) or nonmodifiable (such as previous history of concussion, sex, age, and genetics). In part 2, we address concussion assessment and management. Once a concussion is suspected, the player should be removed from play and further assessed by a qualified health care professional (FIGURE 2). 215-219 View Record in Scopus Google Scholar 2008 Jan;27(1):19-50, vii. 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. Jetelina KK, Beauchamp AM, Reingle Gonzalez JM, Molsberry RJ, Bishopp SA, Lee SC. 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. 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 context of sport (both in the presence and absence of injury) that alter risk and affect etiology in a dynamic, recursive fashion. 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? Types of models c. Dataset i. Exploratory analysis d. Analysis e. Results f. Summary and exercises 6. Recursive Models of Dynamic Linear Economies Lars Hansen University of Chicago Thomas J. Sargent New York University and ... agent model. Front Psychol. 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. 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? Thus, consideration of sport-specific skills should be an integral part of a rehabilitation program. It is important for sports professionals to know why certain athletes may be at risk of injury risk factors and how injuries occur (i… This type of difficulty has been termed physiological postconcussion syndrome and has been hypothesized to occur secondary to autonomic nervous system involvement.67,68 For individuals who report difficulty with exertion, the Buffalo Concussion Treadmill Test is a widely used clinical test (based on the Balke test) that progressively increases the level of physical activity by increasing the incline and then speed of a treadmill.67 The test is stopped when symptoms increase (termed the symptom threshold and defined as at least a 2-point increase in symptom severity on a 0-to-10 rating scale) or when the individual reaches voluntary exhaustion. 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. In this section, we summarize the key intrinsic and extrinsic risk factors for concussion. Integrated model of psychological response to the sport injury and rehabilitation Psychological Responses Having discussed the integrated model that depicts how the psycho- logical consequences of sport injury relate to the overall injury experi- Get the latest research from NIH: This model considers the implications of repeated exposure, whether such exposure produces adaptation, maladaptation, injury or complete/incomplete recovery from injury. eCollection 2020. 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. (2016) propose a complex, albeit theoretical, model for injury etiology. Get the latest public health information from CDC: 2020 Sep 1;55(9):967-976. doi: 10.4085/1062-6050-477-19.  |   |   |  16.2. Recursive Risk Sensitive Control 369 16.1. 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. 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. 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. This integrated model encompasses personal and situational moderating factors. 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. Pessimistic Inter-pretation. In youth athletes, growth and development may result in changes in performance and adaptations. Sport-specific and performance-related skills may be necessary to return to full participation. Following concussion, it is necessary to recognize and remove the player from additional risk and refer the player to appropriate medical management as early as possible.28,84 Trauma followed by observable signs or symptoms of concussion should trigger an assessment to screen for concussion.28,84 A multifaceted assessment can inform appropriate management.37,78,84,102 Once the player has recovered and received clearance to return to play, the player may re-enter the dynamic process of adapting through recurrent participation. 2007;17(3):215–219. Self-reported injury history and lower limb function as risk factors for injuries in female youth soccer. 17, 215–219. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment, Risk factors for sports concussion: an evidence-based systematic review, Vestibular rehabilitation for dizziness and balance disorders after concussion, Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion, Immediate removal from activity after sport-related concussion is associated with shorter clinical recovery and less severe symptoms in collegiate student-athletes, Hypopituitarism in pediatric survivors of inflicted traumatic brain injury, Pituitary dysfunction after blast traumatic brain injury: the UK BIOSAP study, A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program, Clinical practice guideline: benign paroxysmal positional vertigo (update), Physical activity and concussion risk in youth ice hockey players: pooled prospective injury surveillance cohorts from Canada, Risk factors associated with sustaining a sport-related concussion: an initial synthesis study of 12,320 student-athletes, Vestibular rehabilitation for unilateral peripheral vestibular dysfunction, Peripheral vestibular disorders in children and adolescents with concussion, National Institute of Neurological Disorders and Stroke and Department of Defense Sport-Related Concussion Common Data Elements version 1.0 recommendations, Football players' head-impact exposure after limiting of full-contact practices, Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis, The epidemiology of new versus recurrent sports concussions among high school athletes, 2005–2010, Prevalence and consequences of sleep disorders in traumatic brain injury, An exploratory study of the potential effects of vision training on concussion incidence in football, Neck strength: a protective factor reducing risk for concussion in high school sports, Tackling concussion in professional rugby union: a case–control study of tackle-based risk factors and recommendations for primary prevention, The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale, Descriptive epidemiology of collegiate men's football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. 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. per 1000 hours of sports participation) in order to facilitate the comparability of research results. 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. A concussion should be suspected after a direct blow to the head or following trauma to the body by which force has been transmitted to the head.84 Some of the observable signs of concussion are lying motionless, clutching the head, unsteadiness, or appearing dazed or confused immediately following a concussion (see the Concussion Recognition Tool Fifth Edition28). The literature is inconsistent regarding sex as a risk factor for concussion. Injury, Illness, and Training Load in a Professional Contemporary Dance Company: A Prospective Study. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Interventions aimed at primary prevention have shown promise in decreasing the risk of concussion. In this paper, the authors build on Meeuwisse’s dynamic, recursive model but argue a complex system approach is necessary to understand the nature of injury aetiology. In part 1 of this commentary, we address etiology, risk factors, and detection of concussion. . Ericsson, K. A. 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. Jeffries AC, Wallace L, Coutts AJ, Cohen AM, McCall A, Impellizzeri FM. 2020 Jul 20;20(1):1137. doi: 10.1186/s12889-020-09219-x. doi: 10.1016/j.csm.2007.10.008. Journal of Orthopaedic & Sports Physical Therapy, 21 April 2020 | Brain Injury, Vol. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007). Each individual who participates in an activity brings a specific set of intrinsic and extrinsic factors (FIGURE 1). 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. ↑ Alonso JM, Junge A, Renstrom P, Engebretsen L, Mountjoy M, Dvorak J. 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. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. Symptom onset can be delayed, with the duration of the delay predicting a longer time to recovery following injury. 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. 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. Injury surveillance in multi-sport events: the International Olympic Committee approach. Please enable it to take advantage of the complete set of features! The Journal of Sport Rehabilitation (JSR) is your source for the latest peer-reviewed research in the field of sport rehabilitation.All members of the sports-medicine team will benefit from the wealth of important information in each issue. ERAIQ. 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. [abstract], Sport-related concussion: optimizing treatment through evidence-informed practice, Rest and treatment/rehabilitation following sport-related concussion: a systematic review, Cervicovestibular rehabilitation following sport-related concussion [letter], Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players, Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial, Changes in measures of cervical spine function, vestibulo-ocular reflex, dynamic balance, and divided attention following sport-related concussion in elite youth ice hockey players, Concussion burden, recovery, and risk factors in elite youth ice hockey players, Prevalence of and risk factors for anxiety and depressive disorders after traumatic brain injury: a systematic review, Near point of convergence after concussion in children, Vestibular rehabilitation is associated with visuovestibular improvement in pediatric concussion, Individuals with pain need more sleep in the early stage of mild traumatic brain injury. When the 2 injuries occur concurrently, they must be treated appropriately. Epidemiology of injury in child and adolescent sports: injury rates, risk factors, and prevention. 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? and behavioral responses of athletes to sport injury. eCollection 2020. How Do We Meet the Challenges of Assessing and Managing Concussion? Is there a gender difference in concussion incidence and outcomes? The best way to decrease the burden of concussion is to prevent the injury before it occurs (ie, through primary prevention). When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. as well as cognitive, emotional. 6, International Journal of Athletic Therapy and Training, 31 October 2019 | Journal of Orthopaedic & Sports Physical Therapy, Vol. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. Criticisms focus on the lack of research supporting a uniformed sequence of stages as a feature of response to athletic injury. However, while protective equipment, such as helmets, headgear, and mouthguards, may mitigate the risk of concussion, the literature is inconclusive. Clinicians should use a multifaceted assessment that includes symptoms, a neurological screen, and assessment of multiple clinical domains.27,37 The Sport Concussion Assessment Tool Fifth Edition (SCAT5)29 includes an immediate/on-field assessment that incorporates red flags, observable signs, memory assessment (ie, the Maddocks questions), the Glasgow Coma Scale, and a cervical spine assessment. In addition, decisions regarding return to sport may be affected by the intrinsic and extrinsic factors that characterize the individual athlete. Knowledge of modifiable risk factors helps to efficiently direct injury prevention efforts, and knowledge of nonmodifiable risk factors helps the clinician achieve an understanding of the overall risk to the athlete and informs return-to-play decision making. 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. If symptoms recur, then the athlete should move back to the previous step. In many cases, medical management is required; for some headache types, such as cervicogenic headaches, physical therapy may be of benefit.54,125 Botulinum toxin injection can be considered for posttraumatic chronic migraine headaches.24 Repetitive transcranial magnetic stimulation may be effective in the treatment of posttraumatic headache.60,69,70 Often, a multimodal approach to headache management includes both acute and prophylactic medication. Headaches are the most frequent symptom following concussion. When feasible, future studies on sport injury prevention should adopt a methodology and analysis strategy that takes the cyclic nature of changing risk factors into account to create a dynamic, recursive picture of etiology. Introduction. Recursive Preferences. 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. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Pre-injury factors lead to post-injury responses Dynamic Core of Model: Cognitive appraisals, emotional responses, behavioral responses, recovery outcomes. In these cases, the athlete continues to play, and ongoing adaptation and changes in the set of risk factors to which the athlete is exposed may occur, resulting in higher or lower concussion risk. A Control Problem. Whether its recreational or professional, injury is a common occurrence at all levels of sport and exercise. A dynamic model of etiology in sport injury: the recursive nature of risk and causation. BMC Public Health. 34, No. Epub 2008 Jan 28. Diagnosis directs appropriate management. days following the injury, and a strategy involving a gradual return to sport and school is recommend-ed. 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? 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.
2020 dynamic, recursive model of sport injury