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      A Case for Mental and Physical Rest in Youth Sports Concussion: It’s Never too Late

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          Abstract

          Over the past decade, there has been a considerable increase in research on, and media attention to, sports-related concussion. However, despite accurate diagnosis, effective treatment and management of sports-related concussion have remained a challenge. There are approximately 1.8 million traumatic brain injuries in the United States annually (Faul et al., 2010) and emergency department pediatric visits for suspected concussion have doubled in the past decade (Bakhos et al., 2010). However, health care providers and medical researchers have yet to offer an effective, reliable evidence-based treatment for concussive brain injury. The Zurich 2008 Consensus Statement on Concussion in Sport codified the prescription for cognitive and physical rest immediately following a concussion based on clinical acumen and common sense (McCrory et al., 2009). Currently, rest is the considered the best immediate treatment for concussion. Other supportive and anecdotal treatments are often applied throughout the post-concussive recovery process to address persistent symptoms. The need for empirical research to translate current guidelines for rest into evidence-based treatment protocols is essential. A recent study evaluated the efficacy of comprehensive rest and concluded that such rest may be helpful whether applied soon after a concussion or weeks to months later (Moser et al., 2012). Here, we present a case illustrating the effectiveness of rest in a youth athlete, commenced after experiencing 13 months of post-concussion symptoms. There appears to be value in applying a specific period of cognitive and physical rest following concussion, whether immediately or later in the recovery phase.

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          Most cited references31

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          Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury.

          Since the 1920s, it has been known that the repetitive brain trauma associated with boxing may produce a progressive neurological deterioration, originally termed dementia pugilistica, and more recently, chronic traumatic encephalopathy (CTE). We review 48 cases of neuropathologically verified CTE recorded in the literature and document the detailed findings of CTE in 3 profession althletes, 1 football player and 2 boxers. Clinically, CTE is associated with memory disturbances, behavioral and personality changes, parkinsonism, and speech and gait abnormalities. Neuropathologically, CTE is characterized by atrophy of the cerebral hemispheres, medial temporal lobe, thalamus, mammillary bodies, and brainstem, with ventricular dilatation and a fenestrated cavum septum pellucidum. Microscopically, there are extensive tau-immunoreactive neurofibrillary tangles, astrocytic tangles, and spindle-shaped and threadlike neurites throughout the brain. The neurofibrillary degeneration of CTE is distinguished from other tauopathies by preferential involvement of the superficial cortical layers, irregular patchy distribution in the frontal and temporal cortices, propensity for sulcal depths, prominent perivascular, periventricular, and subpial distribution, and marked accumulation of tau-immunoreactive astrocytes. Deposition of beta-amyloid, most commonly as diffuse plaques, occurs in fewer than half the cases. Chronic traumatic encephalopathy is a neuropathologically distinct slowly progressive tauopathy with a clear environmental etiology.
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            The Neurometabolic Cascade of Concussion.

            OBJECTIVE: To review the underlying pathophysiologic processes of concussive brain injury and relate these neurometabolic changes to clinical sports-related issues such as injury to the developing brain, overuse injury, and repeated concussion. DATA SOURCES: Over 100 articles from both basic science and clinical medical literature selected for relevance to concussive brain injury, postinjury pathophysiology, and recovery of function. DATA SYNTHESIS: The primary elements of the pathophysiologic cascade following concussive brain injury include abrupt neuronal depolarization, release of excitatory neurotransmitters, ionic shifts, changes in glucose metabolism, altered cerebral blood flow, and impaired axonal function. These alterations can be correlated with periods of postconcussion vulnerability and with neurobehavioral abnormalities. While the time course of these changes is well understood in experimental animal models, it is only beginning to be characterized following human concussion. CONCLUSIONS/RECOMMENDATIONS: Following concussion, cerebral pathophysiology can be adversely affected for days in animals and weeks in humans. Significant changes in cerebral glucose metabolism can exist even in head-injured patients with normal Glasgow Coma Scores, underscoring the need for in-depth clinical assessment in an effort to uncover neurocognitive correlates of altered cerebral physiology. Improved guidelines for clinical management of concussion may be formulated as the functional significance and duration of these postinjury neurometabolic derangements are better delineated.
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              Long-term consequences of repetitive brain trauma: chronic traumatic encephalopathy.

              Chronic traumatic encephalopathy (CTE) has been linked to participation in contact sports such as boxing and American football. CTE results in a progressive decline of memory and cognition, as well as depression, suicidal behavior, poor impulse control, aggressiveness, parkinsonism, and, eventually, dementia. In some individuals, it is associated with motor neuron disease, referred to as chronic traumatic encephalomyelopathy, which appears clinically similar to amyotrophic lateral sclerosis. Results of neuropathologic research has shown that CTE may be more common in former contact sports athletes than previously believed. It is believed that repetitive brain trauma, with or possibly without symptomatic concussion, is responsible for neurodegenerative changes highlighted by accumulations of hyperphosphorylated tau and TDP-43 proteins. Given the millions of youth, high school, collegiate, and professional athletes participating in contact sports that involve repetitive brain trauma, as well as military personnel exposed to repeated brain trauma from blast and other injuries in the military, CTE represents an important public health issue. Focused and intensive study of the risk factors and in vivo diagnosis of CTE will potentially allow for methods to prevent and treat these diseases. Research also will provide policy makers with the scientific knowledge to make appropriate guidelines regarding the prevention and treatment of brain trauma in all levels of athletic involvement as well as the military theater. Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Front Neurol
                Front Neurol
                Front. Neur.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                11 December 2012
                2012
                : 3
                : 171
                Affiliations
                [1] 1Sports Concussion Center of New Jersey Lawrenceville, NJ, USA
                [2] 2International Brain Research Foundation Flanders, NJ, USA
                [3] 3St. Joseph’s University Philadelphia, PA, USA
                Author notes

                Edited by: Vernon Williams, Kerlan-Jobe Orthopaedic Clinic, USA

                Reviewed by: Jeff Victoroff, University of Southern California, USA; Frank Conidi, Florida State University College of Medicine, USA

                *Correspondence: Rosemarie Scolaro Moser, Sports Concussion Center of New Jersey, 3131 Princeton Pike, Building 5, Suite 110, Lawrenceville, NJ 08648, USA. e-mail: rmoser@ 123456sportsconcussionnj.com

                This article was submitted to Frontiers in Sports Neurology, a specialty of Frontiers in Neurology.

                Article
                10.3389/fneur.2012.00171
                3518809
                23248612
                3360af8d-19af-4880-b2ae-27e3f601a048
                Copyright © 2012 Moser and Schatz.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and subject to any copyright notices concerning any third-party graphics etc.

                History
                : 13 August 2011
                : 10 November 2012
                Page count
                Figures: 4, Tables: 1, Equations: 0, References: 43, Pages: 7, Words: 5067
                Categories
                Neuroscience
                Clinical Case Study

                Neurology
                cognitive rest,concussion,mild traumatic brain injury,sports concussion,treatment of concussion,youth concussion

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