Download PDF
Semin Neurol 2021; 41(02): 124-131
DOI: 10.1055/s-0041-1725134
Review Article

Rehabilitation of Concussion and Persistent Postconcussive Symptoms

Charles G. Wilber
1   Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
,
John J. Leddy
1   Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
,
Itai Bezherano
1   Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
,
Lacey Bromley
2   Department of Physical Therapy, School of Health Professions, D'Youville College, Buffalo, New York
3   Bennett Rehabilitation Institute, Buffalo, New York
,
Amanda E. Edwards
4   UB Counseling Services, Department of Athletics, State University of New York at Buffalo, Buffalo, New York
,
Barry S. Willer
5   Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
,
Mohammad N. Haider
1   Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, UBMD, State University of New York at Buffalo, Buffalo, New York
6   PhD Program in Biomedical Science, Program of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies.

Keywords

concussion - persistent post concussion symptoms - post-concussion syndrome - cervicogenic headache - active rehabilitation

Financial Support and Sponsorship/Funding

Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (NIH) under award number 1R01NS094444 and the National Center for Advancing Translational Sciences of the NIH under award number UL1TR001412 to the University at Buffalo, State University of New York . The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.




Publication History

Article published online:
04 March 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Signoretti S, Lazzarino G, Tavazzi B, Vagnozzi R. The pathophysiology of concussion. PM R 2011; 3 (10) (Suppl. 02) S359-S368
    CrossrefPubMedGoogle Scholar
  • 2 Choe MC. The pathophysiology of concussion. Curr Pain Headache Rep 2016; 20 (06) 42
    CrossrefPubMedGoogle Scholar
  • 3 Arbogast KB, Curry AE, Pfeiffer MR. et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatr 2016; 170 (07) e160294-e160294
    CrossrefPubMedGoogle Scholar
  • 4 McCrory P, Meeuwisse W, Dvořák J. et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51 (11) 838-847
    PubMedGoogle Scholar
  • 5 Grool AM, Aglipay M, Momoli F. et al; Pediatric Emergency Research Canada (PERC) Concussion Team. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 2016; 316 (23) 2504-2514
    CrossrefPubMedGoogle Scholar
  • 6 Jotwani V, Harmon KG. Postconcussion syndrome in athletes. Curr Sports Med Rep 2010; 9 (01) 21-26
    CrossrefPubMedGoogle Scholar
  • 7 Prigatano GP, Gale SD. The current status of postconcussion syndrome. Curr Opin Psychiatry 2011; 24 (03) 243-250
    CrossrefPubMedGoogle Scholar
  • 8 Iverson GL, Lange RT. Post-concussion syndrome. In: Schoenberg MR, Scott JG. eds. The Little Black Book of Neuropsychology. Springer; 2011: 745-763
    CrossrefGoogle Scholar
  • 9 Arciniegas DB, Anderson CA, Topkoff J, McAllister TW. Mild traumatic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatr Dis Treat 2005; 1 (04) 311-327
    PubMedGoogle Scholar
  • 10 Haider MN, Leddy JJ, Pavlesen S. et al. A systematic review of criteria used to define recovery from sport-related concussion in youth athletes. Br J Sports Med 2018; 52 (18) 1179-1190
    CrossrefPubMedGoogle Scholar
  • 11 Asken BM, Snyder AR, Clugston JR, Gaynor LS, Sullan MJ, Bauer RM. Concussion-like symptom reporting in non-concussed collegiate athletes. Arch Clin Neuropsychol 2017; 32 (08) 963-971
    CrossrefPubMedGoogle Scholar
  • 12 Zasler ND. Post-traumatic sensory disorders in TBI. In: Arcineigas D, Vanderploeg R, Zasler ND, Jaffee MS. eds. Management of Adults with Traumatic Brain Injury. American Psychiatric Publishing, Inc.; 2013
    Google Scholar
  • 13 Hammond FM, Masel B. Cranial nerve disorders. In: Zasler N, Katz D, Zafonte R. eds. Brain Injury Medicine: Principles and Practice. 2nd ed.. Demos Medical Publishing; 2012
    Google Scholar
  • 14 Sady MD, Vaughan CG, Gioia GA. Psychometric characteristics of the postconcussion symptom inventory in children and adolescents. Arch Clin Neuropsychol 2014; 29 (04) 348-363
    CrossrefPubMedGoogle Scholar
  • 15 Haider MN, Leddy JJ, Du W, J Macfarlane A, Viera KB, Willer BS. Practical management: brief physical examination for sport-related concussion in the outpatient setting. Clin J Sport Med 2018; DOI: 10.1097/JSM.0000000000000687. (epub ahead of print)
    CrossrefPubMedGoogle Scholar
  • 16 Haider MN, Leddy JJ, Wilber CG. et al. The predictive capacity of the Buffalo Concussion Treadmill Test after sport-related concussion in adolescents. Front Neurol 2019; 10: 395
    CrossrefPubMedGoogle Scholar
  • 17 Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R. Test-retest reliability of computerized concussion assessment programs. J Athl Train 2007; 42 (04) 509-514
    PubMedGoogle Scholar
  • 18 Matuszak JM, McVige J, McPherson J, Willer B, Leddy J. A practical concussion physical examination toolbox. Sports Health 2016; 8 (03) 260-269
    CrossrefPubMedGoogle Scholar
  • 19 Len TK, Neary JP. Cerebrovascular pathophysiology following mild traumatic brain injury. Clin Physiol Funct Imaging 2011; 31 (02) 85-93
    PubMedGoogle Scholar
  • 20 La Fountaine MF, Heffernan KS, Gossett JD, Bauman WA, De Meersman RE. Transient suppression of heart rate complexity in concussed athletes. Auton Neurosci 2009; 148 (1-2): 101-103
    CrossrefPubMedGoogle Scholar
  • 21 Acharya UR, Joseph KP, Kannathal N, Min LC, Suri JS. Heart rate variability. In: Advances in Cardiac Signal Processing. Springer; 2007: 121-165
    Google Scholar
  • 22 Hutchison MG, Mainwaring L, Senthinathan A, Churchill N, Thomas S, Richards D. Psychological and physiological markers of stress in concussed athletes across recovery milestones. J Head Trauma Rehabil 2017; 32 (03) E38-E48
    CrossrefPubMedGoogle Scholar
  • 23 Abaji JP, Curnier D, Moore RD, Ellemberg D. Persisting effects of concussion on heart rate variability during physical exertion. J Neurotrauma 2016; 33 (09) 811-817
    CrossrefPubMedGoogle Scholar
  • 24 Senthinathan A, Mainwaring LM, Hutchison M. Heart rate variability of athletes across concussion recovery milestones: a preliminary study. Clin J Sport Med 2017; 27 (03) 288-295
    CrossrefPubMedGoogle Scholar
  • 25 Kamins J, Bigler E, Covassin T. et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med 2017; 51 (12) 935-940
    CrossrefPubMedGoogle Scholar
  • 26 Fife TD, Giza C. Posttraumatic vertigo and dizziness. Semin Neurol 2013; 33 (03) 238-243
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Kozlowski KF, Graham J, Leddy JJ, Devinney-Boymel L, Willer BS. Exercise intolerance in individuals with postconcussion syndrome. J Athl Train 2013; 48 (05) 627-635
    CrossrefPubMedGoogle Scholar
  • 28 Silver JM, McAllister TW, Archiniegas DB. Textbook of Traumatic Brain Injury. 3rd ed.. American Psychiatric Pub; 2019
    Google Scholar
  • 29 Von Noorden G, Campos E. Physiology of the ocular movements. Binocular Vision and Ocular Motility: Theory and Management of Strabismus. 6th ed.. St Louis: Mosby; 2002: 52-84
    Google Scholar
  • 30 Master CL, Scheiman M, Gallaway M. et al. Vision diagnoses are common after concussion in adolescents. Clin Pediatr (Phila) 2016; 55 (03) 260-267
    CrossrefPubMedGoogle Scholar
  • 31 Ventura RE, Balcer LJ, Galetta SL. The neuro-ophthalmology of head trauma. Lancet Neurol 2014; 13 (10) 1006-1016
    CrossrefPubMedGoogle Scholar
  • 32 Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed 2015; 43 (03) 274-284
    CrossrefPubMedGoogle Scholar
  • 33 Rice SM, Parker AG, Rosenbaum S, Bailey A, Mawren D, Purcell R. Sport-related concussion and mental health outcomes in elite athletes: a systematic review. Sports Med 2018; 48 (02) 447-465
    CrossrefPubMedGoogle Scholar
  • 34 McCrory P, Meeuwisse WH, Aubry M. et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47 (05) 250-258
    CrossrefPubMedGoogle Scholar
  • 35 Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery 2014; 75 (04) (Suppl. 04) S24-S33
    CrossrefPubMedGoogle Scholar
  • 36 Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed physical exertion in recovery from sports-related concussion: a randomized pilot study. Dev Neuropsychol 2015; 40 (05) 273-278
    CrossrefPubMedGoogle Scholar
  • 37 Majerske CW, Mihalik JP, Ren D. et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008; 43 (03) 265-274
    CrossrefPubMedGoogle Scholar
  • 38 Leddy JJ, Haider MN, Ellis MJ. et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr 2019; 173 (04) 319-325
    CrossrefPubMedGoogle Scholar
  • 39 Leddy JJ, Haider MN, Hinds AL, Darling S, Willer BS. A preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males. Clin J Sport Med 2019; 29 (05) 353-360
    CrossrefPubMedGoogle Scholar
  • 40 Gauvin-Lepage J, Friedman D, Grilli L. et al. Effectiveness of an exercise-based active rehabilitation intervention for youth who are slow to recover after concussion. Clin J Sport Med 2018; DOI: 10.1097/JSM.0000000000000634. (epub ahead of print)
    CrossrefPubMedGoogle Scholar
  • 41 Micay R, Richards D, Hutchison MG. Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study. BMJ Open Sport Exerc Med 2018; 4 (01) e000404
    CrossrefPubMedGoogle Scholar
  • 42 Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One 2018; 13 (04) e0196062
    CrossrefPubMedGoogle Scholar
  • 43 Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc 2011; 86 (09) 876-884
    CrossrefPubMedGoogle Scholar
  • 44 Coupé M, Fortrat JO, Larina I, Gauquelin-Koch G, Gharib C, Custaud MA. Cardiovascular deconditioning: from autonomic nervous system to microvascular dysfunctions. Respir Physiol Neurobiol 2009; 169 (Suppl. 01) S10-S12
    CrossrefPubMedGoogle Scholar
  • 45 Tan CO, Meehan III WP, Iverson GL, Taylor JA. Cerebrovascular regulation, exercise, and mild traumatic brain injury. Neurology 2014; 83 (18) 1665-1672
    CrossrefPubMedGoogle Scholar
  • 46 Erickson KI, Voss MW, Prakash RS. et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 2011; 108 (07) 3017-3022
    CrossrefPubMedGoogle Scholar
  • 47 Stroth S, Hille K, Spitzer M, Reinhardt R. Aerobic endurance exercise benefits memory and affect in young adults. Neuropsychol Rehabil 2009; 19 (02) 223-243
    CrossrefPubMedGoogle Scholar
  • 48 Griffin EW, Mullally S, Foley C, Warmington SA, O'Mara SM, Kelly AM. Aerobic exercise improves hippocampal function and increases BDNF in the serum of young adult males. Physiol Behav 2011; 104 (05) 934-941
    CrossrefPubMedGoogle Scholar
  • 49 Griesbach GS, Tio DL, Vincelli J, McArthur DL, Taylor AN. Differential effects of voluntary and forced exercise on stress responses after traumatic brain injury. J Neurotrauma 2012; 29 (07) 1426-1433
    CrossrefPubMedGoogle Scholar
  • 50 Morin M, Langevin P, Fait P. Cervical spine involvement in mild traumatic brain injury: a review. J Sports Med (Hindawi Publ Corp) 2016; 2016: 1590161
    PubMedGoogle Scholar
  • 51 Leddy JJ, Baker JG, Merchant A. et al. Brain or strain? Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury. Clin J Sport Med 2015; 25 (03) 237-242
    CrossrefPubMedGoogle Scholar
  • 52 Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Inj 2015; 29 (02) 238-248
    CrossrefPubMedGoogle Scholar
  • 53 Luedtke K, Boissonnault W, Caspersen N. et al. International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: a Delphi study. Man Ther 2016; 23: 17-24
    CrossrefPubMedGoogle Scholar
  • 54 Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Man Ther 2008; 13 (01) 2-11
    CrossrefPubMedGoogle Scholar
  • 55 Schneider KJ, Leddy JJ, Guskiewicz KM. et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017; 51 (12) 930-934
    CrossrefPubMedGoogle Scholar
  • 56 Klatt BN, Carender WJ, Lin CC. et al. A conceptual framework for the progression of balance exercises in persons with balance and vestibular disorders. Phys Med Rehabil Int 2015; 2 (04) 1044
    PubMedGoogle Scholar
  • 57 McCrea M, Randolph C, Kelly J. Standardized Assessment of Concussion (SAC): Manual for Administration, Scoring and Interpretation. Waukesha, WI: CNS. Inc;; 2000: 2
    Google Scholar
  • 58 McCrea M, Kelly JP, Randolph C. et al. Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete. J Head Trauma Rehabil 1998; 13 (02) 27-35
    CrossrefPubMedGoogle Scholar
  • 59 Lovell MR. Neuropsychological assessment of the professional athlete. Sports Neuropsychology 2006; 176-190
    PubMedGoogle Scholar
  • 60 Beck AT, Steer RA, Brown GK. Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996
    Google Scholar
  • 61 Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56 (06) 893-897
    CrossrefPubMedGoogle Scholar
  • 62 Connery AK, Peterson RL, Baker DA, Randolph C, Kirkwood MW. The role of neuropsychological evaluation in the clinical management of concussion. Phys Med Rehabil Clin N Am 2016; 27 (02) 475-486
    CrossrefPubMedGoogle Scholar
  • 63 Brassil HE, Salvatore AP. The frequency of post-traumatic stress disorder symptoms in athletes with and without sports related concussion. Clin Transl Med 2018; 7 (01) 25
    CrossrefPubMedGoogle Scholar
  • 64 Silverberg ND, Hallam BJ, Rose A. et al. Cognitive-behavioral prevention of postconcussion syndrome in at-risk patients: a pilot randomized controlled trial. J Head Trauma Rehabil 2013; 28 (04) 313-322
    CrossrefPubMedGoogle Scholar
  • 65 Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol 2006; 21 (01) 91-99
    CrossrefPubMedGoogle Scholar
  • 66 Gualtieri CT, Johnson LG. Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs. Arch Clin Neuropsychol 2006; 21 (07) 623-643
    CrossrefPubMedGoogle Scholar
  • 67 Sellbom M, Graham JR, Schenk PW. Incremental validity of the MMPI-2 Restructured Clinical (RC) scales in a private practice sample. J Pers Assess 2006; 86 (02) 196-205
    CrossrefPubMedGoogle Scholar
  • 68 Morey LC. Personality Assessment Inventory (PAI): Professional Manual. 2nd ed.. Odessa, FL: Psychological Assessment Resources; 2007
    Google Scholar
  • 69 Slavin-Mulford J, Sinclair SJ, Stein M, Malone J, Bello I, Blais MA. External validity of the personality assessment inventory (PAI) in a clinical sample. J Pers Assess 2012; 94 (06) 593-600
    CrossrefPubMedGoogle Scholar
  • 70 Snyder JJ, Elhai JD, North TC, Heaney CJ. Reliability and validity of the Trauma Symptom Inventory with veterans evaluated for posttraumatic stress disorder. Psychiatry Res 2009; 170 (2-3): 256-261
    CrossrefPubMedGoogle Scholar
  • 71 Briere J, Agee E, Dietrich A. Cumulative trauma and current posttraumatic stress disorder status in general population and inmate samples. Psychol Trauma 2016; 8 (04) 439-446
    CrossrefPubMedGoogle Scholar
  • 72 Meehan III WP. Medical therapies for concussion. Clin Sports Med 2011; 30 (01) 115-124 , ix
    CrossrefPubMedGoogle Scholar
  • 73 Reddy CC, Collins M, Lovell M, Kontos AP. Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. J Head Trauma Rehabil 2013; 28 (04) 260-265
    CrossrefPubMedGoogle Scholar
  • 74 Williams SE, Ris MD, Ayyangar R, Schefft BK, Berch D. Recovery in pediatric brain injury: is psychostimulant medication beneficial?. J Head Trauma Rehabil 1998; 13 (03) 73-81
    CrossrefPubMedGoogle Scholar
  • 75 Plenger PM, Dixon CE, Castillo RM, Frankowski RF, Yablon SA, Levin HS. Subacute methylphenidate treatment for moderate to moderately severe traumatic brain injury: a preliminary double-blind placebo-controlled study. Arch Phys Med Rehabil 1996; 77 (06) 536-540
    CrossrefPubMedGoogle Scholar
  • 76 Pangilinan PH, Giacoletti-Argento A, Shellhaas R, Hurvitz EA, Hornyak JE. Neuropharmacology in pediatric brain injury: a review. PM R 2010; 2 (12) 1127-1140
    CrossrefPubMedGoogle Scholar
  • 77 Hinds A, Jungquist CR, Leddy JJ, Seemant F, Baker JG, Willer B. Sleep disturbance in patients with chronic concussive effects. Concussion 2016; 1 (03) CNC15
    CrossrefPubMedGoogle Scholar
  • 78 Jaffee MS, Winter WC, Jones CC, Ling G. Sleep disturbances in athletic concussion. Brain Inj 2015; 29 (02) 221-227
    CrossrefPubMedGoogle Scholar
  • 79 Kemp S, Biswas R, Neumann V, Coughlan A. The value of melatonin for sleep disorders occurring post-head injury: a pilot RCT. Brain Inj 2004; 18 (09) 911-919
    CrossrefPubMedGoogle Scholar
  • 80 Zeitzer JM, Friedman L, O'Hara R. Insomnia in the context of traumatic brain injury. J Rehabil Res Dev 2009; 46 (06) 827-836
    CrossrefPubMedGoogle Scholar
  • 81 Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. J Rehabil Res Dev 2009;46(06): CP1–68
    Google Scholar
  • 82 Ontario Neurotrauma Foundation. Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms: For Adults (18+ Years of Age). Ontario Neurotrauma Foundation; 2013
    Google Scholar
  • 83 Register-Mihalik JK, Vander Vegt CB, Cools M, Carnerio K. Factors associated with sport-related post-concussion headache and opportunities for treatment. Curr Pain Headache Rep 2018; 22 (11) 75
    CrossrefPubMedGoogle Scholar
  • 84 Petrelli T, Farrokhyar F, McGrath P. et al. The use of ibuprofen and acetaminophen for acute headache in the postconcussive youth: a pilot study. Paediatr Child Health 2017; 22 (01) 2-6
    CrossrefPubMedGoogle Scholar
  • 85 Trojian TH, Wang DH, Leddy JJ. Nutritional supplements for the treatment and prevention of sports-related concussion-evidence still lacking. Curr Sports Med Rep 2017; 16 (04) 247-255
    CrossrefPubMedGoogle Scholar
  • 86 Bailes JE, Mills JD. Docosahexaenoic acid reduces traumatic axonal injury in a rodent head injury model. J Neurotrauma 2010; 27 (09) 1617-1624
    CrossrefPubMedGoogle Scholar
  • 87 Wu A, Ying Z, Gomez-Pinilla F. Dietary omega-3 fatty acids normalize BDNF levels, reduce oxidative damage, and counteract learning disability after traumatic brain injury in rats. J Neurotrauma 2004; 21 (10) 1457-1467
    CrossrefPubMedGoogle Scholar
  • 88 Xu GZ, Wang MD, Liu KG, Bai YA, Wu W, Li W. A meta-analysis of treating acute traumatic brain injury with calcium channel blockers. Brain Res Bull 2013; 99: 41-47
    CrossrefPubMedGoogle Scholar
  • 89 Barrett EC, McBurney MI, Ciappio ED. ω-3 fatty acid supplementation as a potential therapeutic aid for the recovery from mild traumatic brain injury/concussion. Adv Nutr 2014; 5 (03) 268-277
    CrossrefPubMedGoogle Scholar
  • 90 Eakin K, Baratz-Goldstein R, Pick CG. et al. Efficacy of N-acetyl cysteine in traumatic brain injury. PLoS One 2014; 9 (04) e90617
    CrossrefPubMedGoogle Scholar
  • 91 Dessy AM, Rasouli J, Yuk F, Choudhri TF. Second impact syndrome: a rare, devastating consequence of repetitive concussions. Contemp Neurosurg 2015; 37 (20) 1-5
    CrossrefPubMedGoogle Scholar
  • 92 Dean PJ, O'Neill D, Sterr A. Post-concussion syndrome: prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj 2012; 26 (01) 14-26
    CrossrefPubMedGoogle Scholar
  • 93 Lovell MR, Pardini JE, Welling J. et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes. Neurosurgery 2007; 61 (02) 352-359 , discussion 359–360
    CrossrefPubMedGoogle Scholar
  • 94 Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics 2012; 129 (01) 28-37
    CrossrefPubMedGoogle Scholar
  • 95 Slobounov S, Sebastianelli W, Hallett M. Residual brain dysfunction observed one year post-mild traumatic brain injury: combined EEG and balance study. Clin Neurophysiol 2012; 123 (09) 1755-1761
    CrossrefPubMedGoogle Scholar