Abstracts: Neurologia

Mayers LB, Redick TS.: Journal of Clinical and Experimental Neuropsychology, Mar 2012, 34(3):235-42.

Computerized neuropsychological testing is commonly utilized in the management of sport-related concussion. In particular, the Immediate Postconcussion Assessment and Cognitive Testing 2.0 program (ImPACT) is widely used to assess the cognitive functioning of athletes before and after a concussion. We review the evidence for the clinical utility of this program in terms of validity, reliability, and use in return-to-play decisions. We conclude that the empirical evidence does not support the use of ImPACT testing for determining the time of postconcussion return to play.

The sports concussion note: should SCAT become SCOAT?

Patricios J, Collins R, Branfield A, Roberts C, Kohler R.: British Journal of Sports Medicine, Março 2012, 46(3):198-201.

Sports concussion research and clinical guidelines have evolved rapidly. The most recent concussion consensus statement and guidelines (Zurich, 2008) provided clinicians with the Sports Concussion Assessment Tool version 2 (SCAT2) as a clinical template for the assessment of acute concussion. For the subsequent serial examinations required for the complete assessment of the concussed athlete, SCAT2 may be inadequate. This paper describes the experience and suggestions of South African sports physicians in evolving a more comprehensive clinical evaluation tool and record of patient care, the Sports Concussion Office Assessment Tool.

Walking speed and distance in different environments of subjects in the later stage post-stroke.

Carvalho C, Sunnerhagen KS, WillÃ©n C.: Physiotherapy theory and Practice, 2010, 26(8):519-27. Institute of Neuroscience and Physiology, Section of Clinical Neuroscience and Rehabilitation Medicine, University of Gothenburg, Gothenburg, Sweden.

The purpose of this study is to assess short- and long-distance walking performance in indoor and outdoor environments of slow and fast walkers' subjects living in the community in the later stage post-stroke. Thirty-six subjects with at least 6 months post-stroke were included and divided into two groups based on their walking speed in the clinical setting. Thirty-meter walk tests (30?mWT) at self-selected and maximum speeds were assessed in three environments: (1) clinical setting; (2) basement setting; and (3) outdoor setting. Six-minute walk test (6?MWT) distance was assessed in the clinical and outdoor settings. The differences between the 30?mWT and the 6?MWT, as measured by the actual distance obtained in the 6?MWT and the predicted distance calculated for the 30?mWT, were also investigated. There was no difference in walking speed when subjects performed short-distance walking in different environments. However, a difference was found in performance of long-distance walking. Subjects who walked 0.8?m/s or faster also walked further in the outdoor setting. The findings of our study demonstrate that in those who scored below 0.8?m/s, performance of short- and long-distance walking evaluated in an indoor environment reflects the results obtained in an outdoor environment. However, for subjects post-stroke who score 0.8?m/s or faster, distance was increased in the outdoor environments during long-distance walking. Walking speed obtained over a short distance seemed to overestimate long-distance walking capacity for the slow walkers, despite the environment.

The "swing-ding": a golf-related head injury in children.

Wang A, Cohen AR, Robinson S.: Journal of neurosurgery. Pediatrics, 2011 7(1):111-5. Division of Pediatric Neurosurgery, University Hospitals Rainbow Babies and Children's Hospital, The Neurological Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Object In recent years there has been an increased incidence of golf-associated head injuries in children and adolescents. At the authors' institution, they have identified a unique pattern of head injury associated with a swinging golf club. In this study, the authors highlight the mechanism of this injury and report their experience treating it. Methods The authors reviewed the database of Rainbow Babies and Children's Hospital Trauma Center and performed a retrospective analysis of golf injuries recorded over a 10-year period (January 2000-April 2010). They identified 13 children (9 boys and 4 girls) who sustained head injuries in golfing accidents. All patients were 10 years of age or younger. The medical charts were reviewed and follow-up interviews were conducted to better delineate the details of the injuries. Results Injuries included 13 depressed skull fractures, 7 epidural hematomas, and 1 cerebral contusion. All 13 patients sustained their injuries after being struck in the head by a golf club. Seven sustained injuries on the follow-through of the initial swing and 3 sustained injuries on the backswing. All but one patient required neurosurgical intervention. Five patients developed neurological sequelae. None of the children had prior experience with golf equipment. All but one injury occurred in the child's own backyard. There was no direct supervision by an adult in any of the cases. Conclusions Golfing can lead to serious head injuries in children. The authors noticed a unique pattern of golf-related head injuries, previously not described, that they have termed the "swing-ding." This golf club-inflicted injury occurs when a child stands too close to a swinging golfer and is struck in the head, subsequently sustaining a comminuted depressed skull fracture in the frontal or temporal region, with or without further intracranial injury. The study suggests that a lack of adult supervision, minimal previous golf experience, and proximity of the child to the swinging golfer are all implicated in this head injury pattern.

Physical activity in young children with cerebral palsy

J. Nathalie Zwier, Petra E.m. van Schie, Jules G. Becher, Dirk-Wouter Smits, Jan Willem Gorter, Annet J. Dallmeijer: 2010, Vol. 32, No. 18 , Pages 1501-1508.

Purpose. The aim of this study was to describe the physical activity levels of 5- and 7-year-old children with cerebral palsy (CP, n=97), to compare their physical activity levels with those of typically developing peers (TD, n=57) and the Dutch recommendation for physical activity, and to investigate the associated factors. Method.The level of physical activity (hours spent on sports and physical activity per week) and contextual factors were assessed with standardised questionnaires. Results.Mean duration of self-reported physical activity for children with CP was 3.4 (±1.9) h/week, which was significantly less than the 5.8 (±2.3) h/week for TD-peers. Ninety-three percent of the children with CP were insufficiently physically active according to the Dutch recommendation for physical activity. Multiple regression analyses showed that younger age and lower educational level of the mother were significantly associated with lower levels of physical activity for children with CP, while severity of CP was not associated with physical activity levels. Twenty-two percent of the parents reported that more facilities in sport and games are required for children with CP. Conclusion.Physical activity is low in young children with CP and needs to be promoted at an early stage.

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

Echlin PS, Tator CH, Cusimano MD, Cantu RC, Taunton JE, Upshur RE, Hall CR, Johnson AM, Forwell LA, Skopelja EN.: Neurosurgical focus, 2010 29(5):E4.

AIM Health Group Family Medicine, London, Ontario; Object The objective of this study was to measure the incidence of concussion (scaled relative to number of athlete exposures) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players (16-21 years old) during 1 regular season. Methods A prospective cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season (2009-2010) involving 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing. If the protocol was not followed, the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels. Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer. Players who suffered a suspected concussion were evaluated at the game. If a concussion diagnosis was made, the player was subsequently examined in the physician's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated. Based on these evaluations, players were counseled on the decision of when to return to play. Athlete exposure was defined as 1 game played by 1 athlete. Results Twenty-one concussions occurred during the 52 physician-observed games (incidence 21.5 concussions per 1000 athlete exposures). Five players experienced repeat concussions. No concussions were reported during practice sessions. A concussion was diagnosed by the physician in 19 (36.5%) of the 52 observed games. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 total concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. Conclusions The incidence of game-related concussions (per 1000 athlete exposures) in these fourth-tier ice hockey players was 3.3 times higher than the highest rate previously reported in the literature. This difference may be the result of the use of standardized direct physician observation, diagnosis, and subsequent treatment. The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings. These follow-up studies should involve other contact sports (for example football and rugby) and also include the full spectrum of gender, age, and skill levels.

Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion.

Echlin PS, Tator CH, Cusimano MD, Cantu RC, Taunton JE, Upshur RE, Czarnota M, Hall CR, Johnson AM, Forwell LA, Driediger M, Skopelja EN.: Neurosurgical focus, 2010, 29(5):E5.

AIM Health Group Family Medicine, London, Ontario; Object The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior (16-21-year-old) ice hockey players during a regular season. Methods The authors conducted a prospective cohort study during 1 junior regular season (2009-2010) of 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years [SD], range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments that were determined using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT. If the protocol was not followed, the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels. Each game was directly observed by a physician and at least 1 neutral nonphysician observer. Players suspected of suffering a concussion were evaluated by the physician during the game. If a concussion was diagnosed, the player underwent clinical evaluation at the physician's office within 24 hours. The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol (contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008). This clinical evaluation and return-to-play protocol was augmented by the 2 tests (SCAT2 and ImPACT) also recommended by the Zurich consensus statement, for which baseline values had been obtained. Results Seventeen players sustained a physician-observed or self-reported, physician-diagnosed concussion during a physician-observed ice hockey game. The mean clinical return-to-play duration (in 15 cases) was 12.8 ± 7.02 days (median 10 days, range 7-29 days); the mean number of physician office visits by players who suffered a concussion (15 cases) was 2.1 ± 1.29 (median 1.5 visits). Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days (median 82 days), and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days (median 60 days). Conclusions The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions. The time interval between the first and second concussions was also greater than previously cited. This difference may be the result of the methodology of direct independent physician observation, diagnosis, and adherence to the Zurich return-to-play protocol.

Boxing-related head injuries.

Jayarao M, Chin LS, Cantu RC.: The Physician and sportsmedicine, 2010 38(3):18-26. Department of Neurosurgery, Boston Medical Center, Boston, MA, USA.

Fatalities in boxing are most often due to traumatic brain injury that occurs in the ring. In the past 30 years, significant improvements in ringside and medical equipment, safety, and regulations have resulted in a dramatic reduction in the fatality rate. Nonetheless, the rate of boxing-related head injuries, particularly concussions, remains unknown, due in large part to its variability in clinical presentation. Furthermore, the significance of repeat concussions sustained when boxing is just now being understood. In this article, we identify the clinical manifestations, pathophysiology, and management of boxing-related head injuries, and discuss preventive strategies to reduce head injuries sustained by boxers.

Gender differences in head impacts sustained by collegiate ice hockey players. Brainard LL, Beckwith JG, Chu JJ, Crisco JJ, McAllister TW, Duhaime AC, Maerlender AC, Greenwald RM

Medicine and science in sports and exercise44(2):297-304, 2012 PURPOSE: This study aimed to quantify the frequency, magnitude, and location of head impacts sustained by male and female collegiate ice hockey players during two seasons of play. METHODS: During two seasons, 88 collegiate athletes (51 females, 37 males) on two female and male National Collegiate Athletic Association varsity ice hockey teams wore instrumented helmets. Each helmet was equipped with six single-axis accelerometers and a miniature data acquisition system to capture and record head impacts sustained during play. Data collected from the helmets were postprocessed to compute linear and rotational accelerations of the head as well as impact location. The head impact exposure data (frequency, location, and magnitude) were then compared between genders. RESULTS: Female hockey players experienced a significantly lower (P 0.278) for all locations except the right side of the head, where males received fewer impacts than females (P = 0.031). Female hockey players were 1.1 times more likely than males to sustain an impact less than 50g, whereas males were 1.3 times more likely to sustain an impact greater than 100g. Similarly, males were 1.9 times more likely to sustain an impact with peak rotational acceleration greater than 5000 rad·s and 3.5 times more likely to sustain an impact greater than 10,000 rad·s. CONCLUSIONS: Although the incidence of concussion has typically been higher for female hockey players than male hockey players, female players sustain fewer impacts and impacts resulting in lower head acceleration than males. Further study is required to better understand the intrinsic and extrinsic risk factors that lead to higher rates of concussion for females that have been previously reported.

Cardiovascular responses to arm static exercise in men with thoracic spinal cord lesions. Sakamoto K, Nakamura T, Umemoto Y, Koike Y, Sasaki Y, Tajima F

112(2):661-6, 2012Isometric muscle contraction (static exercise) induces circulatory response. Static exercise in individuals with thoracic spinal cord injury (TSCI) induces cardiovascular response and blood redistribution to the non-exercising muscles. The aim of our study was to determine the circulatory response during arm static exercise in individuals with TSCI and able-bodied (AB) controls. Mean blood pressure (MBP), heart rate (HR), cardiac output (CO), leg skin blood flow (SBF), and leg muscle blood flow (MBF) were recorded noninvasively, total peripheral resistance (TPR) was estimated by dividing MBP by CO, and hormonal changes were measured before, during and after static 35% maximal voluntary contraction (MVC) of the arm flexor muscles in seven male individuals with TSCI (T7-T11) and seven age-comparable AB control (32.2 ± 7.6 and 31.0 ± 4.7 years, respectively). The 35% MVC was similar in TSCI and AB individuals (107.3 ± 28.2 and 101.0 ± 22.5 N, respectively). HR, CO, MBP, TPR, SBF and MBF increased in both groups during arm static exercise. Plasma epinephrine concentration increased during arm static exercise in AB controls only (P < 0.05). Circulation to leg muscles was similar in TSCI and AB individuals and the lack of sympathetic vasoconstriction in the paralyzed leg area did not alter the cardiovascular responses during 35% MVC of arm static exercise. We conclude that sympathetic vasoconstriction in the resting leg area did not contribute to the pressor reflex during 35% MVC of arm static exercise.

Cardiorespiratory response to exercise testing in individuals with Alzheimer's disease. Billinger SA, Vidoni ED, Honea RA, Burns JM

UNLABELLED: Billinger SA, Vidoni ED, Honea RA, Burns JM. Cardiorespiratory response to exercise testing in individuals with Alzheimer's disease. OBJECTIVE: To examine exercise testing response in Alzheimer's disease (AD) and possible disease-related change over time. DESIGN: Retrospective assessment of a 2-year observational study. SETTING: University medical center. PARTICIPANTS: Individuals without dementia (n=50) and with AD (n=31). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants underwent a clinical dementia evaluation and performed an incremental exercise test using a treadmill and the modified Bruce protocol at baseline and at a 2-year follow-up. We examined oxygen consumption, minute ventilation, heart rate, and ventilatory equivalents for oxygen and carbon dioxide at submaximal and peak exercise intensities to determine whether the measures were different between groups or over time. RESULTS: Participants with AD and those without dementia performed similarly at submaximal effort, and both groups showed similar changes in exercise response over 2 years. However, nondemented individuals had consisten tly higher values of oxygen consumption (P=.02) and minute ventilation at peak effort at baseline (P=.003). CONCLUSIONS: Individuals with AD demonstrate physiologic responses to submaximal exercise effort that are not significantly different than individuals without dementia. However, differences are apparent at the extreme of effort.

Risk of injury and concussion associated with team performance and penalty minutes in competitive youth ice hockey. Emery CA, Kang J, Schneider KJ, Meeuwisse WH

45(16):1289-93, 2011 DezObjective To determine if there is an association between the risk of all injury or concussion and win-loss records or penalty minutes in competitive youth ice hockey players (ages 11-14). Design, setting, participants This is a secondary data analysis of a 2-year cohort study in Alberta and Quebec on the 2007/2008 (Pee Wee) and 2008/2009 (Bantam) seasons. Main outcome measures Incidence rate ratios (IRRs) were estimated based on Poisson regression for game-related injury and concussion and adjusted for cluster by team. Results A total of 140 teams from Alberta (n=2081) and 137 teams (n=2018) from Quebec were included in the analysis. There were 451 game-related injuries (121 concussions) from Alberta and 280 (62 concussions) from Quebec. For game-related injuries, the IRR between players from teams with more than 50% wins and players with less or equal to 50% wins was 0.78 (95% CI 0.64-0.95) for all injuries, 0.75 (95% CI 0.52-1.08) for concussions, 0.64 (95% CI 0.47-0.88) for injuries resulting in time loss of more than 7 days, and 0.74 (95% CI 0.39-1.40) for concussions resulting in time loss of more than 10 days; adjusting for clustering by team and other important risk factors (ie, province, age, level of play, previous injury, weight and position). There was no association found between the total penalty minutes per game and game-related injury or concussion. Conclusions There was a significant association found between team performance (ie, win/loss/tie record) and injury risk with a 22% lower injury rate and 36% lower injury rate resulting in less than 7 days time loss in Pee Wee and Bantam ice hockey teams winning more than 50% of all season games. Total penalty minutes per game were not associated with injury or concussion rates.

Physical activity, ambulation, and motor impairment late after stroke. Danielsson A, WillÃ©n C, Sunnerhagen KS

Stroke research and treatment 2012:818513, Institute of Neuroscience and Physiology/Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45 Göteborg, Sweden.

Objective. To assess walking capacity and physical activity using clinical measures and to explore their relationships with motor impairment late after stroke. Subjects. A nonrandomised sample of 22 men and 9 women with a mean age of 60 years, 7-10 years after stroke. Methods. Fugl-Meyer Assessment, maximum walking speed, 6?min walk test, perceived exertion, and heart rate were measured, and the Physiological Cost Index was calculated. Physical activity was reported using The Physical Activity Scale for the Elderly. Results. Mean (SD) 6?min walking distance was 352 (±136)?m, and Physiological Cost Index was 0.60 (±0.41). Self-reported physical activity was 70% of the reference. Motor impairment correlated with walking capacity but not with the physical activity level. Conclusion. It may be essential to enhance physical activity even late after stroke since in fairly young subjects both walking capacity and the physical activity level were lower than the reference.

Effects of walking endurance reduction on gait stability in patients with stroke. Iosa M, Morone G, Fusco A, Pratesi L, Bragoni M, Coiro P, Multari M, Venturiero V, De Angelis D, Paolucci S

Stroke research and treatment 2012:810415.Clinical Laboratory of Experimental Neurorehabilitation, Santa Lucia Foundation I.R.C.C.S., via Ardeatina 306, 00179 Rome, Italy.

Control of gait is usually altered following stroke, and it may be further compromised by overexertion and fatigue. This study aims to quantitatively assess patients' gait stability during six-minute walking, measuring upper body accelerations of twenty patients with stroke (64 ± 13 years old) and ten age-matched healthy subjects (63 ± 10 years old). Healthy subjects showed a steady gait in terms of speed and accelerations over the six minutes. Conversely, the patients unable to complete the test (n = 8) progressively reduced their walking speed (-22 ± 11%, confidence interval CI(95%): -13, -29%, P = 0.046). Patients able to complete the test (n = 12) did not vary their walking speed over time (P = 0.493). However, this ability was not supported by an adequate capacity to maintain their gait stability, as shown by a progressive increase of their upper body accelerations (+5 ± 11%, CI(95%): -1; +12%, P = 0.010). Walking endurance and gait stability should be both quantitatively assessed and carefully improved during the rehabilitation of patients with stroke.

American childhood football as a possible risk factor for cerebral infarction. Brosch JR, Golomb MR

1 Indiana University School of Medicine, Department of Neurology, Division of Pediatric Neurology and Indiana University Health Physician, Indianapolis, IN, USA.

Three adolescent football players who had ischemic stroke associated with football practice and play are described. The literature on stroke associated with childhood sports and football in particular is reviewed, and the multiple mechanisms by which football can contribute to ischemic stroke are discussed.

Improved cerebral vasomotor reactivity after exercise training in hemiparetic stroke survivors. Ivey FM, Ryan AS, Hafer-Macko CE, Macko RF

.: Stroke, 2011,07 - 42(7):1994-2000. BACKGROUND AND PURPOSE: Animal studies provide strong evidence that aerobic exercise training positively influences cerebral blood flow, but no human studies support the use of exercise for improving cerebral hemodynamics. This randomized study in stroke survivors assessed the effects of treadmill aerobic exercise training (TM) on cerebral blood flow parameters compared to a control intervention of nonaerobic stretching.

METHODS: Thirty-eight participants (19 in TM group and 19 in control group) with remote stroke (>6 months) and mild to moderate gait deficits completed middle cerebral artery blood flow velocity measurements by transcranial Doppler ultrasonography before and after a 6-month intervention period. Middle cerebral artery blood flow velocity was assessed bilaterally during normocapnia and hypercapnia (6% CO(2)). Cerebral vasomotor reactivity (cVMR) was calculated as percent change in middle cerebral artery blood flow velocity from normocapnia to hypercapnia (cVMR percent) and as an index correcting percent change for absolute increase in end tidal CO(2) (cVMR index).

RESULTS: The TM group had significantly larger improvements than did controls for both ipsilesional and contralesional cVMR index (P=0.05) and contralesional cVMR percent (P=0.01). Statin users in the TM group (n=10) had higher baseline cVMR and lower training-induced cVMR change, indicating that cVMR change among those not using statins (n=9) primarily accounted for the between-group effects. There was a 19% increase in Vo(2) peak for the TM group compared to a 4% decrease in the control group (P<0.01), and peak fitness change correlated with cVMR change (r=0.55; P<0.05).

CONCLUSIONS: Our data provide the first evidence to our knowledge of exercise-induced cVMR improvements in stroke survivors, implying a protective mechanism against recurrent stroke and other brain-related disorders. Statin use appears to regulate cVMR and the cVMR training response.

Does vigorous exercise have a neuroprotective effect in Parkinson disease? Ahlskog JE.: Neurology, 2011,07 - 77(3):288-94.

Parkinson disease (PD) is progressive, with dementia and medication-refractory motor problems common reasons for late-stage nursing-home placement. Increasing evidence suggests that ongoing vigorous exercise/physical fitness may favorably influence this progression. Parkinsonian animal models reveal exercise-related protection from dopaminergic neurotoxins, apparently mediated by brain neurotrophic factors and neuroplasticity (predicted from in vitro studies). Similarly, exercise consistently improves cognition in animals, also linked to enhanced neuroplasticity and increased neurotrophic factor expression. In these animal models, immobilization has the opposite effect. Brain-derived neurotrophic factor (BDNF) may mediate at least some of this exercise benefit. In humans, exercise increases serum BDNF, and this is known to cross the blood-brain barrier. PD risk in humans is significantly reduced by midlife exercise, documented in large prospective studies. No studies have addressed whether exercise influences dementia risk in PD, but exercised patients with PD improve cognitive scores. Among seniors in general, exercise or physical fitness has not only been associated with better cognitive scores, but midlife exercise significantly reduces the later risk of both dementia and mild cognitive impairment. Finally, numerous studies in seniors with and without dementia have reported increased cerebral gray matter volumes associated with physical fitness or exercise. These findings have several implications for PD clinicians. 1) Ongoing vigorous exercise and physical fitness should be highly encouraged. 2) PD physical therapy programs should include structured, graduated fitness instruction and guidance for deconditioned patients with PD. 3) Levodopa and other forms of dopamine replenishment therapy should be utilized to achieve the maximum capability and motivation for patients to maintain fitness.

Cycling with functional electrical stimulation in an adult with spastic diplegic cerebral palsy. Johnston TE, Wainwright SF

Physical therapy, 91(6):970-82BACKGROUND AND PURPOSE: /b> Adults with cerebral palsy (CP) are at risk for decreased mobility and health complications, and exercise may combat some of these negative changes. Because people with CP have difficulty generating sufficient muscle force, exercise augmented with functional electrical stimulation (FES) is an option for increasing exercise intensity. This mixed-method (quantitative-qualitative) case report describes the effects-across the International Classification of Functioning, Disability and Health (ICF) model-of cycling with FES (FES cycling) in an adult with CP.

CASE DESCRIPTION: /b> An ambulatory 49-year-old man with spastic diplegic CP cycled with FES at home for 30 minutes, 3 times per week, for 12 weeks. Volitional efforts were augmented by FES of the bilateral quadriceps, gastrocnemius, and gluteal muscles. Testing was performed before and after the intervention and 4 weeks after intervention withdrawal.

OUTCOMES: /b> After training, quadriceps muscle strength (force-generating capacity) improved by 22.2%, hamstring muscle strength improved by 18.5%, and the Timed "Up & Go" Test time decreased from 11.9 to 9.0 seconds. The patient reported increased performance and satisfaction for self-identified goals at the ICF level of participation, and his score on the Medical Outcomes Study 36-Item Health Survey questionnaire increased from 62.1 to 77.6. However, he reported increased back pain, which he attributed to positioning while cycling. Qualitative interviews provided context (the patient's perspective) for some of the quantitative results.

DISCUSSION: /b> The patient made gains in body structure and function, activity, and participation (ICF levels) after FES cycling. The mixed-method approach provided insight into his experiences and perceptions about the measures assessed quantitatively. Further investigation on FES cycling in this population as well as positioning during cycling is warranted.

Exercise training increases size of hippocampus and improves memory. Erickson KI, Voss MW, Prakash RS, Basak C, Szabo A, Chaddock L, Kim JS, Heo S, Alves H, White SM, Wojcicki TR, Mailey E, Vieira VJ, Martin SA, Pence BD, Woods JA, McAuley E, Kramer AF. 2010, 108(7):3017-22.Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15260. The hippocampus shrinks in late adulthood, leading to impaired memory and increased risk for dementia. Hippocampal and medial temporal lobe volumes are larger in higher-fit adults, and physical activity training increases hippocampal perfusion, but the extent to which aerobic exercise training can modify hippocampal volume in late adulthood remains unknown. Here we show, in a randomized controlled trial with 120 older adults, that aerobic exercise training increases the size of the anterior hippocampus, leading to improvements in spatial memory. Exercise training increased hippocampal volume by 2%, effectively reversing age-related loss in volume by 1 to 2 y. We also demonstrate that increased hippocampal volume is associated with greater serum levels of BDNF, a mediator of neurogenesis in the dentate gyrus. Hippocampal volume declined in the control group, but higher preintervention fitness partially attenuated the decline, suggesting that fitness protects against volume loss. Caudate nucleus and thalamus volumes were unaffected by the intervention. These theoretically important findings indicate that aerobic exercise training is effective at reversing hippocampal volume loss in late adulthood, which is accompanied by improved memory function.

Clinics in neurology and neurosurgery–extradural and subdural haematoma (Dez 2010)

Physical activity in young children with cerebral palsy

J. Nathalie Zwier, Petra E.m. van Schie, Jules G. Becher, Dirk-Wouter Smits, Jan Willem Gorter, Annet J. Dallmeijer: 2010, Vol. 32, No. 18 , Pages 1501-1508.

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

Echlin PS, Tator CH, Cusimano MD, Cantu RC, Taunton JE, Upshur RE, Hall CR, Johnson AM, Forwell LA, Skopelja EN.: Neurosurgical focus, 2010 29(5):E4.

Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion.

Echlin PS, Tator CH, Cusimano MD, Cantu RC, Taunton JE, Upshur RE, Czarnota M, Hall CR, Johnson AM, Forwell LA, Driediger M, Skopelja EN.: Neurosurgical focus, 2010, 29(5):E5.

Reduced processing speed in rugby union players reporting three or more previous concussions.

Gardner A, Shores EA, Batchelor J.: Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists, 2010-05 25(3):174-81. Department of Psychology, Macquarie University, New South Wales, Australia.

The issue pertaining to the effect of multiple self-reported sports-related concussions on cognitive function is controversial. Although this topic has received increased attention in the literature recently, the issue remains unresolved. Evidence supporting a detrimental cognitive effect has been reported at a sub-concussive level and following one, two, and three or more previous concussions. However, numerous studies have been unable to replicate these findings. Additionally, discrepancies between neuropsychological testing formats have been identified, where studies utilizing traditional tests tend to support the notion of detrimental cognitive effects whereas studies with computerized tests have tended to demonstrate no effect. The present study sought to examine possible detrimental cognitive effects in a sample of adult male rugby union players who reported a history of three or more concussions (n = 34) compared with those who reported no previous concussions (n = 39). A computerized neuropsychological battery and a traditional neuropsychological measure of processing speed were administered for this purpose. Findings revealed that there were differences between groups on two processing speed measures from both traditional and computerized tests. Athletes with a history of multiple concussions performed significantly lower on these measures than those with no history of concussion. These results provide further evidence to suggest that a history of three or more self-reported concussions in active athletes may have a detrimental effect on cognitive function. Future research may focus on identifying moderating factors in an attempt to resolve some of the conflicting findings and identify potential athletes at risk for sustaining cognitive deficits.

Measurement of physical performance and objective fatigability in people with mild-to-moderate traumatic brain injury.

Merritta C, Cherian B, Macaden AS, John JA.: International Journal of Rehabilitation Research. Internationale Zeitschrift für Rehabilitationsforschung. Revue internationale de recherches de réada, 2010, 33(2):109-14. Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India.

The aims of this study were to objectively measure the physical performance and physical endurance of patients with traumatic brain injury with minimization of cognitive and psychological fatigue, and to compare the physical performance of brain injured patients with that of healthy controls. This was a nonrandomized partially blinded controlled study. The study setting was the Outpatient Multidisciplinary Brain Injury Clinic in the Department of Physical Medicine and Rehabilitation of a tertiary care university teaching hospital. Participants included an experimental group that comprised independently ambulant men (age 18-55 years) with mild-to-moderate traumatic brain injury (n = 24) who complained of greater fatigue than before their injury and an age-matched and sex-matched control group (n = 24). The intervention included the Six-Minute Walk Test. The primary outcome measures were the Six-Minute Walk Distance, the Fatigue Severity Scale, Addenbrooke's Cognitive Examination, and the Fatigue Visual Numeric Scale; the secondary outcome measures were the Physiological Cost Index of Walking and the Borg Scale of Perceived Exertion. The Six-Minute Walk Distance of the experimental group (452.33+/-68.816) when compared with that of the control group (518.08+/-92.114) was reduced by 12.7 and 30.5%, respectively, when compared with the predicted Six-Minute Walking Distance (650.04+/-79.142) for the same age and sex. The mean Fatigue Severity Scale values were 2.51 and 1.62 for the experimental and control groups, respectively. The mean Addenbrooke's Cognitive Examination Score for the patients was 85.5+/-7.265. In conclusion, the Six-Minute Walk Test is useful in segregating physical fatigue from cognitive and psychological aspects of fatigue when cognitive and psychological dimensions are known. The Six-Minute Walk Test can be used as a tool for exercise intensity prescription in men with mild-to-moderate brain injury, to avoid the deleterious effects of fatigue.

Predicting exercise capacity through submaximal fitness tests in persons with multiple sclerosis.

Kuspinar A, Andersen RE, Teng SY, Asano M, Mayo NE.: Archives of Physical Medicine and Rehabilitation, 2010, 91(9):1410-7, School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, QC, Canada.

OBJECTIVE: To estimate, for persons with multiple sclerosis (MS), the extent to which peak oxygen consumption (Vo(2)peak) can be predicted by the results on submaximal tests. DESIGN: Cross-sectional study. SETTING: Three MS clinics in the Greater Montreal region, Canada. PARTICIPANTS: A center-stratified random sample of 135 women and 48 men was drawn (N=183). A subgroup of 59 subjects with MS, who were able to perform the step test, was selected from this sample to complete the maximal exercise test. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Vo(2)peak. RESULTS: In this sample (mean age +/- SD, 39 +/- 9 y; median Expanded Disability Status Scale=1.5), the mean Vo(2)peak +/- SD was 27.6 +/- 7.3 mL.kg(-1).min(-1). This value is considerably low when compared with healthy persons, ranking below the 25th percentile for both men and women. In a multivariate regression analysis, the step test and grip strength were identified as the only significant predictors of Vo(2)peak. When combined with body weight, grip strength and the step test explained 74% of the variance in Vo(2)peak. CONCLUSIONS: Patients with MS with a mild degree of disability exhibit marked reductions in exercise capacity. Also, in persons with MS, submaximal tests are good predictors of exercise capacity. These measures may be used in clinical settings to help assess and monitor maximum oxygen consumption and in research to evaluate the effect of exercise-related interventions. Furthermore, they will allow people with MS to self-monitor their exercise capacity and be more actively engaged in taking charge of their fitness level.

Predictors of physical performance and functional ability in people 50+ with and without fibromyalgia.

Jones CJ, Rutledge DN, Aquino J.: Journal of Aging and Physical Activity, 2010, 18(3):353-68. Health Science Dept., California State University, Fullerton, Fullerton, CA, USA.

The purposes of this study were to determine whether people with and without fibromyalgia (FM) age 50 yr and above showed differences in physical performance and perceived functional ability and to determine whether age, gender, depression, and physical activity level altered the impact of FM status on these factors. Dependent variables included perceived function and 6 performance measures (multidimensional balance, aerobic endurance, overall functional mobility, lower body strength, and gait velocity-normal or fast). Independent (predictor) variables were FM status, age, gender, depression, and physical activity level. Results indicated significant differences between adults with and without FM on all physical-performance measures and perceived function. Linear-regression models showed that the contribution of significant predictors was in expected directions. All regression models were significant, accounting for 16-65% of variance in the dependent variables.

Update on concussion: here's what the experts say.

Ferullo SM, Green A.: The Journal of Family Practice, 2010, 59(8):428-33. Department of Family Medicine, Boston Medical Center, Boston, MA, USA.

Don't allow an athlete who has symptoms at rest or with exertion to return to play. Consider neuropsychological testing in conjunction with continued clinical assessment for objective measurements to assist in managing concussion. Recommend up-to-date protective equipment for athletes. Recent improvements, especially in football, have been shown to help decrease the incidence of concussion.

Effects of various treadmill interventions on the development of joint kinematics in infants with Down syndrome.

Wu J, Looper J, Ulrich DA, Angulo-Barroso RM:: Physical Therapy, 2010, 90(9):1265-76. Department of Kinesiology and Health, Georgia State University, Atlanta, Georgia, USA.

BACKGROUND: Infants with Down syndrome (DS) have delayed walking and produce less-coordinated walking patterns. OBJECTIVE: The aim of this study was to investigate whether 2 treadmill interventions would have different influences on the development of joint kinematic patterns in infants with DS. DESIGN: Thirty infants with DS were randomly assigned to a lower-intensity, generalized (LG) treadmill training group (LG group) or a higher-intensity, individualized (HI) treadmill training group (HI group) and trained until walking onset. Twenty-six participants (13 in each group) completed a 1-year gait follow-up assessment. METHODS: During the gait follow-up assessment, reflective markers were placed bilaterally on the participants to measure the kinematic patterns of the hip, knee, and ankle joints. Both the timing and the magnitude of peak extension and flexion at the hip, knee, and ankle joints, as well as peak adduction and abduction at the hip joint, in the 2 groups were compared. RESULTS: Both the LG group and the HI group showed significantly advanced development of joint kinematics at the gait follow-up. In the HI group, peak ankle plantar flexion occurred at or before toe-off, and the duration of the forward thigh swing after toe-off increased. LIMITATIONS: Joint kinematics in the lower extremities were evaluated in this study. It would be interesting to investigate the effect of treadmill interventions on kinematic patterns in the trunk and arm movement. CONCLUSIONS: The timing of peak ankle plantar flexion (before toe-off) in the HI group implies further benefits from the HI intervention; that is, the HI group may use mechanical energy transfer better at the end of stance and may show decreased hip muscle forces and moments during walking. It was concluded that the HI intervention can accelerate the development of joint kinematic patterns in infants with DS within 1 year after walking onset.

Concomitant cranial and lumbar subdural hematomas -case report-.

Kim K, Katsuno M, Isu T, Mishina M, Yoshida D, Kobayashi S, Teramoto A.: Neurologia Medico-Chirurgica, 2010, 50(5):402-4. Department of Neurosurgery, Chiba Hokusoh Hospital, Nippon Medical School, Inba-mura, Inba-gun, Chiba, Japan.

A 24-year-old woman presented with concomitant spinal and bilateral intracranial subdural hematomas (SDHs) after hitting her head and lower back in a fall while snowboarding. She developed lower back pain and posture headache. Magnetic resonance imaging revealed bilateral intracranial SDHs and spinal SDH. Her symptoms improved and all hematomas resolved gradually without treatment, and completely disappeared by 5 months after the accident. Simultaneous intracranial SDH and spinal SDH have been reported in only 18 patients, including ours, of whom 6 had suffered trauma. The mechanism of concomitant SDHs has not been clarified, but migration of the hematoma from the intracranial to spinal sites may be an important mechanism. In our patient, low cerebrospinal fluid pressure syndrome and double trauma may also have been involved.

Artigo disponível: http://www.jstage.jst.go.jp/article/nmc/50/5/50_402/_article

Hypopituitarism due to Sports related head trauma and the effects of growth hormone replacement in retired amateur boxers.

Tanriverdi F, Unluhizarci K, Karaca Z, Casanueva FF, Kelestimur F.: Pituitary, 2010, 13(2):111-4 . Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey.

Traumatic brain injury (TBI) has been recently recognized as a leading cause of pituitary dysfunction. Current data clearly demonstrated that Sports related head trauma due to boxing, kickboxing, and soccer might Results in pituitary hormone deficiencies, isolated growth hormone (GH) deficiency in particular. In the present report physiologic dose GH replacement therapy (GHRT) was performed in two GH deficient retired amateur boxers for the first time. The boxers received recombinant GH for 6 months. After 6 months of GHRT there were substantial improvements, but not complete normalization, in the body composition parameters, lipid profiles and quality of life scores in both boxers. These preliminary Results suggest that GHRT may have beneficial effects in retired boxers with severe isolated GH deficiency due to Sports related head trauma. But more data with higher number of boxers and longer GHRT duration are warranted.

Gait training with progressive external auditory cueing in persons with Parkinson's disease.

Ford MP, Malone LA, Nyikos I, Yelisetty R, Bickel CS.: Archives of Physical Medicine and Rehabilitation, 2010, 91(8):1255-61 . Department of Physical Therapy, University of Alabama, Birmingham, Birmingham, AL, USA.

Objective: To investigate the progressively increasing external auditory cues during mobility training with persons with Parkinson's disease (PD). Design: Experimental. Setting: General community. Participants: Convenience sample of persons with PD (N=12) who walked independently. Interventions: Gait training to external auditory cues was based on a participant's comfortable walking pace. Training external auditory cues rates were increased if patients were able to maintain or increase stride length with increasing external auditory cues rate. Movement synchronization was not monitored during training. Participants trained for 30min/session, 3 sessions/wk, for 8 weeks. Main Outcome Measures: Walking velocity, stride length, and cadence. Results: Participants trained at a mean maximal rate of 157bpm. They showed a significant (P<.01) increase in walking velocity, stride length, and cadence after 8 weeks of training. Conclusions: Walking velocity, stride length, and cadence can significantly improve when community-dwelling persons with PD participate in progressive mobility training.

Endurance training and cardiorespiratory conditioning after traumatic brain injury.

Mossberg KA, Amonette WE, Masel BE.: The Journal of Head Trauma Rehabilitation, 2010, 25(3):173-83. University of Texas Medical Branch, Galveston, Texas 77555, USA.

Objective: To examine the importance of cardiorespiratory conditioning after traumatic brain injury (TBI) and provide recommendations for patients recovering from TBI. Method: Review of literature assessing the effectiveness of endurance training programs. Main outcome and Results: A sedentary lifestyle and lack of endurance are common characteristics of individuals with TBI who have a reduction in peak aerobic capacity of 25% to 30% compared with healthy sedentary persons. Increased physical activity and exercise training improves cardiorespiratory fitness in many populations with physical and cognitive impairments. Therefore, increasing the endurance and cardiorespiratory fitness of persons with TBI would seem to have important health implications. However, review of the TBI literature reveals that there have been few well-designed, well-controlled studies of physiologic and psychological adaptations of fitness training. Also lacking are long-term follow-up studies of persons with TBI. Conclusions: Assessing endurance capacity and cardiorespiratory fitness early in the TBI rehabilitation process merits consideration as a standard of care by professional rehabilitation societies. Also, providing effective, safe, and accessible training modalities would seem to be an important consideration for persons with TBI, given the mobility impairments many possess. Long-term follow-up studies are needed to assess the effectiveness of cardiorespiratory training programs on overall morbidity and mortality.

Evaluation of a conceptual framework for retraining high-level mobility following traumatic brain injury: two case reports.

Williams GP, Schache AG.: The Journal of Head Trauma Rehabilitation, 2010, 25(3):164-72 .Centre for Health, Exercise and Sports Medicine, School of Physiotherapy, University of Melbourne, Victoria, Australia.

Traumatic brain injury (TBI) is the primary cause of death and disability for 18- to 45-year-olds. High-level mobility is important for many of the social, leisure, sporting, and employment roles of young adults. The aim of these case reports was to evaluate a conceptual framework for retraining high-level mobility after TBI. The progression of 2 patients who had sustained a severe TBI but had contrasting clinical presentations was monitored over 6 months. Patient 1 presented with left hemiplegia following a TBI 10 years earlier, whereas patient 2 presented with ataxia 2 months following a TBI. Quantitative gait analysis and clinical measures of mobility were used to evaluate outcomes of a 6-month intervention phase. Intervention strategies were based on a conceptual framework comprising 2 main elements: (1) the hierarchical ordering of high-level mobility tasks and (2) the key biomechanical features of able-bodied running. Both patients achieved the ability to run by the end of the intervention phase. Patient 1 displayed improved gait symmetry associated with improved high-level mobility, despite the long-standing duration of his injury. Patient 2 demonstrated improved postural control and stability in gait that resulted in an ability to run, skip, hop, and jump. Findings of these case reports provide evidence supporting "proof of concept" that clinical interventions can lead to improvement in high-level mobility following severe TBI.

Circuit class therapy for improving mobility after stroke.

English C, Hillier SL.: , Cochrane database of systematic reviews (Online), 2010, 7:CD007513 . Centre for Allied Health Evidence, University of South Australia (City East), North Terrace, Adelaide, SA, Australia, 5000.

Background: Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practise time without increasing staffing. Objectives: To examine the effectiveness and safety of CCT on mobility in adults with stroke. Search Strategity: We searched the Cochrane Stroke Group Trials Register (last searched October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2009), MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), CINAHL (1982 to November 2008) and 14 other electronic databases (to November 2008). We also searched proceedings from relevant conferences, reference lists and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers. Selection criteria: Randomised or quasi-randomised controlled trials including people over 18 years old diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT. Data Collection and analysis: Two review authors independently selected trials for inclusion, assessed methodological quality and extracted data. Main Results: We included six trials involving 292 participants. Participants were long-term stroke survivors living in the community or receiving inpatient rehabilitation. All could walk 10 metres with or without assistance. Four studies measured walking capacity and three measured gait speed, demonstrating that CCT was superior to the comparison intervention (Six Minute Walk Test: mean difference (MD), fixed 76.57 metres, 95% confidence interval (CI) 38.44 to 114.70, P < 0.0001; gait speed: MD, fixed 0.12 m/s, 95% CI 0.00 to 0.24, P = 004). Two studies measured balance, showing a superior effect in favour of CCT (Step Test: MD, fixed 3.00 steps, 95% CI 0.08 to 5.91, P = 0.04; activities-specific balance and confidence: MD, fixed 7.76, 95% CI 0.66 to 14.87, P = 0.03). Studies also measured other balance items showing no difference in effect. Length of stay (two studies) showed a significant effect in favour of CCT (MD, fixed -19.73 days, 95% CI -35.43 to -4.04, P = 0.01). Only two studies measured adverse events (falls during therapy): all were minor. Author’ Conclusions: CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.

Evaluation of artificial sweat in athletes with spinal cord injuries.

Pritchett RC, Bishop PA, Yang Z, Pritchett KL, Green JM, Katica CP, Del Pozzi AT.: European Journal of Applied Physiology, 2010, 109(1):125-31. Department of Nutrition, Exercise and Health Sciences, Central Washington University, 400 East University Way, Ellensburg, WA 98923, USA.

Athletes with spinal cord injury often experience high heat storage due to reduced sweating capacity below the spinal injury. Spray bottle (SB) may be used to apply mist for evaporative cooling during breaks in competitions. This study examined the efficacy of SB during rest breaks. Seven participants, four female and three males, (mean +/- SD age 24 +/- 4.1 year, weight 56.2 +/- 7.0 kg, upper-body VO(2) peak 2.4 +/- 0.6 l/min) volunteered for the study. Participants were paraplegic athletes (T3-T12/L1) with both complete and incomplete lesions. Participants arm-cranked using a ramp protocol in an environment of 21 +/- 1.5 degrees C and 55 +/- 3% rh once using a SB during 1-min rest between 7-min stages of increasing intensity and once without the SB (CON). Mean total work was similar (p = 0.86) for the SB and CON (2495.7 +/- 914.6 vs. 2407.1 +/- 982.3 kJ, respectively). Likewise, the mean work times were similar between trials (27 +/- 6 and 26 +/- 7 min for SB and CON, respectively). Furthermore, there were no significant differences detected between trials for skin temperature, rectal temperature, esophageal temperature (p > 0.05). There were no statistically significant differences detected between trials for RPE (p > 0.05). In conclusion, the application of artificial sweat via SB was ineffective in attenuating the onset of uncompensable heat strain during high-intensity arm exercise in a comfortable

Reduced muscle power is associated with slower walking velocity and falls in people with Parkinson's disease.

Allen NE, Sherrington C, Canning CG, Fung VS.: Parkinsonism & Related Disorders, 2010-05 16(4):261-4. Neurological Rehabilitation Research Group, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.

PURPOSE: Muscle strength (force) and power (force x velocity) are reduced in Parkinson's disease (PD). Reduced muscle power is associated with slower walking velocity and falls in the older population, but these associations in people with PD have not previously been investigated. This study investigated the relationships between leg extensor muscle power and strength with walking speed and past falls in people with PD. PARTICIPANTS AND METHODS: Forty people with mild to moderate PD were assessed. Walking velocity was measured over 10 m and the number of falls the participant reported having in the past 12 months was recorded. Leg extensor muscle power and strength were measured using a Keiser leg press machine. RESULTS: Muscle power explained more than half of the variance (R(2) = 0.54) in walking velocity and remained significantly (p < 0.05) associated with walking velocity in models which included Unified Parkinson's Disease Rating Scale (UPDRS) motor scores. Participants with low muscle power were 6 times more likely to report multiple falls in the past year than those with high muscle power (OR = 6.0, 95% CI 1.1 to 33.3), though this association between falls and power was no longer significant in models which included UPDRS motor scores (p = 0.09). CONCLUSION: Muscle power is a significant determinant of walking velocity in PD even after adjusting for UPDRS motor score. Muscle power training warrants investigation in people with PD.

Sport-related concussion in adolescents.

Patel DR, Reddy V.: Pediatric Clinics of North America, 2010-06 57(3):649-70. Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Kalamazoo Center for Medical Studies, Kalamazoo, MI 49008, USA.

Sport-related concussion is a common problem encountered by pediatricians and other primary care physicians. Assessment of concussion is based on clinical evaluation. The Zurich consensus statement provides a basic framework to guide concussion management decisions and recommends an individualized approach and the exercising of clinical judgment in return-to-play decisions. This article reviews practice aspects of concussion for the adolescent athletes who present in the primary care office or clinic setting.

Variability and symmetry of gait in early walkers with and without bilateral cerebral palsy.

Prosser LA, Lauer RT, VanSant AF, Barbe MF, Lee SC.: Gait & Posture, 2010-04 31(4):522-6. Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD 20892, United States.

PURPOSE: Investigating gait characteristics during the early stages of walking in CP may contribute to the understanding of the development of impaired gait. The objective of this study was to investigate differences in the variability and symmetry of spatiotemporal gait characteristics during the early years of walking in children with bilateral spastic CP compared to children with similar amounts of walking experience and typical development (TD). METHODS: The spatiotemporal gait parameters of 31 children (15 with spastic CP, 16 with TD) who had an average of 28.5 (18.1 SD) months of walking experience were collected using an instrumented walkway. RESULTS: All primary spatiotemporal parameters were reduced in the CP group, who also demonstrated greater stride-to-stride variability, compared to the TD group. There were no statistically significant differences in side-to-side symmetry between groups. IMPLICATIONS: Clinical trials investigating gait interventions during the early years of walking in children with CP should be conducted to determine if treatment can reduce the functional limitations that are present during the emergence of walking skills. Further investigation should examine variability and symmetry in the kinematics, kinetics, and muscle activity patterns of early walkers with CP, and the effect of treatment on the variability and symmetry of walking characteristics.

Sport is not always healthy: Executive brain dysfunction in professional boxers.

Di Russo F, Spinelli D.: Psychophysiology, 2010-05-01 47(3):425-34. Department of Education Sciences for Motor Activity and Sport, University of Rome Foro Italico, 00194 Rome, Italy.

We measured ERPs of professional boxers in a Go/No-Go task, comparing them to fencers and non-athletes. Results showed that fencing improved attention and motor response control, but boxing did not. More strikingly, in boxers, as in brain trauma patients, the P3 component was delayed and reduced. The P3 delay of boxers was correlated with the amount of performed sport exercise. Furthermore, in terms of behavior, boxers showed increased intra-individual variability and switch cost. Results were consistent with the hypothesis of specific impairment at the level of response inhibition processing. We suggest that this impairment is derived from the cumulative effect of blows to the head. The changes found in boxers suggest that ERPs and reaction times may be a tool for early detection of specific brain dysfunction.

Effects of dance on gait and balance in Parkinson's disease: a comparison of partnered and nonpartnered dance movement.

Hackney ME, Earhart GM.: Neurorehabilitation and Neural Repair, 2010-05 24(4):384-92. Washington University School of Medicine, St. Louis, MO 63108, USA.

Partnered tango dance can improve balance and gait in individuals with Parkinson's disease (PD). Partnered dance may allow these individuals to challenge balance more than nonpartnered dance. Alternatively, partnered practice could reduce balance gains because the participant may rely on the partner as a balance aid when challenged. The authors compared the effects of partnered and nonpartnered dance on balance and mobility in 39 people (11 women) with mild-moderate PD (Hoehn and Yahr stages I-III). Participants were randomly assigned to partnered or nonpartnered tango and attended 1-hour classes twice per week, completing 20 lessons within 10 weeks. Balance and gait were evaluated in the weeks immediately before, immediately after, and 1 month after the intervention. Both groups significantly improved on the Berg Balance Scale, comfortable and fast-as-possible walking velocity, and cadence. Improvements were maintained at the 1-month follow-up. The nonpartnered class improved as much as the partnered class; however, partnered participants expressed more enjoyment and interest in continuing.

Walking ability and predictors of performance on the 6-minute walk test in adults with spastic cerebral palsy.

Maanum G, Jahnsen R, Frøslie KF, Larsen KL, Keller A.: Developmental Medicine and Child Neurology

2010-06 52(6):e126-32. Sunnaas Rehabilitation Hospital, Nesoddtangen, and Faculty of Medicine, University of Oslo, Oslo, Norway.

AIM: To describe walking ability and identify factors predicting walking capacity in adults with spastic cerebral palsy (CP) assessed with the 6-minute walk test (6MWT). METHOD: A cross-sectional clinical study as part of the recruitment process for a randomized controlled trial on the effects of botulinum toxin A. Data analysed were the 6MWT, Timed Up and Go (TUG) test, Borg Scale, spasticity, muscle strength, popliteal angle, pain, fatigue, type of CP, foot deformity, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, a gait questionnaire, interview, and demographic data. RESULTS: In total, 126 persons were included (53 males, 73 females; mean age 39 y [SD 12 y]; 59 with unilateral and 67 with bilateral spastic CP; GMFCS level I, n=12; level II, n=94; level III, n=20). Mean distance on the 6MWT was 485 m (SD 95 m) with FMS scores reflecting independent walking performance in daily life. Multiple regression analysis identified sex, type of CP, popliteal angle, pain, and TUG values as significant predictors, with TUG values as the strongest predictor (standardized regression coefficient=-0.57, p<0.001). INTERPRETATION: Our results demonstrate that 39% of the participants had declined one GMFCS level from adolescence to their present age, and that the TUG was the strongest predictor for the 6MWT. This implicates the importance of focusing specifically on the different elements of functional mobility in further studies.

Neuroimaging findings and brain-behavioral correlates in a former boxer with chronic traumatic brain injury.

Handratta V, Hsu E, Vento J, Yang C, Tanev K.: Neurocase : case studies in neuropsychology, neuropsychiatry, and behavioural neurology, 2010, 16(2):125-34. University of Connecticut Health Center, Farmington, CT, USA.

Chronic traumatic brain injury (CTBI) is associated with contact sports such as boxing. CTBI results from repetitive blows to the head rather than from a single impact. CTBI individuals present with motor symptoms (incoordination, spasticity, parkinsonism), cognitive impairment (executive dysfunction, memory deficits) and neuropsychiatric symptoms (irritability, affective disturbances). The structural and functional neuroimaging findings and clinical presentation of a CTBI case are described. We propose hypotheses about the pathoPhysiology of the observed neuroimaging findings and their relationship to the neuropsychiatric symptoms of the patients.

Normative values for three clinical measures of motor performance used in the neurological assessment of sports concussion.

Schneiders AG, Sullivan SJ, Gray AR, Hammond-Tooke GD, McCrory PR.: Journal of Science and Medicine in sport / Sports Medicine Australia, 2010, 13(2):196-201. Centre for Physiotherapy Research , University of Otago, New Zealand.

Postural control and motor coordination are essential components of normal athletic activity. Tasks involving balance and coordination are used to determine neurological function in sports-related concussion. Determining normative values for these tasks is therefore essential to provide sports medicine professionals with a frame of reference with which to interpret clinical measures obtained from players suspected of sustaining a concussion. One hundred and seventytwo healthy subjects (16-37 yrs) performed three timed tests: Tandem Gait (TG); Finger-to-Nose (FTN); Single-Leg-Stance (SLS) on firm and foam surfaces. Unadjusted geometric means (+/-SD) for each measure were averaged across three trials. Time to complete TG was 11.2+/-1.2s. FTN for the dominant and non-dominant arm were 2.9+/-1.1s and 3.0+/-1.2s, respectively. SLS values for dominant and non-dominant leg were 20.4+/-3.0s (firm), 3.4+/-1.6s (foam), and 21.0+/-2.9s (firm), 3.3+/-1.6s (foam), respectively. For TG, there was an order effect (P<.001) but no age, sex or BMI effects. FTN demonstrated a dominant arm preference (P<.001), sex (P=.006), BMI (P=.043) and order effects (P<.001). SLS demonstrated an order effect on the firm surface (P=.009) and an order (P<.001) and BMI (P=.001) effect on foam. Intra-rater reliability, as measured by ICC (3,3), demonstrated that TG and FTN had excellent reliability compared to SLS. FTN and TG should continue to be used in test batteries to determine neurological function in sports-related concussion.

Akathisia after mild traumatic head injury.

Desai A, Nierenberg DW, Duhaime AC.: Journal of Neurosurgery. Pediatrics, 2010, 5(5):460-4 Section of Pediatric Surgery (Neurosurgery), Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756, USA.

The authors describe the case of a 13-year-old boy who exhibited progressive disabling motor restlessness, torticollis, urinary symptoms, and confusion following a fall from a bicycle. The differential diagnosis of this striking symptom complex in this clinical context can be problematic. In this case, the symptoms ultimately appeared most consistent with severe akathisia resulting from a single administration of haloperidol used at an outside hospital to sedate the patient prior to a head CT scan. The literature on akathisia in pediatric patients, and especially in patients following acute head injury, is reviewed, with suggestions for an approach to these symptoms in this clinical setting.

Natural history of Charcot-Marie-Tooth 2: 2-year follow-up of muscle strength, walking ability and quality of life.

Padua L, Pareyson D, Aprile I, Cavallaro T, Quattrone DA, Rizzuto N, Vita G, Tonali P, Schenone A.: Neurological Sciences : official Journal of the Italian Neurological Society and of the Italian Society of Clinical NeuroPhysiology, 2010, 31(2):175-8. Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy.

Charcot-Marie-Tooth (CMT) disease is the most frequent inherited neuropathy, no therapies are available at the moment but clinical trials are ongoing. For that reason it is very important to know the natural history of the disease. We report the results of the natural history of clinical features and quality of life (QoL) in patients with CMT2. Twenty patients were enrolled. At recruitment and at follow-up (2 years), all patients underwent neurological evaluation, QoL and disability assessments. The study-end evaluation took place 20-28 months after the baseline evaluation. During the 2-year follow-up period, CMT2 patients showed a mild reduction of strength of distal muscles of upper limbs and proximal muscles of lower limbs, a worsening sensory function and a mild increase in walking disability. However, there was no relevant worsening of QoL, except for a mild deterioration of one mental health domain.

Measuring deficits in visually guided action post-concussion.

Locklin, Bunn, Roy, Danckert Year: 2010 Presented at/ Published In: Sports Medicine Type: Article Status: Published Abstract:

Recent concussion Research has led to the development of computerized test batteries designed to measure working memory and psychomotor speed deficits in acute stage post-concussion. These tests lack a measure of motor control deficits, which may linger well after other symptoms have remitted. For athletes, this may mean returning to play while still uncoordinated or neurologically fragile. The present Research involved the development of a visuomotor pointing task designed to induce a speed-accuracy trade off to measure motor planning and execution performance in concussed athletes. Data collected using this tool were contrasted with CogSport, a commercially available computerized test battery designed to assess residual cognitive effects of concussion in athletes. Results suggest that a motor task may be able to detect long-term effects of concussion not measurable with CogSport. If future Research can confirm these findings, we suggest that a measure of motor control may need to be added to existing batteries to improve their sensitivity to long term effects.

Sinus barotrauma leading to extradural muco-pneumocephalus.

Murugesan C, Powell M, Khayal HB.: British Journal of Neurosurgery, 2010, 24(1):80-1. Departments of Neurosurgery, The National Hospital, London UK.

An amateur scuba (Self Contained Underwater Breathing Apparatus) diver experienced an acute frontal headache following a low-depth dive. After 12 hours of worsening and unremitting headache, CT and MRI imaging were performed; these revealed gas and mucous in the frontal sinus and extradural space. This appears to be the first case of MRI-documented barotrauma of the frontal and ethmoidal sinuses resulting in extradural pneumo- and muco-cephalus.

The predicted risk of head injury from fall-related impacts on to third-generation artificial turf and grass soccer surfaces: a comparative biomechanical analysis.

Theobald P, Whitelegg L, Nokes LD, Jones. Trauma Biomechanics Research Group, Institute of Medical Engineering & Medical Physics, Cardiff University, Cardiff, UK.

The risk of soccer players sustaining mild traumatic brain injury (MTBI) following head impact with a playing surface is unclear. This study investigates MTBI by performing headform impact tests from varying heights onto a range of third-generation artificial turf surfaces. Each turf was prepared as per manufacturers specifications within a laboratory, before being tested immediately following installation and then again after a bedding-in period. Each turf was tested dry and when wetted to saturation. Data from the laboratory tests were compared to an in situ third-generation surface and a professional grass surface. The surface performance threshold was set at a head impact criterion (HIC) = 400, which equates to a 10% risk of the head impact causing MTBI. All six third-generation surfaces had a > 10% risk of MTBI from a fall > 0.77 m; the inferior surfaces required a fall from just 0.46 m to have a 10% MTBI risk. Wetting the artificial turf did not produce a statistically significant improvement (P > 0.01). The in situ third-generation playing surface produced HIC values within the range of bedded-in experimental values. However, the natural turf pitch was the superior performer--necessitating fall heights exceeding those achievable during games to achieve HIC = 400.

Investigating baseline neurocognitive performance between male and female athletes with a history of multiple concussion.

Covassin T, Elbin R, Kontos A, Larson E.: Journal of Neurology, Neurosurgery, and Psychiatry, 2010, 81(6):597-601. Michigan State University, 105 Im Sport Circle, East Lansing, MI 48824-1049, USA.

OBJECTIVE: The purpose of this study was to examine, using a dose-response model, sex differences in computerised neurocognitive performance among athletes with a history of multiple concussions. DESIGN: Retrospective with randomly selected concussion cases from four levels/numbers of previous concussion. SETTING: Multicentre analysis of NCAA student-athletes. PARTICIPANTS: Subjects included a total of 100 male and 88 female NCAA athletes. INTERVENTION: Sex and four mutually exclusive groups of self-reported concussion history: (1) no history of concussion, (2) one previous concussion, (3) two previous concussions, (4) three or more previous concussions. MAIN OUTCOME MEASUREMENTS: Neurocognitive performance as measured by a computerised neurocognitive test battery (Immediate Postconcussion Assessment Cognitive Testing (ImPACT)). RESULTS: A dose-response gradient was found for two or more previous concussions and decreased neurocognitive performance. Females with a history of two and three or more concussions performed better than males with a history of two (p=0.001) and three or more concussions (p=0.012) on verbal memory. Females performed better than males with a history of three or more concussions (p=0.021) on visual memory. Finally, there was a significant difference for sex on both motor processing speed and reaction-time composite scores. Specifically, males performed worse than females on both processing speed (p=0.029) and reaction time (p=0.04). CONCLUSION: The current study provided partial support for a dose-response model of concussion and neurocognitive performance decrements beginning at two or more previous concussions. Sex differences should be considered when examining the effects of concussion history on computerised neurocognitive performance.

Neurometabolic changes in the acute phase after sports concussions correlate with symptom severity.

Henry LC, Tremblay S, Boulanger Y, Ellemberg D, Lassonde M.: Journal of Neurotrauma, 2010, 27(1):65-76. Centre de Recherche en Neuropsychologie et Cognition, Department of Psychology, University of Montréal, Montréal, Québec, Canada.

Sports concussion is a major problem that affects thousands of people in North America every year. Despite negative neuroimaging findings, many athletes display neurophysiological alterations and post-concussion symptoms such as headaches and sensitivity to light and noise. It is suspected that neurometabolic changes may underlie these changes. In this study we investigated the effects of sports concussion on brain metabolism using (1)H-MR spectroscopy by comparing a group of 12 non-concussed athletes with a group of 12 concussed athletes of the same age (mean 22.5 years) and education (mean 16 years). All athletes were scanned 1-6 days post-concussion in a 3T Siemens MRI, and were administered a symptom scale to evaluate post-concussion symptomatology. Participants also completed a neuropsychological test battery to assess verbal memory, visual memory, information processing speed, and reaction time, and no group differences were detected relative to controls. Concussed athletes showed a higher number of symptoms than non-concussed athletes, and they also showed a significant decrease in glutamate in the primary motor cortex (M1), as well as significant decreases in N-acetylaspartate in the prefrontal and primary motor cortices. No changes were observed in the hippocampus. Furthermore, the metabolic changes in M1 correlated with self-reported symptom severity despite equivalent neuropsychological performance. These results confirm cortical neurometabolic changes in the acute post-concussion phase, and demonstrate for the first time a correlation between subjective self-reported symptoms and objective physical changes that may be related to increased vulnerability of the concussed brain.

Knee extensor strength, dynamic stability, and functional ambulation: are they related in Parkinson's disease?

Nocera JR, Buckley T, Waddell D, Okun MS, Hass CJ.: Archives of Physical Medicine and Rehabilitation, 2010, 91(4):589-95. Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA.

OBJECTIVE: To evaluate the relationship between knee extensor strength, postural stability, functional ambulation, and disease severity in Parkinson's disease (PD). DESIGN: A cohort study. SETTING: University Research laboratory. PARTICIPANTS: Patients (N=44) with idiopathic PD. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Participants were evaluated on their isokinetic knee extensor strength. Additionally, participants completed an assessment of their postural stability (Functional Reach Test for static stability and a dynamic postural stability assessment as measured by the center of pressure-center of mass moment arm during gait initiation). Participants also underwent an evaluation of their functional ambulation as measured by a 6-minute walk test. Lastly, participants were evaluated by a neurologist specially trained in movement disorders to assess neurologic status and disease severity using the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr disability score. RESULTS: Knee extensor strength positively correlated with dynamic postural stability and negatively correlated with disease severity. Further, dynamic postural stability was negatively correlated to disease severity and positively correlated with functional ambulation in this cohort of patients with PD (P<.05). The results also suggest that the Functional Reach Test may be a valuable assessment tool to examine postural stability in PD. CONCLUSIONS: These findings suggest a malleable relationship between knee extensor strength, dynamic stability, and disease severity in PD. Although strength is only one piece of the puzzle in the functional outcome of PD, these findings may assist clinicians in designing appropriate interventions aimed at increasing function and decreasing fall risk in PD.

Sleep following sport-related concussions.

Gosselin, Lassonde, Petit, Leclerc, Mongrain, Collie & Montplaisir. Sleep Medicine, 2009- 10, 35-46

Objectives: Sleep and vigilance disorders are among the most commonly reported symptoms following a concussion. The aim of the study was thus to investigate the effects of sport-related concussions on subjective and objective sleep quality. Methods: Ten concussed athletes and 11 non-concussed athletes were included. Concussed athletes had a history of 4.6 ± 2.1 concussions with at least one concussion during the last year. They were recorded for two consecutive nights in the laboratory and during a 10-min period of wakefulness. They completed questionnaires related to sleep quality and symptoms as well as neuropsychological tests and the CogSport computer battery. Results: Concussed athletes reported more symptoms and worse sleep quality than control athletes, but no between-group differences were found on polysomnographic variables or on REM and NREM sleep quantitative EEG variables. However, concussed athletes showed significantly more delta activity and less alpha activity during wakefulness than did control athletes. Conclusion: In spite of the subjective complaints in sleep quality of concussed athletes, no change was observed in objective sleep characteristics. However, concussions were associated with an increase in delta and a reduction in alpha power in the waking EEG. Sport-related concussions are thus associated with wakefulness problems rather than sleep disturbances.

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Rutherford A, Stephens R, Fernie G, Potter D.: Journal of clinical and experimental neuropsychology

2009, 31(6):664-81. School of Psychology, Keele University, Keele, Staffordshire, ST5 5BG, UK.

Male players from football and rugby clubs and sportsmen from a variety of noncontact sports clubs at a UK university were compared on biographical and neuropsychological test measures. A data analysis paradigm was developed and employed to control the inflation of Type 1 error rate due to multiple hypotheses testing. Rugby players sustained most head injuries in their chosen sport, but neuropsychological tests of attention, memory, and executive function provided no evidence of performance impairment attributable to the number of head injuries sustained or the football, rugby, or noncontact sport groups. Footballers' heading frequency was related to the number of football head injuries sustained, but no relationship was detected between footballers' heading frequency and their neuropsychological test performance. Following discussion of pertinent methodological limitations it is concluded that there was no evidence in this dataset of neuropsychological impairment consistent with either mild head injury incidence or football heading frequency. However, a need for further Research examining the long-term neuropsychological consequences of such head injuries was identified.

Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions.

Omalu BI, Hamilton RL, Kamboh MI, DeKosky ST, Bailes J.: Journal of Forensic Nursing,

We present a case of chronic traumatic encephalopathy (CTE) in a retired National Football League (NFL) Player with autopsy findings, apolipoprotein E genotype, and brain tissue evidence of chronic brain damage. This 44-year-old retired NFL player manifested a premortem history of cognitive and neuropsychiatric impairment, which included in part, chronic depression, suicide attempts, insomnia, paranoia, and impaired memory before he finally committed suicide. A full autopsy was performed with Polymerase Chain Reaction-based analyses of his blood to determine the apolipoprotein genotype. Histochemical and immunohistochemical analyses were performed on topographical gross sections of the brain. Autopsy confirmed a fatal gunshot wound of the head. The apolipoprotein E genotype was E3/E3 and the brain tissue revealed diffuse cerebral taupathy (Neurofibrillary Tangles and Neuritic Threads). This will be the third case of CTE in a national football player, which has been reported in the medical literature. Omalu et al., reported the first two cases in 2005 and 2006. This case series manifested similar premortem history of neuropsychiatric impairment with autopsy evidence of cerebral taupathy without any neuritic amyloidopathy. For a definitive diagnosis of CTE to be made, and for medicolegal Purposes, a full autopsy must be performed with histochemical and immunohistochemical analyses of the brain to identify the presence of Neurofibrillary Tangles (NFTs) and Neuritic Threads (NTs). Implications: Further longitudinal prospective studies are required to confirm the common denominators and epidemiology of CTE in professional American football players, which have been identified by this case series.

Akathisia after mild traumatic head injury.

Desai A, Nierenberg DW, Duhaime AC.: Journal of Neurosurgery. Pediatrics. 201005 5(5):460-4 Section of Pediatric Surgery (Neurosurgery), Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756, USA.

Natural history of concussion in sport: markers of severity and implications for management.

Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR.: The American Journal of Sports Medicine, 201003 38(3):464-71. Centre for Health, Exercise and Sports Medicine, University of Melbourne, Parkville, Victoria, Australia.

Background: Evidence-based clinical data are required for safe return to play after concussion in sport. Purpose: The Objective of this study was to describe the natural history of concussion in sport and identify clinical features associated with more severe concussive injury, using return-to-sport decisions as a surrogate measure of injury severity. Study design: Cohort study (prognosis); Level of evidence, 3. Methods: Male elite senior, elite junior, and community-based Australian Rules football players had preseason baseline cognitive testing (Digit Symbol Substitution Test, Trail-Making Test-Part B, and CogSport computerized test battery). Players were recruited into the study after a concussive injury sustained while playing football. Concussed players were tested serially until all clinical features of their injury had resolved. Results: Of 1015 players, 88 concussions were observed in 78 players. Concussion-associated symptoms lasted an average of 48.6 hours (95% confidence interval, 39.5-57.7 hours) with delayed return to sport correlated with > or = 4 symptoms, headache lasting > or = 60 hours, or self-reported "fatigue/fogginess." Cognitive deficits using the Digit Symbol Substitution Test and Trail-Making Test-part B recovered concomitantly with symptoms, but computerized test results recovered 2 to 3 days later and remained impaired in 35% of concussed players after symptom resolution. Conclusions: Delayed return to sport was associated with initially greater symptom load, prolonged headache, or subjective concentration deficits. Cognitive testing recovery varied, taking 2 to 3 days longer for computerized tests, suggesting greater sensitivity to impairment. Therefore, symptom assessment alone may be predictive of but may underestimate time to complete recovery, which may be better estimated with computerized cognitive testing.

Measuring deficits in visually guided action post-concussion.

Locklin J, Bunn L, Roy E, Danckert J.: Sports Medicine (Auckland, N.Z.), 20100301 40(3):183-7. Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.

Impact of prior concussions on health-related quality of life in collegiate athletes.

Kuehl MD, Snyder AR, Erickson SE, McLeod TC.: Clinical Journal of Sport Medicine : official Journal of the Canadian Academy of Sport Medicine, 201003 20(2):86-9 . Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, Arizona 85206, USA.

Objective: To investigate how self-reported sport-related concussion history affects health-related quality of life in collegiate athletes. Design: Cross sectional. Setting: Division I university, Division II university, and a junior college. Participants:: Three hundred two collegiate athletes (210 men, 92 women). Assessment of risk factors: Participants completed a demographic information sheet and concussion history form; they were then grouped by number of previous self-reported concussions, designated as 0, 1-2, or 3+. Main outcome measures: The Medical Outcomes Short Form (SF-36) and the Headache Impact Test (HIT-6). Results: Significant differences between groups were found for the bodily pain, vitality, and social functioning subscales of the SF-36. The 3+ group had significantly lower scores for bodily pain (48.1 +/- 8.9) compared with the 1-2 group (P = 0.028, 52.1 +/- 7.7) and 0 group (P < 0.01, 53.5 +/- 8.3), for vitality (52.4 +/- 8.4) compared with the 0 group (P = 0.011, 55.9 +/- 8.6), and for social functioning (48.5 +/- 9.4) compared with the 1-2 group (P = 0.028, 51.6 +/- 7.3) and 0 group (P = 0.003, 51.9 +/- 8.1). Significant differences were noted on the HIT-6 total score. The 3+ group reported greater impact of headache (46.7 +/- 6.4) than the 1-2 group (P = 0.05, 44.6 +/- 6.4) and 0 group (P < 0.001, 42.9 +/- 5.8). The 1-2 group also had higher HIT-6 scores than the 0 group (P = 0.033). Conclusions: Results suggest that a collegiate athlete's perception of bodily pain, vitality, social functioning, and headache is adversely affected by previous sport-related concussions. However, by incorporating general and specific outcome measures into the standard evaluation of sport-related concussion, the clinician can better determine how the athlete is responding to treatment and recovery.

Impact of recurrent head trauma on olfactory function in boxers: a matched pairs analysis.

Vent J, Koenig J, Hellmich M, Huettenbrink KB, Damm M.: Brain Research, 20100312 1320:1-6 Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Cologne, Cologne, Kerpener Str. 62; 50924 Cologne, Germany.

Recently, interest in the health of boxers has been raised by a petition of the British Medical Association to restrict boxing. However, scientific data on permanent damage are rare and typical localisations of injuries were yet to be defined. The aim of this study was to determine whether there are changes in the sense of smell in people undergoing recurrent head traumas. The hypo hypothesis thesis to be tested was if boxers had a reduced olfactory function. We used a matched pairs analysis design. Fifty healthy, male athletes underwent subjective olfactometry using Sniffin'Sticks testing (including threshold, discrimination and identification, TDI). Nasal endoscopy was performed and a thorough, questionnaire-based history was obtained. These data were correlated with normative data from healthy subjects. Statistical analysis was based on matched pairs analysis by t-tests, i.e. boxers and healthy (non-boxing) subjects. Boxers showed a mean TDI score of 32.5 compared to 35.1 of non-boxing controls (p=0.003). The olfactory threshold (p<0.001) and odour identification (p<0.05) were significantly decreased in boxers; whereas odour discrimination was unaffected. Performance of odour identification showed a correlation with cushioning of the gloves (p<0.05), and thus seems a protective measure regarding the sense of smell. Boxing seems to affect olfactory function, particularly by reducing the olfactory threshold. Furthermore, cushioning of the gloves can be protective and should be increased to safeguard sportsmen from physical damage. Boxing can serve as a model for central regeneration after trauma.

Sinus barotrauma leading to extradural muco-pneumocephalus.

Murugesan C, Powell M, Khayal HB.: British Journal of neurosurgery, 201002 24(1):80-1. Departments of Neurosurgery, The National Hospital, London UK.

The predicted risk of head injury from fall-related impacts on to third-generation artificial turf and grass soccer surfaces: a comparative biomechanical analysis.

Theobald P, Whitelegg L, Nokes LD, Jones MD.: Sports Biomechanics / International Society of Biomechanics in Sports, 201003 9(1):29-37. Trauma Biomechanics Research Group, Institute of Medical Engineering & Medical Physics, Cardiff University, Cardiff, UK.

Table tennis dystonia.

Le Floch A, Vidailhet M, Flamand-Rouvière C, Grabli D, Mayer JM, Gonce M, Broussolle E, Roze E.:

Movement disorders : official Journal of the Movement Disorder Society, 20100215 25(3):394-7. Service de Neurologie, Hôpital Nîmes, Nîmes, France.

Focal task-specific dystonia (FTSD) occurs exclusively during a specific activity that usually involves a highly skilled movement. Classical FTSD dystonias include writer's cramp and musician's dystonia. Few cases of sport-related dystonia have been reported. We describe the first four cases of FTSD related to table tennis (TT), two involving professional international competitors. We also systematically analyzed the literature for reports of sport-related dystonia including detailed clinical descriptions. We collected a total of 13 cases of sport-related dystonia, including our four TT players. Before onset, all the patients had trained for many years, for a large number of hours per week. Practice time had frequently increased significantly in the year preceding onset. As TT is characterized by highly skilled hand/forearm movements acquired through repetitive exercises, it may carry a higher risk of FTSD than other sports. Intensive training may result in maladaptive responses and overwhelm homeostatic mechanisms that regulate cortical plasticity in vulnerable individuals. Our findings support the importance of environmental risk factors in sport-related FTSD, as also suggested in classical FTSD, and have important implications for clinical practice.

Neurometabolic changes in the acute phase after sports concussions correlate with symptom severity.

Henry LC, Tremblay S, Boulanger Y, Ellemberg D, Lassonde M.: Journal of Neurotrauma, 201001 27(1):65-76. Centre de Recherche en Neuropsychologie et Cognition, Department of Psychology, University of Montréal, Montréal, Québec, Canada.

Sports concussion is a major problem that affects thousands of people in North America every year. Despite negative neuroimaging findings, many athletes display neurophysiological alterations and post-concussion symptoms such as headaches and sensitivity to light and noise. It is suspected that neurometabolic changes may underlie these changes. In this study we investigated the effects of sports concussion on brain metabolism using (1)H-MR spectroscopy by comparing a group of 12 non-concussed athletes with a group of 12 concussed athletes of the same age (mean 22.5 years) and education (mean 16 years). All athletes were scanned 1-6 days post-concussion in a 3T Siemens MRI, and were administered a symptom scale to evaluate post-concussion symptomatology. Participants also completed a neuropsychological test battery to assess verbal memory, visual memory, information processing speed, and reaction time, and no group differences were detected relative to controls. Concussed athletes showed a higher number of symptoms than non-concussed athletes, and they also showed a significant decrease in glutamate in the primary motor cortex (M1), as well as significant decreases in N-acetylaspartate in the prefrontal and primary motor cortices. No changes were observed in the hippocampus. Furthermore, the metabolic changes in M1 correlated with self-reported symptom severity despite equivalent neuropsychological performance. These results confirm cortical neurometabolic changes in the acute post-concussion phase, and demonstrate for the first time a correlation between subjective self-reported symptoms and Objective physical changes that may be related to increased vulnerability of the concussed brain.

Knee extensor strength, dynamic stability, and functional ambulation: are they related in Parkinson's disease?

Nocera JR, Buckley T, Waddell D, Okun MS, Hass CJ.: Archives of Physical Medicine and Rehabilitation, 201004 91(4):589-95. Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA.

Objective: To evaluate the relationship between knee extensor strength, postural stability, functional ambulation, and disease severity in Parkinson's disease (PD). Design: A cohort study. Setting: University Research laboratory. Participants: Patients (N=44) with idiopathic PD. Intervention: Not applicable. Main outcome measures: Participants were evaluated on their isokinetic knee extensor strength. Additionally, participants completed an assessment of their postural stability (Functional Reach Test for static stability and a dynamic postural stability assessment as measured by the center of pressure-center of mass moment arm during gait initiation). Participants also underwent an evaluation of their functional ambulation as measured by a 6-minute walk test. Lastly, participants were evaluated by a neurologist specially trained in movement disorders to assess neurologic status and disease severity using the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr disability score. Results: Knee extensor Strength positively correlated with dynamic postural stability and negatively correlated with disease severity. Further, dynamic postural stability was negatively correlated to disease severity and positively correlated with functional ambulation in this cohort of patients with PD (P<.05). The results also suggest that the Functional Reach Test may be a valuable assessment tool to examine postural stability in PD. Conclusions : These findings suggest a malleable relationship between knee extensor strength, dynamic stability, and disease severity in PD. Although Strength is only one piece of the puzzle in the functional outcome of PD, these findings may assist clinicians in designing appropriate interventions aimed at increasing function and decreasing fall risk in PD.

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Rutherford A, Stephens R, Fernie G, Potter D.: Journal of Clinical and Experimental Neuropsychology

200908 31(6):664-81. School of Psychology, Keele University, Keele, Staffordshire, ST5 5BG, UK.

Orbital trauma, bradycardia, and vomiting: trapdoor fracture and the oculocardiac reflex: a case report.

Jackson BF .: Pediatric Emergency Care, 201002 26(2):143-5. Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA.

The presentation of vomiting and bradycardia after closed head trauma should invariably prompt concern for significant intracranial injury, yet other less common causes for the clinical picture do exist. This case reports one such scenario in which fracture to the patient's inferior orbital wall resulted in the rare though potentially life-threatening oculocardiac reflex, a vagally mediated phenomenon with possible respiratory, cardiovascular, and gastric motility effects.

Neuromuscular control and exercise-related leg pain in triathletes.

Chapman AR, Hodges PW, Briggs AM, Stapley PJ, Vicenzino B.: Medicine and Science in Sports and Exercise, 2010, 42(2):233-43. Division of Physiotherapy, The University of Queensland, Brisbane, Australia.

Previous studies have shown that cycling can directly influence neuromuscular control during subsequent running in some highly trained triathletes. A relationship between this altered neuromuscular control of running and musculoskeletal pain and injury has been proposed; however, this link has not been investigated. Purpose: This study aimed to evaluate the influence of cycling on neuromuscular control during subsequent running in highly trained triathletes with and without exercise-related leg pain (ERLP). Methods: Participants were 34 highly trained triathletes: 10 triathletes with a history of ERLP and 24 training-matched control triathletes with no history of ERLP. Knee and ankle kinematics and leg muscle recruitment were compared between a baseline run (no prior exercise) and a transition run (preceded by cycling; i.e., run vs cycle run). Results: Knee and ankle joint kinematics were not different between baseline and transition runs for any triathletes: absolute mean difference (+/-95% confidence interval) was 1.49 degrees +/- 0.17 degrees. However, muscle recruitment was different between baseline and transition runs, defined by absolute mean difference in EMG amplitude > or = 10%, in 5 of 24 control triathletes (11/130 muscles exhibited altered recruitment) and in 5 of 10 triathletes with a history of ERLP (12/50 muscles exhibited altered recruitment). This represents a relative risk of 2.40 (0.89-6.50; P = 0.089) when defined by athletes and 2.62 (1.34-6.01; P < 0.01) when defined by muscles. The magnitude of change in muscle recruitment between baseline and transition runs was not different between control (14.10% +/- 2.34%) and ERLP triathletes (16.31% +/- 3.64%; P = 0.41). Conclusions: This study demonstrates an association between ERLP in triathletes and their neuromuscular control when running off the bike.

Exercise on a treadmill or walking outdoors? A randomized controlled trial comparing effectiveness of two walking exercise programmes late after stroke.

Langhammer B, Stanghelle JK.: Clinical Rehabilitation, 2010, 24(1):46-54. Physiotherapy Programme, Faculty of Health, Oslo University College/Sunnaas Rehabilitation Hospital, Oslo 4/1450 Nesoddtangen, Norway.

Objective: To evaluate spatial and temporal gait characteristics and endurance late after stroke in people who had received two different walking exercises. A secondary aim was to compare the outcomes in relation to length of time exercising and number of exercise occasions between the two. Design: A randomized controlled trial. Setting: A private rehabilitation centre. Subjects: Thirty-nine people with stroke entered the study, and five dropped out. Interventions: Treadmill training versus walking outdoors. Main measures: Six-Minute Walk Test, a 10-metre walk test and pulse rates at rest and in activity. Results: There were significant differences in favour of the treadmill group in Six-Minute Walk Test distance (P = 0.04), Six-Minute Walk Test speed (P = 0.03), 10-m walking speed (P = 0.03), bilateral stride length (right leg; P = 0.009, left leg; P = 0.003) and step width (P = 0.01), indicating more symmetrical use of the legs in the treadmill group (1.02-1.10 m versus 0.97-0.92 m). There were no significant differences between groups in cadence (P = 0.78). All participants complied 100% with their respective programmes. Exercise frequency did not differ between the groups but significantly less time was spent exercising on the treadmill compared with walking exercise outdoors (107 versus 316 minutes, P = 0.002). There were no differences in use of assistive aids between the groups on arrival at the clinic or at departure. Conclusion: The results indicate that treadmill walking improves spatial and temporal gait characteristics more effectively than walking outdoors.

Repetitive breath-hold diving causes serious brain injury.

Tamaki H, Kohshi K, Sajima S, Takeyama J, Nakamura T, Ando H, Ishitake T.: Undersea & Hyperbaric Medicine, 2010, 37(1):7-11. Division of Emergency Medicine, Tamaki Hospital, Hagi, Japan.

We report on a Japanese male professional breath-hold diver (Ama) who developed neurological disorders during repetitive dives to 22 meters of sea water. Each diving duration and surface interval were 40-80 seconds and 20-30 seconds, respectively. He suffered from sensory numbness of the right cheek, hand and foot, and double vision after more than two hours of consecutive dives. Magnetic resonance images of his brain showed multiple cerebral infarcts, and one of the lesions was situated in the brainstem. There is a possibility that repetitive deep breath-hold dives with short surface intervals can induce fatal accidents for divers.

The 6-minute walk test as a new outcome measure in Duchenne muscular dystrophy.

McDonald CM, Henricson EK, Han JJ, Abresch RT, Nicorici A, Elfring GL, Atkinson L, Reha A, Hirawat S, Miller LL.: Muscle & Nerve, 2010, 41(4):500-10. Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, California, 95817, USA.

Walking abnormalities are prominent in Duchenne muscular dystrophy (DMD). We modified the 6-minute walk test (6MWT) for use as an outcome measure in patients with DMD and evaluated its performance in 21 ambulatory boys with DMD and 34 healthy boys, ages 4 to 12 years. Boys with DMD were tested twice, approximately 1 week apart; controls were tested once. The groups had similar age, height, and weight. All tests were completed. Boys who fell recovered rapidly from falls without injury. Mean +/- SD [range] 6-minute walk distance (6MWD) was lower in boys with DMD than in controls (366 +/- 83 [125-481] m vs. 621 +/- 68 [479-754] m; P < 0.0001; unpaired t-test). Test-retest correlation for boys with DMD was high (r = 0.91). Stride length (R(2) = 0.89; P < 0.0001) was the major determinant of 6MWD for both boys with DMD and controls. A modified 6MWT is feasible and safe, documents disease-related limitations on ambulation, is reproducible, and offers a new outcome measure for DMD natural history and therapeutic trials.

Exercise programs improve mobility and balance in people with Parkinson's disease.

Gobbi LT, Oliveira-Ferreira MD, Caetano MJ, Lirani-Silva E, Barbieri FA, Stella F, Gobbi S.: Parkinsonism & Related Disorders, 2009, 15 Suppl 3:S49-52. Posture and Gait Studies Lab, UNESP - São Paulo State University at Rio Claro, São Paulo, Brazil.

Compromised balance and loss of mobility are among the major consequences of Parkinson's disease (PD). The literature documents numerous effective interventions for improving balance and mobility. The purpose of this study was to verify the effectiveness of two exercise programs on balance and mobility in people with idiopathic PD. Thirty-four participants, with idiopathic PD that ranged from Stage I to Stage III on the Hoehn & Yahr (H&Y) scale, were assigned to two groups. Group 1 (n = 21; 67+/-9 years old) was engaged in an intensive exercise program (aerobic capacity, flexibility, strength, motor coordination and balance) for 6 months: 72 sessions, 3 times a week, 60 minutes per session; while Group 2 (n = 13; 69+/-8 years old) participated in an adaptive program (flexibility, strength, motor coordination and balance) for 6 months: 24 sessions, once a week, 60 minutes per session. Balance and basic functional mobility were assessed in pre- and post-tests by means of the Berg Balance Scale and the Timed Up and Go Test. Before and after the interventions, groups were similar in clinical conditions (H&Y, UPDRS, and Mini-Mental). A MANOVA 2 (programs) by 2 (moments) revealed that both groups were affected by the exercise intervention. Univariate analyses showed that participants improved their mobility and balance from pre- to post-test. There were no differences between groups in either mobility or balance results. Both the intensive and adaptive exercise programs improved balance and mobility in patients with PD.

Immediate post-concussion assessment and cognitive testing (ImPACT) practices of sports medicine professionals.

Covassin T, Elbin RJ, Stiller-Ostrowski JL, Kontos AP.: Journal of Athletic Training, 2009, 44(6):639-44. 105 IM Sports Circle, Michigan State University, East Lansing, MI 48823, USA.

Context: Computerized neurocognitive testing is becoming popular among clinicians evaluating sport-related concussions across all levels of sport. Baseline neurocognitive testing has been recommended to provide more accurate representation of the preconcussion cognitive status of individual athletes. However, little is known about the use of baseline neurocognitive testing in concussion assessment and management. Objective: To examine implementation and practice trends of sports medicine professionals using baseline neurocognitive testing at the high school and collegiate levels. Design: Quantitative survey research. Setting: Online survey. Patients or other participants: Certified athletic trainers (ATs) from approximately 1209 US institutions listed on the ImPACT Web site were recruited. A total of 399 ATs completed the survey, for a response return rate of 32.7%. Main outcome resul(s): Survey questions addressed educational level, years of certification, employment setting, percentage of athletes baseline tested, and accuracy of baseline tests. Other items addressed postconcussive neurocognitive testing protocols and scenarios for return-to-play decisions based on neurocognitive testing. Results: Nearly all ATs (94.7%) administered baseline computerized neurocognitive testing to their athletes. However, only 51.9% examined these baseline tests for validity. The majority of ATs indicated that they administer baseline neurocognitive tests most frequently to football players (88.4%), followed by women's soccer players (78.8%) and men's soccer players (71.2%). Nearly all respondents (95.5%) stated that they would not return a symptomatic athlete to play if the athlete's neurocognitive scores were back to baseline. However, when asked if they would return an athlete who is symptom free but who scores below his or her baseline, 86.5% responded no, 9.8% responded yes, and 3.8% indicated that it depended on the importance of the competition. Conclusions: The use of baseline testing, baseline testing readministration, and postconcussion protocols among ATs is increasing. However, the ATs in this study reported that they relied more on symptoms than on neurocognitive test scores when making return-to-play decisions.

Advances in sport concussion assessment: from behavioral to brain imaging measures.

Ellemberg D, Henry LC, Macciocchi SN, Guskiewicz KM, Broglio SP.: Journal of Neurotrauma, 2009, 26(12):2365-82. Department of Kinesiology, University of Montréal, Montréal, Québec, Canada.

Given that the incidence of sports-related concussion is considered to have reached epidemic proportions, in the past 15 years we have witnessed an explosion of research in this field. The purpose of the current review is to compare the results provided by the different assessment tools used in the scientific literature in order to gain a better understanding of the sequelae and recovery following a concussion. Until recently, the bulk of the has literature focused on the immediate outcome in the hours and days post-injury as a means to plan the safest return-to-play strategy. This has led to the development of several assessment batteries that are relatively easy and rapid to administer and that allow for multiple testing sessions. The main conclusion derived from that literature is that cognitive symptoms tend to resolve within 1 week. However, accumulating evidence indicates that cognitive testing should be viewed as one of several complementary tools necessary for a comprehensive assessment of concussion. Including an objective measure of postural stability increases the sensitivity of the return-to-play decision-making process and minimizes the consequences of mitigating factors (e.g., practice effects and motivation) on neuropsychological test results. This is consistent with findings that symptom severity, neuropsychological function, and postural stability do not appear to be related or affected to the same degree after a concussion. Furthermore, recent evidence from brain imaging, including event-related potentials and functional and metabolic imaging, suggest abnormalities in the electrical responses, metabolic balance, and oxygen consumption of neurons that persist several months after the incident. We explain this apparent discrepancy in recovery by suggesting an initial and rapid phase of functional recovery driven by compensatory mechanisms and brain plasticity, which is followed by a prolonged neuronal recovery period during which subtle deficits in brain functioning are present but not apparent to standard clinical assessment tools.

Incidence, risk, and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players.

Hollis SJ, Stevenson MR, McIntosh AS, Shores EA, Collins MW, Taylor CB.: The American Journal of Sports Medicine, 2009, 37(12):2328-33. The George Institute, The University of Sydney, PO Box M201, Missenden Road, Sydney, NSW, 2050, Australia.

Background: Mild traumatic brain injury (mTBI) is an emerging public health issue in high-contact sports. Understanding the incidence along with the risk and protective factors of mTBI in high-contact sports such as rugby is paramount if appropriate preventive strategies are to be developed. Purpose: To estimate the incidence and identify the risk and protective factors of mTBI in Australian nonprofessional rugby players. Study design: Cohort study; Level of evidence, 2. Methods: A cohort of 3207 male nonprofessional rugby players from Sydney, Australia, was recruited and followed over 1 or more playing seasons. Demographic information, history of recent concussion, and information on risk and protective factors were collected. The incidence of mTBI was estimated and the putative risk and protective factors were modeled in relation to mTBI. Results: The incidence of mTBI was 7.97 per 1000 player game hours, with 313 players (9.8%) sustaining 1 or more mTBIs during the study. Players who reported always wearing protective headgear during games were at a reduced risk (incident rate ratio [IRR], 0.57; 95% confidence interval [CI], 0.40-0.82) of sustaining an mTBI. In contrast, the likelihood of mTBI was almost 2 times higher among players who reported having sustained either 1 (IRR, 1.75; 95% CI, 1.11-2.76) or more mTBIs (IRR, 1.65; 95% CI, 1.11-2.45) within the 12 months before recruitment. Conclusion: Nonprofessional rugby has a high incidence of mTBI, with the absence of headgear and a recent history of mTBI associated with an increased risk of subsequent mTBI. These findings highlight that both use of headgear and the management of prior concussion would likely be beneficial in reducing the likelihood of mTBI among nonprofessional rugby players, who compose more than 99% of rugby union players in Australia.

Walking economy of adults with Down syndrome.

Mendonca GV, Pereira FD, Morato PP, Fernhall B.: International Journal of Sports Medicine, 2010, 31(1):10-5. Human Kinetics Faculty, Human Kinetics, Lisboa, Portugal.

This study intended to investigate walking economy (WE) in response to different treadmill speeds and grades in adults with Down syndrome (DS) and in non-disabled controls. Eighteen participants (14 males; 4 females) with DS (33.6+/-7.6 years) and 16 non-disabled (12 males, 4 females) controls (33.3+/-8.0 years) performed submaximal (2.5 km . h (-1) and 4 km . h (-1) at 0% grade; 4 km . h (-1) at 2.5% and 5% grade, for 5 min each) and maximal treadmill tests with metabolic and heart rate measurements. Oxygen uptake (VO(2)) was not different between groups at rest or during the slowest treadmill speed. However, at faster speeds and increased grades, adults with DS presented lower WE than controls (p<0.0001). Subsequent analyses revealed that, despite showing higher delta VO(2) response to the selected speed increments (p<0.0001), individuals with DS produced similar VO(2) increase as controls to grade variations. Therefore, adults with DS exhibit lower WE than non-disabled controls at a speed faster than their preferred walking speed. Additionally, in comparison to controls, individuals with DS show a greater change in energy expenditure with a change in walking speed. In conclusion, lower WE in individuals with DS is mainly related to their inability to adapt efficiently to positive variations in walking speed.

Effects of treadmill training on walking economy in Parkinson's disease: a pilot study.

Pelosin E, Faelli E, Lofrano F, Avanzino L, Marinelli L, Bove M, Ruggeri P, Abbruzzese G.: Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 2009, 30(6):499-504. Department of Neurosciences, Ophthalmology and Gentics, University of Genoa, Via de Toni 5, 16132 Genoa, Italy.

Gait disturbances are frequent in Parkinson's disease (PD) and are associated with increased energy expenditure during walking. This study evaluated whether the effects of treadmill training are associated with an improvement of walking economy. Ten patients with idiopathic PD underwent treadmill training (30 min, three times a week for 4 weeks). Walking performance (Tauimed Up and Go, 6-min and 10-m walking tests) and metabolic function (oxygen uptake, heart and respiratory rate) were evaluated before training, at the end of treatment and after 30 days with two different graded exercises (treadmill and cycloergometer). Training significantly improved walking performance. Oxygen uptake, and heart and respiratory rates were significantly decreased only during graded exercise on the treadmill, but not on the cycloergometer. Treadmill training reduces energy expenditure during walking in PD, but the improvements of metabolic walking economy are associated with the specifically trained motor activity.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete.

Swartz EE, Decoster LC, Norkus SA, Boden BP, Waninger KN, Courson RW, Horodyski M, Rehberg RS.: The Physician and Sportsmedicine, 2009, 37(4):20-30. University of New Hampshire, Durham, NH 03824, USA.

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

Sport concussion assessment tool: baseline values for varsity collision sport athletes

Objective: To determine baseline symptom and neurocognitive norms for non-concussed and previously concussed varsity athletes using the sport concussion assessment tool (SCAT). Study Design: Descriptive cohort study. Setting: University of Calgary. Subjects: 260 male and female university football, ice hockey and wrestling athletes over three seasons (2005–7). Methods: A baseline SCAT was completed during preseason medical evaluation. Subjects were grouped as follows: all participants, men, women, never concussed (NC) and previously concussed (PC). Main Results: The mean age of participants was 20.5 years (range 17–32). In total, 41.2% of all athletes had a total post-concussion symptom scale (PCSS) score of 0. The mean baseline PCSS scores were as follows: all participants 4.29; men 3.52; women 6.39; NC 3.75 and PC 5.25. The five most frequently reported symptoms for all athletes were fatigue/low energy (37% of subjects), drowsiness (23%), neck pain (20%), difficulty concentrating (18%) and difficulty remembering (18%). The median immediate recall score was 5/5 for all groups. Women scored a median of 5/5 on delayed recall, whereas all remaining groups scored a median of 4/5. Months in reverse order were successfully completed by 91.6% of subjects. All participants, women and PC scored a median of 6 on reverse digits, whereas men and NC scored a median of 5. Conclusions: The mean SCAT baseline PCSS score was approximately 5, although just under half of the athletes scored 0. Female athletes scored better on tests of neurocognitive function. PC athletes scored better than NC athletes on all neurocognitive tests except delayed five-word recall.

The prevention of catastrophic head and spine injuries in high school and college sports

The incidence of catastrophic injuries in sports at the high school and college levels is low, <0.5 per 100 000 participants, but even one is too many.1 Permanent paralysis, brain damage and death should not be associated with teenagers and young adults participating in high school and college athletics. Catastrophic injury is devastating not only to the injured athlete, but also to the athlete’s family, school and community. Many of these injuries can be prevented by utilising proper data collection and proper medical care and safety precautions such as implementing safer rules, proper conditioning and coaching techniques. While there are some sports with a higher incidence of catastrophic injury than others, there are also some sports with higher injury rates per 100 000 participants. For example, American football has the greatest number of catastrophic injuries, but it also has the greatest number of participants. Gymnastics, ice hockey, and cheerleading have higher rates per 100 000 participants than American football, but fewer participants and thus fewer total injuries. Table 1 gives the participation numbers for high school and college sports from the autumn of 1982 to the spring of 2008, and table 2 gives the injury rates per 100 000 participants. Emphasis should be placed on the fact that no matter how low the incidence levels or rates per number of participants are, an increased effort should be placed on prevention of catastrophic injuries. Methods: The collection of American football death data began in 1931, when the American Football Coaches Association initiated the first Annual Survey of Football Fatalities.2 The research has been carried out on a national level every year except for 1942 and has been conducted at the University of North Carolina, Chapel Hill since 1965. The title of the survey …

Sport concussion assessment tool: baseline values for varsity collision sport athletes

The prevention of catastrophic head and spine injuries in high school and college sports

State anxiety and subjective well-being responses to acute bouts of aerobic exercise in patients with depressive and anxiety disorders

Objective: Acute aerobic exercise is associated with a reduction in state anxiety and an improvement in subjective well-being. The objective of the present study was to contrast the effects of aerobic exercise at self-selected intensity versus prescribed intensity on state anxiety and subjective well-being (negative affect, positive well-being and fatigue) in patients with depressive and/or anxiety disorders. In addition, the potential impact of heart rate feedback was assessed. Methods: Nineteen men and 29 women performed three test conditions on a bicycle ergometer during 20 minutes: two tests at self-selected intensity; one with and another without heart rate feedback, and a third test at the prescribed intensity of 50% of the maximal heart rate reserve according to Karvonen. Tests were executed in random order. State anxiety and subjective well-being were evaluated using the state anxiety inventory and the subjective exercise experiences scale. Results: After 20 minutes cycling, patients showed significantly decreased state anxiety and negative affect in the three conditions. The magnitude of the reduction did not differ significantly between the three conditions. Only cycling at self-selected intensity enhanced positive well-being. Cycling at 50% of the maximal heart rate reserve decreased fatigue, whereas cycling at self-selected intensity increased fatigue. Conclusions: The response in state anxiety and negative affect was unaffected by the type of aerobic exercise. Self-selected intensity influenced exercise-induced changes in positive well-being and fatigue in a positive and negative way, respectively.

Natural history of concussion in sport: markers of severity and implications for management.

BACKGROUND: Evidence-based clinical data are required for safe return to play after concussion in sport. PURPOSE: The objective of this study was to describe the natural history of concussion in sport and identify clinical features associated with more severe concussive injury, using return-to-sport decisions as a surrogate measure of injury severity. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 3. METHODS: Male elite senior, elite junior, and community-based Australian Rules football players had preseason baseline cognitive testing (Digit Symbol Substitution Test, Trail-Making Test-Part B, and CogSport computerized test battery). Players were recruited into the study after a concussive injury sustained while playing football. Concussed players were tested serially until all clinical features of their injury had resolved. RESULTS: Of 1015 players, 88 concussions were observed in 78 players. Concussion-associated symptoms lasted an average of 48.6 hours (95% confidence interval, 39.5-57.7 hours) with delayed return to sport correlated with > or = 4 symptoms, headache lasting > or = 60 hours, or self-reported "fatigue/fogginess." Cognitive deficits using the Digit Symbol Substitution Test and Trail-Making Test-part B recovered concomitantly with symptoms, but computerized test results recovered 2 to 3 days later and remained impaired in 35% of concussed players after symptom resolution. CONCLUSION: Delayed return to sport was associated with initially greater symptom load, prolonged headache, or subjective concentration deficits. Cognitive testing recovery varied, taking 2 to 3 days longer for computerized tests, suggesting greater sensitivity to impairment. Therefore, symptom assessment alone may be predictive of but may underestimate time to complete recovery, which may be better estimated with computerized cognitive testing.

OBJECTIVES: Sleep and vigilance disorders are among the most commonly reported symptoms following a concussion. The aim of the study was thus to investigate the effects of sport-related concussions on subjective and objective sleep quality. METHODS: Ten concussed athletes and 11 non-concussed athletes were included. Concussed athletes had a history of 4.6+/-2.1 concussions with at least one concussion during the last year. They were recorded for two consecutive nights in the laboratory and during a 10-min period of wakefulness. They completed questionnaires related to sleep quality and symptoms as well as neuropsychological tests and the CogSport computer battery. RESULTS: Concussed athletes reported more symptoms and worse sleep quality than control athletes, but no between-group differences were found on polysomnographic variables or on REM and NREM sleep quantitative EEG variables. However, concussed athletes showed significantly more delta activity and less alpha activity during wakefulness than did control athletes. CONCLUSION: In spite of the subjective complaints in sleep quality of concussed athletes, no change was observed in objective sleep characteristics. However, concussions were associated with an increase in delta and a reduction in alpha power in the waking EEG. Sport-related concussions are thus associated with wakefulness problems rather than sleep disturbances.

Endurance exercise improves walking distance in MS patients with fatigue.

Acta neurologica Scandinavica, 120(4):251-7, 2009. Kliniken Schmieder Konstanz, Konstanz, Germany.

Objectives: Effects of endurance training in multiple sclerosis (MS) patients complaining of motor fatigue. Materials and methods: Thirty MS patients complaining of fatigue with low to moderate disabilities randomly allocated to the intervention (thrice weekly 45-min intervals of endurance exercise) or control treatment (three 45-min episodes of stretching, balance training and coordination), both as 'add-on' therapy for 3 weeks during inpatient rehabilitation. Results: Maximal walking distance before intervention averaged 1043 +/- 568 and 1163 +/- 750 m in the two groups. The intervention group increased its maximal walking distance by 650 +/- 474 m. The control group extended its walking distance by 96 +/- 70 m. Conclusions: The present data confirm a strong effect of endurance exercise on maximal walking distance. Remarkably, there were no parallel improvements on the Modified Fatigue Impact Scale, the Beck Depression Inventory and the Hamburg Quality of Life Questionnaire for MS.

Consensus statement on concussion in sport - the Third International Conference on Concussion in Sport held in Zurich, November 2008.

McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. The Physician and Sportsmedicine, 37(2):141-59, 2009. Center for Health, Exercise and Sports Medicine, University of Melbourne, Parkville, Australia 3010.

This paper is a revision and update of the recommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. The Zurich Consensus statement is designed to build on the principles outlined in the original Vienna and Prague documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the "background" section (see Section 11). This document is developed for use by physicians, therapists, certified athletic trainers, health professionals, coaches and other people involved in the care of injured athletes, whether at the recreational, elite, or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return-to-play (RTP) decisions remain in the realm of clinical judgment on an individualized basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document and/or the Sports Concussion Assessment Tool (SCAT2) card, and neither is subject to any copyright restriction. The authors request, however, that the document and/or the SCAT2 card be distributed in their full and complete format.

Physical exercise, aging, and mild cognitive impairment: a population-based study.

Geda YE, Roberts RO, Knopman DS, Christianson TJ, Pankratz VS, Ivnik RJ, Boeve BF, Tangalos EG, Petersen RC, Rocca WA. Archives of Neurology, 67(1):80-6, 2010. Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Background: Physical exercise is associated with decreased risk of dementia and Alzheimer disease. OBJECTIVE: To investigate whether physical exercise is associated with decreased risk of mild cognitive impairment (MCI). Design: Population-based case-control study. SETTING: The Mayo Clinic Study of Aging, an ongoing population-based cohort study in Olmsted County, Minnesota. Particpants: A total of 1324 subjects without dementia who completed a Physical Exercise Questionnaire. Main Outcome measures: An expert consensus panel classified each subject as having normal cognition or MCI based on published criteria. Results: We compared the frequency of physical exercise among 198 subjects with MCI with that among 1126 subjects with normal cognition and adjusted the analyses for age, sex, years of education, medical comorbidity, and depression. The odds ratios for any frequency of moderate exercise were 0.61 (95% confidence interval, 0.43-0.88; P = .008) for midlife (age range, 50-65 years) and 0.68 (95% confidence interval, 0.49-0.93; P = .02) for late life. The findings were consistent among men and women. Light exercise and vigorous exercise were not significantly associated with decreased risk of MCI. Conclusion: In this population-based case-control study, any frequency of moderate exercise performed in midlife or late life was associated with a reduced odds of having MCI.

Idiopathic intracranial hypertension is associated with lower body adiposity.

Neuro-ophthalmology unit, Department of Ophthalmology, Tel Aviv-Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To characterize the obesity phenotype(s) in patients with idiopathic intracranial hypertension (IIH). DESIGN: Database study. Participants: We studied 44 consecutive patients with IIH, in addition to 184 women attending the obesity clinic of the same medical center and 199 obese women participating in the first Israeli national survey on health and nutrition conducted in 1999 and 2000. Methods: Anthropometric parameters were compared with those of 2 control groups of the same age range. Main Outcome measures: Weight, height, and waist and hip circumference were measured. Results: Forty subjects, comprising 91.0% of this cohort, were either overweight (body mass index, 25.0-29.9 kg/m(2)) or obese (body mass index > or = 30 kg/m2). Mean waist circumference was 95.3 cm for IIH, 99.8 cm for the national survey, and 114.5 cm for the obesity clinic cohort (P<0.001), whereas hip circumference was 121 cm for IIH, 118.4 cm for the national survey, and 125.8 cm (P = not significant) for the obesity clinic cohorts. Waist-to-hip ratio, a descriptive measure of body fat distribution approximately reflecting upper to lower body fat ratio, was 0.79 in the patients with IIH, 0.84 in the national survey group, and 0.91 in the obesity clinic cohort (P<0.001; all comparisons were adjusted for age and body mass index). Conclusions: In IIH, fat tends to preferentially accumulate in the lower body relative to other obese women of the same range. Whereas most complications of obesity, such as hypertension, diabetes, dyslipidemia, and the metabolic syndrome, are linked to upper body adiposity, IIH may represent a unique condition potentially induced by nonvisceral fat-related mechanisms. Financial disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Marathon runner's retinopathy.

Labriola LT, Friberg TR, Hein A. Seminars in ophthalmology, 2009 Nov-Dec 24(6):247-50, 2009. The Retina Service, Eye and Ear Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.

Purpose: To report a case of an unusual retinopathy in an otherwise healthy 25-year-old marathon runner. Methods: Case report. Results: A 25-year-old female marathon runner developed sudden onset of monocular vision loss during a routine training run. The retinal features included a large, central, subhyaloid hemorrhage, multiple intraretinal hemorrhages, disc edema and venous dilation and tortuosity resembling characteristics of both valsalva retinopathy and nonischemic central retinal vein occlusion. Work up for underlying systemic cause was negative. However, the patient did participate in endurance exercise. Conclusion: Strenuous exercise increases activated platelets and other clotting factor elements. During exercise, this increase in clotting factors in the coagulation cascade is usually balanced by activation of key elements in the fibrinolysis cascade as well. However, certain individuals, especially those who already have a predisposition to clotting or other thrombogenic risk factors may disrupt the balance between coagulation and fibrinolysis during strenuous exercise favoring coagulation which places them at risk for thrombus formation

Peripheral nerve entrapment and injury in the upper extremity.

Peripheral nerve injury of the upper extremity commonly occurs in patients who participate in recreational (e.g., sports) and occupational activities. Nerve injury should be considered when a patient experiences pain, weakness, or paresthesias in the absence of a known bone, soft tissue, or vascular injury. The onset of symptoms may be acute or insidious. Nerve injury may mimic other common musculoskeletal disorders. For example, aching lateral elbow pain may be a symptom of lateral epicondylitis or radial tunnel syndrome; patients who have shoulder pain and weakness with overhead elevation may have a rotator cuff tear or a suprascapular nerve injury; and pain in the forearm that worsens with repetitive pronation activities may be from carpal tunnel syndrome or pronator syndrome. Specific history features are important, such as the type of activity that aggravates symptoms and the temporal relation of symptoms to activity (e.g., is there pain in the shoulder and neck every time the patient is hammering a nail, or just when hammering nails overhead?). Plain radiography and magnetic resonance imaging are usually not necessary for initial evaluation of a suspected nerve injury. When pain or weakness is refractory to conservative therapy, further evaluation (e.g., magnetic resonance imaging, electrodiagnostic testing) or surgical referral should be considered. Recovery of nerve function is more likely with a mild injury and a shorter duration of compression. Recovery is faster if the repetitive activities that exacerbate the injury can be decreased or ceased. Initial treatment for many nerve injuries is nonsurgical.

Traumatic brachiocephalic pseudoaneurysm presenting as stroke in a seventeen-year-old.

Kanwar M, Desai D, Joumaa M, Guduguntla V. Clinical Cardiology, 32(11):E43-5, 2009.

Division of Cardiology, Department of Medicine, St. John Hospital and Medical Center, 22151 Moross Road, Suite 126 Detroit, MI 48236, USA.

We present a 17-y-old male who presented to the emergency room with left arm weakness along with slurred speech. On physical examination, he had stable vital signs with left facial weakness suggestive of lower motor neuron seventh nerve palsy. He was also noted to have a small pulsatile mass in the right infraclavicular region. Further questioning revealed that 3 mo earlier he had suffered blunt chest wall trauma during a football game with fracture-dislocation of the right clavicular head, which was managed conservatively. MRI of the brain showed right frontal cortical changes suggestive of infarct versus vasculitis or edema. Chest CT revealed a 2.5- to 3-cm pseudoaneurysm arising from the brachiocephalic artery, with thrombus formation, along with a surrounding 3 x 4.5 cm hematoma. The patient underwent a successful repair of the pseudoaneurysm with no further neurological sequelae. Traumatic pseudoaneurysm with thrombus formation is an extremely rare cause of stroke. It has been reported in association with the carotid artery, but to our knowledge, this is the first reported case with isolated innominate artery pseudoaneurysm. This case highlights the need for a broad differential when evaluating young patients with neurological deficits.

Walk and die: an unusual presentation of head injury.

Veevers AE, Lawler W, Rutty GN.: Journal of Forensic Sciences, 54(6):1466-9, 2009.

We report three deaths in young adult males following closed blunt trauma to the head and face where the affected individuals were able to walk away from the incident, before subsequently collapsing and dying a short distance from the site of the assault. In each case, due to the rapidity of the posttrauma collapse, the pathologist was faced with a diagnostic difficulty at autopsy; the external examination revealed multiple injuries to the head and face, but internal examinations showed limited findings with no structural explanation for the death. We discuss possible mechanisms that could account for this scenario, the implications of alcohol consumption with a concussive head injury, and parallels that can be drawn with the so-called "talk and die,""talk and deteriorate," and "second impact syndrome." Finally, the possible role of so-called "post-exercise peril" is discussed in relation to these deaths.

Lutfi R, Mullett CJ, Nield LS.: Pediatric emergency care, 25(9):582-3, 2009.Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV 26505, USA.

A 16-year-old adolescent boy presented with headache, dizziness, loss of consciousness, and a tonic-clonic seizure after heading a soccer ball in a competitive match. A computed tomographic scan of the head revealed an acute subdural hematoma with a mass effect. The patient was emergently referred to a tertiary care facility where he eventually recovered completely with conservative care. No predisposing medical conditions were found. To the best of our knowledge, this is the first report of an intracranial hemorrhage secondary to the heading of a soccer ball alone in an otherwise healthy child without any underlying predisposing central nervous system abnormalities.

Health-related quality of life and alternative forms of exercise in Parkinson disease.Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO 63108, USA.Parkinsonism & related disorders, 15(9):644-8, 2009.

Parkinson disease (PD) reduces health-related quality of life (HRQoL), but exercise may improve HRQoL. This pilot study compared the effects of Tango, Waltz/Foxtrot, Tai Chi and No Intervention on HRQoL in individuals with PD. Seventy-five persons with PD (Hoehn and Yahr I-III) were assigned to 20 lessons of Tango, Waltz/Foxtrot, Tai Chi, or an untreated No Intervention group. Participants completed the PDQ-39 before and after participation in 20 classes or within 13 weeks in the case of the No Intervention group. Two-way repeated measures ANOVAs determined differences between interventions. Tango significantly improved on mobility (p=0.03), social support (p=0.05) and the PDQ-39 SI (p<0.01) at post-testing. No significant changes in HRQoL were noted in the Waltz/Foxtrot, Tai Chi or No Intervention. Tango may be helpful for improving HRQoL in PD because it addresses balance and gait deficits in the context of a social interaction that requires working closely with a partner.

Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: Psychometric issues.

The sports concussion note: should SCAT become SCOAT?

Walking speed and distance in different environments of subjects in the later stage post-stroke.

The "swing-ding": a golf-related head injury in children.

Physical activity in young children with cerebral palsy

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion.

Boxing-related head injuries.

Clinics in neurology and neurosurgery–extradural and subdural haematoma (Dez 2010)

Physical activity in young children with cerebral palsy

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion.

Reduced processing speed in rugby union players reporting three or more previous concussions.

Measurement of physical performance and objective fatigability in people with mild-to-moderate traumatic brain injury.

Predicting exercise capacity through submaximal fitness tests in persons with multiple sclerosis.

Predictors of physical performance and functional ability in people 50+ with and without fibromyalgia.

Update on concussion: here's what the experts say.

Effects of various treadmill interventions on the development of joint kinematics in infants with Down syndrome.

Concomitant cranial and lumbar subdural hematomas -case report-.

Hypopituitarism due to Sports related head trauma and the effects of growth hormone replacement in retired amateur boxers.

Gait training with progressive external auditory cueing in persons with Parkinson's disease.

Endurance training and cardiorespiratory conditioning after traumatic brain injury.

Evaluation of a conceptual framework for retraining high-level mobility following traumatic brain injury: two case reports.

Circuit class therapy for improving mobility after stroke.

Evaluation of artificial sweat in athletes with spinal cord injuries.

Reduced muscle power is associated with slower walking velocity and falls in people with Parkinson's disease.

Sport-related concussion in adolescents.

Variability and symmetry of gait in early walkers with and without bilateral cerebral palsy.

Sport is not always healthy: Executive brain dysfunction in professional boxers.

Effects of dance on gait and balance in Parkinson's disease: a comparison of partnered and nonpartnered dance movement.

Walking ability and predictors of performance on the 6-minute walk test in adults with spastic cerebral palsy.

Neuroimaging findings and brain-behavioral correlates in a former boxer with chronic traumatic brain injury.

Normative values for three clinical measures of motor performance used in the neurological assessment of sports concussion.

Akathisia after mild traumatic head injury.

Natural history of Charcot-Marie-Tooth 2: 2-year follow-up of muscle strength, walking ability and quality of life.

Measuring deficits in visually guided action post-concussion.

Sinus barotrauma leading to extradural muco-pneumocephalus.

The predicted risk of head injury from fall-related impacts on to third-generation artificial turf and grass soccer surfaces: a comparative biomechanical analysis.

Investigating baseline neurocognitive performance between male and female athletes with a history of multiple concussion.

Neurometabolic changes in the acute phase after sports concussions correlate with symptom severity.

Knee extensor strength, dynamic stability, and functional ambulation: are they related in Parkinson's disease?

Sleep following sport-related concussions.

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions.

Akathisia after mild traumatic head injury.

Natural history of concussion in sport: markers of severity and implications for management.

Measuring deficits in visually guided action post-concussion.

Impact of prior concussions on health-related quality of life in collegiate athletes.

Impact of recurrent head trauma on olfactory function in boxers: a matched pairs analysis.

Sinus barotrauma leading to extradural muco-pneumocephalus.

The predicted risk of head injury from fall-related impacts on to third-generation artificial turf and grass soccer surfaces: a comparative biomechanical analysis.

Table tennis dystonia.

Neurometabolic changes in the acute phase after sports concussions correlate with symptom severity.

Knee extensor strength, dynamic stability, and functional ambulation: are they related in Parkinson's disease?

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Orbital trauma, bradycardia, and vomiting: trapdoor fracture and the oculocardiac reflex: a case report.

Neuromuscular control and exercise-related leg pain in triathletes.

Exercise on a treadmill or walking outdoors? A randomized controlled trial comparing effectiveness of two walking exercise programmes late after stroke.

Repetitive breath-hold diving causes serious brain injury.

The 6-minute walk test as a new outcome measure in Duchenne muscular dystrophy.

Exercise programs improve mobility and balance in people with Parkinson's disease.

Immediate post-concussion assessment and cognitive testing (ImPACT) practices of sports medicine professionals.

Advances in sport concussion assessment: from behavioral to brain imaging measures.

Incidence, risk, and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players.

Walking economy of adults with Down syndrome.

Effects of treadmill training on walking economy in Parkinson's disease: a pilot study.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete.

Sport concussion assessment tool: baseline values for varsity collision sport athletes

The prevention of catastrophic head and spine injuries in high school and college sports

Sport concussion assessment tool: baseline values for varsity collision sport athletes

The prevention of catastrophic head and spine injuries in high school and college sports

State anxiety and subjective well-being responses to acute bouts of aerobic exercise in patients with depressive and anxiety disorders

Natural history of concussion in sport: markers of severity and implications for management.

Endurance exercise improves walking distance in MS patients with fatigue.

Consensus statement on concussion in sport - the Third International Conference on Concussion in Sport held in Zurich, November 2008.

Physical exercise, aging, and mild cognitive impairment: a population-based study.

Idiopathic intracranial hypertension is associated with lower body adiposity.

Marathon runner's retinopathy.

Peripheral nerve entrapment and injury in the upper extremity.

Traumatic brachiocephalic pseudoaneurysm presenting as stroke in a seventeen-year-old.