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.
Report of the Guideline Development Subcommittee of the American Academy of Neurology
NIH study finds spinal manipulation more effective than medication for acute neck pain.
Spinal manipulation or home exercise was more effective than medication for treatment of acute to sub-acute neck pain, according to a recent NCCAM-funded study published in the Annals of Internal Medicine. Researchers from Northwestern Health Sciences University and the Minneapolis Medical Research Foundation randomly assigned 272 participants with neck pain, aged 18 to 65, to receive either spinal manipulation therapy, medication, or home exercise instruction.
In the study, spinal manipulation therapy consisted of various techniques, including spinal adjustments (low amplitude, high velocity) and mobilization (low velocity) of areas of the spine. Participants in the medication group received non-steroidal anti-inflammatory drugs, acetaminophen, or both; those who did not respond to these medications or could not tolerate them received narcotic medications. Home exercise with instruction focused on gentle self-controlled movement of the neck and shoulder joints, and participants were instructed to do the exercises six to eight times each day. In addition, participants in this group received two individualized hour-long sessions of one-on-one exercise instruction, as well as written directions for exercise at home.
The researchers observed significant short-term and long-term improvements in participant-rated pain in the spinal manipulation group compared with those receiving medication. At 12 weeks, 82 percent of participants in the spinal manipulation group (compared to 69 percent in the medication group) experienced reductions of pain of at least 50 percent. Similar findings occurred at 26 and 52 weeks. Additionally, the spinal manipulation group reported greater global improvement, participant satisfaction, and function than the medication group. Home exercise with instruction was just as effective as spinal manipulation at each time point.
Few studies exist to date on the management of neck pain with noninvasive methods, such as spinal manipulation, home exercise, or medications. According to the researchers, the findings from this study suggest that both spinal manipulation and home exercise may be viable treatment options for managing neck pain.
Bronfort G, Evans R, Anderson AV, et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain. Annals of Internal Medicine.
Study confirming successful non-operative treatments for meniscus tears...
The best available evidence from our search consisted of a retrospective review (1), a prospective clinical trial (2), and a randomized trial (3).
Lim et al performed a retrospective chart review among 30 mostly female patients who completed non-operative treatment for degenerative posterior root tear of the medial meniscus (1). Treatment consisted of supervised therapy, exercises, and NSAIDs for 8-12 wks (1). The authors concluded that clinical outcomes of self-reported pain and function improved during the follow-up period, an average of 36 mos (1). However, the study is limited in that the design did not allow for blinding of participants or a control group.
Rimington et al conducted a prospective trial among 26 patients with degenerative medial meniscus tear, comparing non-operative treatment consisting of NSAIDs to operative treatment (2). Almost half of patients improved with non-operative treatment, while remainder did not improve and chose to undergo operative treatment (2). At conclusion of treatment, subjects in both groups showed improved pain and function as assessed by questionnaire (2). Of note, a greater percentage of men elected surgery compared to women (72% vs 13%) (2). Limitations of this study include a lack of randomization, possibility of selection bias, and treatment until improvement was demonstrated on primary outcomes.
Herrlin et al randomized 90 middle-aged patients with degenerative medial meniscal tears to surgery followed by 8 wks of exercise or exercise alone, and found similar improvements in patient questionnaires for pain, function, symptoms, and activity (3). Limitations of this study include lack of blinding and no control group.
Based on this review, it can be concluded that non-operative management of meniscal tears shows promise in achieving successful clinical outcomes in a large percentage of the patients, and should be considered as the initial treatment approach. Sample exercises from VHI PC-Kits have been provided based on information from these articles.