NMDA Receptors and the Working Memory

Posted 22 July 2014 by prehab

The Dorsolateral prefrontal cortex (dlPFC) is responsible for executive functions including working memory, cognitive flexibility, planning, inhibition and abstract reasoning. There has been extensive research of studies on glutamate receptor mechanisms underlying classic neuroplasticity, but few on NMDA receptors mediating the recurrent excitatory circuits underlying working memory in the dlPFC. This is significant to aging and Alzheimer’s because of the decline in expression of NMDA receptors in the dlPFC could be related to impaired cognition. To reach further see article.

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Oculomotor Control and Balance Post-Concussion

Posted 2 July 2014 by prehab

Vestibular dysfunction post-concussion could be a major cause of balance disturbances. This study compares athletes post-concussion, athletes without a history of concussions and their oculomotor control during postural control. Athletes post-concussion had a reduced ability to stabilize a fixed eye position during balance testing. See attached study

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High-altitude induced haemodynamic effects

Posted 5 June 2014 by prehab

The change in pressure of being in high-altitude has traditionally had a hypoxic effect. A study was done to look at the physiological effects of high elevation over a three-day period. The decrease in oxygen was found to lead to a significant increase in diastolic blood pressure (DBP) and mean arterial blood pressure that persisted from immediate exposure and continued over three days. See attached study. The altitude-induced haemodynamic changes on high-altitude UT pilots could also possibly be linked to the presence of white matter hyperintensities (WMHs) or unspecified brain lesions.  See attached study.

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Current state of diagnostic testing in concussion management

Posted 2 February 2014 by prehab

Returning an athlete to the game should imply that who ever made the decision fully understands the nuances of the concussion. 

There are many ways we collect quantitative information that gets us closer to understanding the areas affected after brain injury. The information however needs to be interpreted and understood well to determine the type of rehabilitation that well assists injured individuals on returning their brain to pre injury state. In this attached manuscript, we are reviewing the state of concussion testing, diagnostic rating scales and tools available to identify the nuances of concussions. At Concussion Management of New York we are clinician rather than test centered. We utilize these tools collectively or individually when most appropriate.

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Lasting effects after mild concussions

Posted 22 November 2013 by prehab

Abnormal brain structural patterns persist months after clinical symptoms had resolved from a mild concussion researchers found at the Lovelace Biomedical and Environmental Research Institute in Albuquerque, N.M.

Dr. Mayer and colleagues examined the underlying pathophysiology of mild traumatic brain injury through changes in gray matter diffusion and atrophy during the semiacute stage and found evidence that structural changes persist long past the improvement in neuropsychological tests. In a study that involved 50 participants, 26 patients showed evidence of increased cortical gray matter anisotropic diffusion 4 months post injury.

See full study

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Traumatic-Triggered Migraines vs Concussions

Posted 17 November 2013 by prehab

Family history of migraines is a precursor to headaches in children and as per studies cited bellow, head trauma and concussions may increase the length of headaches and complicate treatment. The question is: are Traumatic-Triggered Migraines (TTM’s) different than headaches as a concussive characteristic? and should they be treated differently? The case study referenced by Lords, Q reported in Sports Health Multidisciplinary App.(Traumatic Migraine Versus Concussion: A Case Report.)   presented a different look at their diagnosis and treatment approach.  This report instead of actually  separating them apart it may be pointing out how related they are or that one is part of the other. Headaches post injury may be more or less severe, longer lasting and have a genetic component but should be dealt with in the contest of brain injury. The word “Concussion” can at this time, after it became a popular word in sports, complicate how we deal with it. Because concussions have the sports connotation is easy to fall into the trap of making us follow the light path others have taken and skip important steps toward treatment. In the brain injury world, per say, I can relate to the stance of wanting to distance ourselves from what the word “concussion” is becoming and try to separate its components, such as headaches, and give it another name as it clearly happens in the cited article. For example in this study the author seem to attempt to separate the diagnosis between what a concussion is and what traumatic related headaches or migraines are. Headaches and migraines most times are components of a concussion were its nature, historic and genetic component challenges current diagnosis and treatment methods.

Have you dealt with headaches and/or migraines pre and post injury? Can you separate them and what approaches have you tried with or without success?

Click for referenced studies here…

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Headache medications may worsen headaches after concussions

Posted 11 November 2013 by prehab

There are many instances in which athletes present with chronic headaches post concussion. Some of them with history of migraines trigger an aggressive approach from some pediatricians. Family history of migraines, for example, increases the possibility of developing migraines and that may trigger a closer look at the benefits of headache medication. In most instants analgesics are indicated but in some times overuse of pain medication may cause the syndrome to worsen. Dr. Geoffrey Heyer, MD reports in his study presented as an abstract, here referenced, headache medications may worsen headaches after concussions and may cause chronification of a headache syndrome.

Have you had any experience in this regard? Anecdotes? How did it resolve?

Source reference: Heyer G, et al “Analgesic overuse contributes to chronic post –traumatic headaches in adolescent concussion patients: CNS 2013; Abstract 113

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Group baseline test administration is less reliable than individual assessments study shows

Posted 6 November 2013 by prehab

by Alex Gometz, DPT, CIC

A recent study finds group approaches to baselines are less reliable. This study is a cohort comparison evaluating the differences in results in skills assessed during neurocognitive baseline testing in groups of athletes versus individualized approaches. Decreased performance was demonstrated in the group setting, in which test takers scored significantly lower on verbal memory and exhibited a greater rate of invalid baselines.

The above referenced study brings to lite the importance of a sound clinical evaluation by healthcare professionals who are most appropriate to make the best use of current evaluating tools. It is, or it should be, common knowledge that a baseline test is important to guiding post injury recovery, and for it to be true it has to be done correctly in conjunction with any other tools available. In many instances, the focus has been on the test performed rather than the clinician’s ability to administer it for best results.

It makes sense therefore to stay away from group assessments due to the expected lack of individualization of the assessment and therefore increased chance of inaccuracies. A study may not have been needed to make that point. It is obvious that the less attention to detail the less accuracy of the information collected.

Head injuries may happen in different environments and when they happen in sports setting they shouldn’t take a lighter approach at any stage weather it is a baseline or management post injury. There may be more benefits realized when left to health care professionals with experience and licensed to deal with the assessment and rehabilitation of brain injury from the beginning to end of the process.

See copy of the study referenced…

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Should we manage male and female concussions differently? Is it that simple?

Posted 6 October 2013 by prehab

It is no new information that male and female brains are different. There is plenty of evidence in the literature identifying those differences in male and female brains. It is also fact that there are differences in their rate of injury and rate of recovery, so why don’t we treat them differently? Here is a review to recent articles and studies reviewed by Dr. Esopenko shedding some light to the controversial subject.

Reed bellow and feel free to participate in the discussion. Click on the bubble or scroll down. I moderate for inappropriate content.

Males and Females brains are different, so why are we not managing their concussions differently?

Carrie Esopenko, PhD

A key aspect of concussion management is the proper assessment and treatment of the injury. We have long known that there are sex-specific differences in brain development and function, and we now know that there are sex-specific differences in how the brain responds to injury. This means that males and females are affected differently by concussion exposure and experience. In their review, Covassin and colleagues (2013) discuss a number of studies highlighting the differences in concussion prevalence (or number) and reported symptoms in male and female athletes. For example, female athletes report a greater number postconcussion symptoms (e.g., concentration problems, fatigue) and these symptoms tend to take longer to resolve as compared to male athletes (Broshek et al., 2005; Covassin et al., 2012). Studies have also shown that male and female athletes perform differently on cognitive tests following concussion (see Covassin et al., 2013 for a review). For instance, female athletes tend to demonstrate more difficulties on tasks assessing visual memory and reaction time following a concussion as compared to male athletes (Broshek et al., 2005; Covassin et al., 2012; 2013; Colvin et al., 2009), although it should be noted that some follow-up studies have failed to replicate these sex-specific differences (see Zuckerman et al., 2012).  It is thought that the functional differences between male and female athletes following concussion could be due to sex hormones, neuroanatomy, and blood flow in the brain (see Covassin et al., 2013 for a review). Given these noted differences, it makes sense to develop concussion management strategies that are sex-specific. However, because of the lack in understanding and research into differences in reported symptoms, functional abilities, and recovery for males and females following concussion, concussion management techniques are not currently tailored to the male and female brain. As concussion management specialists, we should be developing assessment and rehabilitation strategies that are tailored to issues specific to males and females. If we are able to accomplish this, I predict that this would lead to more sensitive assessment techniques for males and females, as well as better management of these injuries.

See full study by Covassin and colleagues for a review of sex-differences in the concussion management for male and female athletes:

Covassin, T., Elbin, R. J., Crutcher, B., & Burkhart, S. (2013). The management of sport-related concussion: Considerations for Male and Female Athletes.  Translational Stroke Research, 4, 420-424.

Other interesting studies on sex differences and concussion outcomes:

Broshek DK, et al. (2005). Sex differences in outcome following sports related concussion. J Neurosurgery, 102(5), 856–63.

Covassin, T., Elbin, R. J,, Harris, W., Parker, T., & Kontos A. (2012). The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after concussion. Am J Sports Med,40(6), 1303-12.

Colvin, A. C., Mullen, J., Lovell, M. R. West, R. V., Collins, M. W., & Groh, M. (2009). The Role of Concussion History and Gender in Recovery From Soccer-Related Concussion. Am J Sports Med37(9), 1699-1704.

Zuckerman, S. L., Solomon, G. S., Forbes, J. A., Haase, R. F., Sills, A. K., & Lovell, M. R. (2012). Response to acute concussive injury in soccer players: Is gender a modifying factor? Journal of Neurosurg Pediatrics,10, 504–510. 

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The North Park Hockey League teams up with Concussion Management of NY

Posted 3 October 2013 by prehab

The North Park Hockey League feels it is vital to do what is best for the athletes and at this time is recommending concussion baseline testing before each season. With the recent focus on the negative effects of concussions on the long-term health of athletes, especially of those athletes in the most physical contact sports like hockey, they felt if was time to team up with a company that delivers the most reliable test procedure. The North Park Hockey League is one step up relying on brain injury experts with no ties to one test but what is best for each individual from baseline testing, clinical assessments and management at Concussion Management of New York.

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