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A 17-year-old female high school soccer player presents to the primary care office 5 days after striking the back of her head on the ground during a game. She did not lose consciousness but had a headache and dizziness and had been observed to have a "wobbly" gait as she walked off the field. She has had persisting symptoms (dizziness, nausea, trouble falling asleep, photosensitivity, and headache) that have kept her out of school. She had had a concussion 2 years earlier that took 4 weeks to recover from fully. On examination, her vital signs are normal, but she reports light-headedness on standing. On confrontation visual testing, her eye movements are not smooth, and she has increased dizziness while finger-tracking back and forth slowly across her visual field (smooth-pursuit eye movements). Motion of the cervical neck is painful, with muscle tenderness. During tandem gait testing for balance assessment, in which the patient walks in a straight line with one foot in front of the other, she takes a sidestep multiple times. During a tandem stance test, in which the patient stands with one foot in front of the other, she takes a sidestep four times in a 20-second period. How would you further evaluate and treat this patient? When can she return to school and soccer? [ABSTRACT FROM AUTHOR]

Background/Objective: Assessing Orthostatic Intolerance (OI, symptoms upon standing from supine) is recommended in athletes with sport-related concussions (SRCs), as this is caused by impairments in the cardiovascular autonomic nervous system (cANS). Early Exercise Intolerance (Early EI, symptoms on light physical exertion) is also due to impairments in the cANS but is difficult to incorporate into outpatient clinical practice (cost of personnel, time, equipment). The purpose of this study was to determine if we could use OI to screen for Early EI, as well as understand differences between adolescents who do and do not report OI. Methods: Retrospective chart review. Adolescents with physician-diagnosed SRC performed the 2 min supine to 1 min standing OI test and the Buffalo Concussion Treadmill Test (BCTT) during their first post-SRC visit. Early EI was defined as more-than-mild symptom exacerbation at a heart rate (HR) below 135 bpm on the BCTT; OI was defined as new or increased symptoms of dizziness or lightheadedness on postural change. The sensitivity, specificity and diagnostic accuracy were calculated. Participants with and without OI were compared. Results: In total, 166 adolescents (mean 15.4 years, 58.8% male) were seen a mean of 5.5 days after injury; 48.2% had OI and 52.4% had Early EI, but there was no association between the two measures (Phi = 0.122, p = 0.115). The sensitivity and specificity (with 95% confidence intervals) for OI to screen for Early EI were 54.0% (43.5, 64.3) and 58.2% (47.2, 68.7), respectively. Adolescents with OI had a higher incidence of delayed recovery (24% vs. 9%, p = 0.012). Conclusions: Although both measures seem to be related to impaired autonomic function after SRC, OI has limited accuracy in screening for Early EI, which suggests that their etiologies may be different. Nevertheless, the assessment of OI has clinical utility in the management of SRC. [ABSTRACT FROM AUTHOR]

Objective: There is greater risk of musculoskeletal (MSK) injury after clinical recovery from sport-related concussion (SRC). We determined whether aerobic exercise treatment within 10 days of SRC reduced the proportion of MSK injury in recovered adolescent athletes at 4 months since injury. Design: Planned secondary analysis of a randomized trial of aerobic exercise versus stretching exercise in adolescents after SRC. Setting: Outpatient and hospital-based sports medicine centers. Participants: Aerobic exercise (n 5 38, 58% male, 15.6 years) and stretching exercise (n 5 25, 64% male, 15.9 years) participants completed a questionnaire at 3.5 and 3.3 months since recovery, respectively. Interventions: Individualized subthreshold aerobic exercise versus placebo-like stretching. Main OutcomeMeasures: Proportion of MSK injury, subsequent concussion, and return to exercise training, school, and sport determined 3 months after clinical recovery from SRC. Results: Overall, 24% of participants randomized to stretching experienced an MSK injury versus 5.3% of participants randomized to aerobic exercise. There was no difference in time to return to school, sport, or incidence of subsequent concussion. Stretching participants were 6.4 times (95% confidence interval 1.135-36.053) more likely to sustain MSK injury than aerobic exercise participants when controlling for the duration of exposure to sport and return to preinjury sport participation. All injuries were in male participants. Conclusion: Adolescent male athletes prescribed aerobic exercise within 10 days of SRC had a significantly lower proportion of individuals injured in the 3 months following clinical recovery when compared with stretching. This may be due to a habituation/rehabilitation effect of aerobic activities to improve autonomic, vestibular, and/or oculomotor function after SRC. [ABSTRACT FROM AUTHOR]

Sport‐related concussion (SRC) is associated with cardiovascular autonomic nervous system (ANS) dysfunction. This study examines resting cardiovascular ANS activity in adolescents with SRC compared to controls early post‐injury and after clinical recovery, analyzing its correlation with symptom severity and recovery outcomes. Cardiovascular ANS function was evaluated using heart rate variability (HRV), systolic blood pressure variability (SBPV) and baroreflex sensitivity (BRS). Symptoms were assessed via the Post‐Concussion Symptom Scale, and recovery outcomes were categorized by recovery duration. Following acute SRC, no significant differences in HRV, SBPV or BRS were found between SRC and control groups, nor between those with delayed or normal recovery. Post‐recovery, SRC participants had higher low frequency (LF) SBPV than controls and their initial assessment. When concussed participants were symptomatic, LF SBPV correlated directly with overall, cognitive, and fatigue symptom severity, while high frequency (HF) HRV inversely correlated with affective symptoms (Spearman's rho: 0.4–0.6). Resting cardiovascular ANS function remains unchanged in adolescent athletes acutely after SRC, suggesting it has limited diagnostic and prognostic potential. Although some correlations between individual symptom domains and ANS activity were observed, they were not significantly different from asymptomatic controls, limiting the ability to interpret these findings. [ABSTRACT FROM AUTHOR]

Background: The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown. Objective: Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI‐related symptoms, and BCTT duration. Design: Prospective, observational, longitudinal. Setting: Academic medical center. Participants: Thirty‐seven adults treated in a level 1 trauma center emergency department with mTBI; 24 uninjured controls (UC). Interventions: N/A. Main Measures: Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15‐minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration. Results: Persons with mTBI discontinued earlier than UC at 1‐week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI‐related intolerance was 55.6% at 1 week (36.1% for mTBI‐related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age‐predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI‐related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39–61%) and physical exertion (9–26%). Shorter duration was associated with higher body mass index (r = −0.42 – −0.45), shorter height (r = 0.22–0.29), female gender (r = −0.26 – −0.27), and greater RPQ symptoms (r = −0.28 – ‐0.47). Conclusion: The BCTT exacerbates mTBI‐related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the extracurricular cadaveric dissection program available to medical students at an institution with a modern (time-compressed, student-centered, and prosection-based) approach to medical anatomy education. Quantitative (Likert-style questions) and qualitative data (thematic analysis of open-ended commentary) were collated from a survey of three medical student cohorts who had completed preclerkship. Perceived benefits of dissection included the hands-on learning style and the development of anatomy expertise, while the main barrier that limited participation was the time-intensive nature of dissection. Despite perceived benefits, students preferred that dissection remain optional. Analysis of assessments for the MD2016 cohort revealed that dissection participation was associated with enhanced performance on anatomy items in each systems-based unit examination, with the largest benefits observed on discriminating items that assessed knowledge application. In conclusion, this study revealed that there are academic and perceived benefits of extracurricular participation in dissection. While millennial medical students recognized these benefits, these students also indicated strong preference for having flexibility and choice in their anatomy education, including the choice to participate in cadaveric dissection.

The purpose of this study was to compare student perceptions regarding two, small group learning approaches to compressed (46.5 prosection-based laboratory hours), integrated anatomy education at the University of Ottawa medical program. In the facilitated active learning (FAL) approach, tutors engage students and are expected to enable and balance both active learning and progression through laboratory objectives. In contrast, the emphasized independent learning (EIL) approach stresses elements from the "flipped classroom" educational model: prelaboratory preparation, independent laboratory learning, and limited tutor involvement. Quantitative (Likert-style questions) and qualitative data (independent thematic analysis of open-ended commentary) from a survey of students who had completed the preclerkship curriculum identified strengths from the EIL (promoting student collaboration and communication) and FAL (successful progression through objectives) approaches. However, EIL led to student frustration related to a lack of direction and impaired completion of objectives, whereas active learning opportunities in FAL were highly variable and dependent on tutor teaching style. A "hidden curriculum" was also identified, where students (particularly EIL and clerkship students) commonly compared their compressed anatomy education or their anatomy learning environment with other approaches. Finally, while both groups highly regarded the efficiency of prosection-based learning and expressed value for cadaveric-based learning, student commentary noted that the lack of grade value dedicated to anatomy assessment limited student accountability. This study revealed critical insights into small group learning in compressed anatomy education, including the need to balance student active learning opportunities with appropriate direction and feedback (including assessment).