Burke Rehabilitation Hospital

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3
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\nThe new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous 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. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level.

OBJECTIVE: Cerebral concussion is common in collision sports such as football, yet the chronic neurological effects of recurrent concussion are not well understood. The purpose of our study was to investigate the association between previous head injury and the likelihood of developing mild cognitive impairment (MCI) and Alzheimer's disease in a unique group of retired professional football players with previous head injury exposure. METHODS: A general health questionnaire was completed by 2552 retired professional football players with an average age of 53.8 (+/-13.4) years and an average professional football playing career of 6.6 (+/- 3.6) years. A second questionnaire focusing on memory and issues related to MCI was then completed by a subset of 758 retired professional football players (> or = 50 yr of age). Results on MCI were then cross-tabulated with results from the original health questionnaire for this subset of older retirees. RESULTS: Of the former players, 61% sustained at least one concussion during their professional football career, and 24% sustained three or more concussions. Statistical analysis of the data identified an association between recurrent concussion and clinically diagnosed MCI (chi = 7.82, df = 2, P = 0.02) and self-reported significant memory impairments (chi = 19.75, df = 2, P = 0.001). Retired players with three or more reported concussions had a fivefold prevalence of MCI diagnosis and a threefold prevalence of reported significant memory problems compared with retirees without a history of concussion. Although there was not an association between recurrent concussion and Alzheimer's disease, we observed an earlier onset of Alzheimer's disease in the retirees than in the general American male population. CONCLUSION: Our findings suggest that the onset of dementia-related syndromes may be initiated by repetitive cerebral concussions in professional football players.

OBJECTIVE: Cerebral concussion is common in collision sports such as football, yet the chronic neurological effects of recurrent concussion are not well understood. The purpose of our study was to investigate the association between previous head injury and the likelihood of developing mild cognitive impairment (MCI) and Alzheimer's disease in a unique group of retired professional football players with previous head injury exposure. METHODS: A general health questionnaire was completed by 2552 retired professional football players with an average age of 53.8 (±13.4) years and an average professional football playing career of 6.6 (± 3.6) years. A second questionnaire focusing on memory and issues related to MCI was then completed by a subset of 758 retired professional football players (≥50 yr of age). Results on MCI were then cross-tabulated with results from the original health questionnaire for this subset of older retirees. RESULTS: Of the former players, 61% sustained at least one concussion during their professional football career, and 24% sustained three or more concussions. Statistical analysis of the data identified an association between recurrent concussion and clinically diagnosed MCI (χ2 = 7.82, df = 2, P = 0.02) and self-reported significant memory impairments (χ2 = 19.75, df = 2, P = 0.001). Retired players with three or more reported concussions had a fivefold prevalence of MCI diagnosis and a threefold prevalence of reported significant memory problems compared with retirees without a history of concussion. Although there was not an association between recurrent concussion and Alzheimer's disease, we observed an earlier onset of Alzheimer's disease in the retirees than in the general American male population CONCLUSION: Our findings suggest that the onset of dementia-related syndromes may be initiated by repetitive cerebral concussions in professional football players.

Peer Reviewed

OBJECTIVE: Systematic review of possible long-term effects of sports-related concussion in retired athletes. DATA SOURCES: Ten electronic databases. STUDY SELECTION: 10 years after the injury. DATA EXTRACTION: Study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors. RESULTS: Following review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes. CONCLUSION: Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.

OBJECTIVE: In patients with stroke, the authors tested whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor outcome. METHODS: Fifty-six patients with stroke and hemiparesis or hemiplegia received standard poststroke multidisciplinary rehabilitation, and were randomly assigned either to receive robotic training (at least 25 hours) or exposure to the robotic device without training. Outcomes were assessed by the same masked raters, before treatment began and at the end of treatment, with the upper extremity component of the Fugl-Meyer Motor Assessment, the Motor Status score, the Motor Power score, and Functional Independence Measurement. RESULT: The robot treatment and control group had comparable clinical characteristics, lesion size, and pretreatment impairment scores. By the end of treatment, the robot-trained group demonstrated improvement in motor outcome for the trained shoulder and elbow (Motor Power score, p < 0.001; Motor Status score, p < 0. 01) that did not generalize to untrained wrist and hand. The robot-treated group also demonstrated significantly improved functional outcome (Functional Independence Measurement-Motor, p < 0. 01). CONCLUSION: Robot-delivered quantitative and reproducible sensorimotor training enhanced the motor performance of the exercised shoulder and elbow. The robot-treated group also demonstrated improved functional outcome. When added to standard multidisciplinary rehabilitation, robotics provides novel therapeutic strategies that focus on impairment reduction and improved motor performance.

A 3-oz water swallow test identified 80% (16/20) of patients aspirating during a subsequent videofluoroscopic modified barium swallow examination (sensitivity, 76%; specificity, 59%). It also identified patients with more severe dysphagia aspirating larger amounts (sensitivity, 94%; specificity, 26%) or thicker consistencies (sensitivity, 94%; specificity, 30%) of test material. The 3-oz water swallow test is a sensitive screening tool for identifying patients at risk for clinically significant aspiration who need referral for more definitive modified barium swallow evaluation.

BACKGROUND: We used MIT-Manus, a robot designed to provide interactive, goal-directed motor activity for clinical neurologic applications. OBJECTIVE: To test whether this robotic manipulation of the impaired limb influenced motor recovery in patients with hemiplegia. METHODS: Sequential patients with a history of a single stroke and hemiplegia (N = 20) hospitalized on the same acute care rehabilitation floor were enrolled in a standard rehabilitation program supplemented by either robot-aided therapy or sham robot-aided therapy. These 2 groups were comparable in age, initial physical impairment, and time between onset of the stroke and enrollment in the trial. Patients, clinical team members, and the clinical evaluator were blinded to the treatment group assignments. Standardized assessment tools measured outcomes. RESULTS: Impairment and disability declined in both groups between hospital admission and discharge. The robot-treated group showed a greater degree of improvement in all 3 measures of motor recovery, and the change in motor status measured in the proximal upper limb musculature was significant (P = .002). No adverse events resulted from robot-assisted therapy. CONCLUSIONS: These results suggest that robotic manipulation of the impaired limb may favorably add to recovery following stroke and that robotics may provide new strategies for neurologic rehabilitation.

BACKGROUND: This study investigated the relationship of executive and memory impairment to relapse, recurrence, and course of residual depressive symptoms and signs after remission of geriatric major depression. METHODS: Fifty-eight elderly subjects remitted from major depression received continuation nortriptyline treatment (plasma levels 60-150 ng/mL) for 16 weeks and then were randomly assigned to either nortriptyline maintenance therapy or placebo for up to 2 years. Diagnosis was made using the Research Diagnostic Criteria and the DSM-IV criteria after an interview using the Schedule for Affective Disorders and Schizophrenia. Executive dysfunction and memory were assessed with the Dementia Rating Scale, disability and social support were rated with the Philadelphia Multiphasic Instrument, and medical burden was assessed with the Cumulative Illness Rating Scale. RESULTS: Abnormal initiation and perseveration scores, but not memory impairment, were associated with relapse and recurrence of geriatric depression and with fluctuations of depressive symptoms in the whole group and in subjects who never met criteria for relapse or recurrence during the follow-up period. Memory impairment, disability, medical burden, social support, and history of previous episodes did not significantly influence the outcome of depression in this sample. CONCLUSIONS: Executive dysfunction was found to be associated with relapse and recurrence of geriatric major depression and with residual depressive symptoms. These observations, if confirmed, will aid clinicians in identifying patients in need of vigilant follow-up. The findings of this study provide the rationale for investigation of the role of specific prefrontal pathways in predisposing or perpetuating depressive syndromes or symptoms in elderly patients.

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004), and 3rd (Zurich 2008) International Consensus Conference on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous 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. This document is developed for use by physicians and health care professionals who are primarily involved in the care of injured athletes, whether at the recreational, elite, or professional level.While agreement exists pertaining to principle messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore, management and 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, the Pocket Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool version 3 (SCAT3), and the Child SCAT3 card (Appendix), and none is subject to any restriction, provided it is not altered in any way or converted to a digital format. The authors request that the document and the accompanying tools be distributed in their full and complete format.This consensus paper is broken into a number of sections:The Zurich 2012 document examines sport concussion and management issues raised in the previous Vienna 2001, Prague 2004, and Zurich 2008 documents and applies the consensus questions from Section 3 to these areas.1–3Panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. There was acknowledgement by the Concussion in Sport Group (CISG) that, although the terms mild traumatic brain injury (mTBI) and concussion are often used interchangeably in the sporting context and particularly in the US literature, others use the term to refer to different injury constructs. Concussion is the historical term representing low-velocity injuries that cause brain “shaking,” resulting in clinical symptoms, and which are not necessarily related to a pathologic injury. Concussion is a subset of TBI, and the term concussion will be used in this document. It was also noted that the term commotio cerebri is often used in European and other countries. Minor revisions were made to the definition of concussion and it is defined as follows: Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:The majority (80% to 90%) of concussions resolve in a short (7–10 day) period, although the recovery timeframe may be longer in children and adolescents.2The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioral features, and sleep disturbance. Furthermore, a detailed concussion history is an important part of the evaluation, both in the injured athlete and when conducting a preparticipation examination. The detailed clinical assessment of concussion is outlined in the SCAT3 and Child SCAT3 forms, which are appendices to this document.The suspected diagnosis of concussion can include 1 or more of the following clinical domains:If any 1 or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted.When a player shows any features of a concussion:Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment, both on and off the field, for all injured athletes. In some sports, this may require rule change to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalizing the injured player's team. The final determination regarding concussion diagnosis and fitness to play is a medical decision based on clinical judgment.Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT3, which incorporates the Maddocks questions,4,5 and the Standardized Assessment of Concussion (SAC).6–8 It is worth noting that standard orientation questions (eg, time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment.5,9 It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing, which should ideally be performed by trained neuropsychologists who are sensitive to subtle deficits that may exist beyond the acute episode; nor should they be used as a standalone tool for the ongoing management of sports concussions.It should also be recognized that the appearance of symptoms or cognitive deficit might be delayed several hours after a concussive episode and that concussion should be seen as an evolving injury in the acute stage.An athlete with concussion may be evaluated in the emergency room or doctor's office as a point of first contact after injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this exam should encompass:In large part, the points above are included in the SCAT3 assessment.A range of additional investigations may be used to assist in the diagnosis or exclusion of injury. Conventional structural neuroimaging is typically normal in concussive injury. Given that caveat, the following suggestions are made. Brain computed tomography (CT; or where available, magnetic resonance imaging [MRI]) contributes little to concussion evaluation but should be employed whenever suspicion of an intracerebral or structural lesion (eg, skull fracture) exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit, or worsening symptoms.Other imaging modalities, such as functional MRI (fMRI) demonstrate activation patterns that correlate with symptom severity and recovery in concussion.10–14 While not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiologic mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting.Published studies, using both sophisticated force-plate technology, as well as those using less sophisticated clinical balance tests (eg, Balance Error Scoring System), have identified acute postural stability deficits lasting approximately 72 hours after sport-related concussion. It appears that postural-stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and should be considered a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where symptoms or signs indicate a balance component.15–21The significance of apolipoprotein (Apo) E4, ApoE promotor gene, tau polymerase, and other genetic markers in the management of sports concussion risk or injury outcome is unclear at this time.22,23 Evidence from human and animal studies in more severe traumatic brain injury demonstrates induction of a variety of genetic and cytokine factors, such as insulin-like growth factor-1 growth growth and such are in sporting concussion is not at this In and of brain injury have been as by which may be There is however, to the routine use of these (eg, magnetic and have in the however, not all studies athletes from The clinical significance of these to be of neuropsychological testing in concussion been shown to be of clinical and contributes in concussion in cognitive recovery with the time of symptom it been that cognitive recovery may or more clinical symptom that the assessment of cognitive function should be an important component in the assessment of concussion in any RTP It be however, that assessment should not be the of management it should be seen as an to the clinical process in with a range of of different clinical domains and is recommended that all athletes should have a clinical neurological assessment assessment of their cognitive as part of their This will be by the often in with screening testing is not for all however, when this is considered it should ideally be performed by a trained neuropsychologists are in the to tests by of their and the RTP decision should remain a medical in which a when been In the of and other (eg, formal balance testing, a more RTP may be testing may be used to assist RTP decisions and is typically performed when an athlete is assessment may important in the early stages after There may be situations where testing is performed early to assist in of management (eg, to in a This will be in with a trained testing was considered by the and was not to be as a of it may be or useful to the of these It also provides an additional for the to the significance of this injury with the present, is to the routine use of of concussion management is physical and cognitive the acute symptoms resolve and a of medical and The the of after a sport-related concussion is of in the acute after injury may be of research to the outcome of and the and of is In the of a involves the to and contact in a that not in a of for those who are to may be of although the after injury for of this is above, the majority of injuries will several In these it is that an athlete will a RTP RTP after a concussion a process as outlined in this the athlete should to to the at the should that an athlete approximately 1 to the full at and with any symptoms occur while in the the should to the previous and to after a further of was that RTP on the of concussive injury should There are demonstrating that, at the and athletes to RTP on the may demonstrate deficits that may not be on the sidelines and are more to have delayed of symptoms are in of In symptoms are not to concussion, and it is important to other of concussion in sport where clinical recovery the should be in a by health care with in may have in this particularly with the are also encouraged to the athlete for symptoms such as and as these symptoms are common in all of traumatic brain in sports concussion may be in The first of these situations is the management of or prolonged symptoms (eg, sleep The situation is where is used to the of the with the of the of the concussion In this to management should be considered by in concussion important in RTP is that athletes should not be symptom but also should not be any or that may or the symptoms of concussion. may be the management of a concussion, the decision to RTP while still on such be considered by the the of a concussion history and the that athletes will not all the concussions they may have in the a detailed concussion history is of Such a history may athletes who into a risk and provides an for the health care to the athlete in to the significance of concussive injury. A concussion history should include questions as to previous symptoms of a concussion and of not the number of It is also worth noting that the of concussive injuries by or been to be The clinical history should also include all previous and as these may also have clinical It is worth that in the of and concussive injuries may be pertaining to may the to a to injury. part of the clinical it is that regarding employed at time of injury be both for and is an additional and often of the preparticipation physical as the evaluation for an with the player as well as of of range of may the and management of concussion in some may the for prolonged or in some the for their is be important to in a detailed concussion history and are outlined in of as a in the management of concussion was at by the There was not agreement that the research is for this to be included as a although it was that may be a risk for injury or injury severity the management of to severe traumatic brain of of is an of While in concussion with early cognitive it not been noted as a of injury Consensus discussion that prolonged be considered as a that may is in the of and its as a of injury that the and of the clinical symptoms may be more important than the or of it be noted that with the time of and is of injury variety of motor (eg, or may a concussion. these clinical features are and require management beyond the standard of the concussive health issues as have been as a of all of traumatic brain including concussion. studies using that a after concussion may an pathophysiological with a of While such health issues may be in it is recommended that the these issues in the management of evaluation and management recommendations can be to children and to the of that children concussion symptoms different from and require symptom as a component of additional in assessing the or athlete with a concussion is that the clinical evaluation by the health care professional may to include both and and and when A SCAT3 been developed to assess concussion for those decision to use testing is the as the assessment although are some of testing may in to assist in and cognitive testing is it be sensitive to the ongoing cognitive that this in the of to the or to In this it is more important to the use of trained neuropsychologists to assessment particularly in children with or who may more sophisticated assessment was by the that to sport or should occur the or athlete to to In the of was with to a to with of that may and may also to be to of should not be to sport symptom which may require a longer timeframe than for of the different and longer recovery after concussion and (eg, related to head and a more RTP is It is appropriate to the of time of or the of the in children and It is not appropriate for a or athlete with concussion to RTP on the as the of the of Concussion more to this than and may more RTP athletes, of of should be using the and RTP The and in concussion evaluation are of more in management than a separation and athlete formal testing may be beyond the of sports or it is recommended that, in all sports, be to this cognitive evaluation, of the or of to be of the for in the management of all athletes. it was that traumatic a with an in It was further that a not been and concussions or to contact present, the of in the studies should It was also recognized that it is important to the of and athletes from related to the of is clinical that will concussion, although have a in and injury. studies have shown a in to the brain with the use of head and but these have not been to a in concussion and are a number of studies to that provide head and injury and should be recommended for in In sports, such as and motor and sports, may other of head injury (eg, skull fracture) that are related to on and may be an important for those of rule to the head injury or severity may be appropriate where a is in a of this is in where research studies that contact in for approximately of noted rule also may be in some sports to allow an off-field medical assessment to occur without the affecting the flow of the or unduly penalizing the player's team. It is important to that rule may be a of injury risk in these and play an important in this important in the use of is the of risk This is where the use of in change such as the of more which can in a in injury The to which this is in more in the in the of Sports This may be a in and athletes, in head injury are often than in nature of sport that it to play and should not be sporting should be encouraged to that may concussion play and should be as key of the to or the of concussive injury after the is of athletes, and the is a of in this and health care be regarding the of concussion, its clinical features, assessment and principles of to including and are important in the In concussion the and of sport such as the International International and International that this have and be play and for are that should be encouraged in all sports and sporting and play an important part in these are on the of November 2001, the 1st International Conference on Concussion in Sport was held in This was by the in with and the of the part of the resulting for the the for and were The 2nd International Conference on Concussion in Sport was by the with the additional of the and was held in in November The of the were to provide recommendations for the of and health of athletes who concussive injuries in and as well as other this a range of were to both to issues of and clinical injury cognitive assessment, new research and 3rd International Conference on Concussion in Sport was held in Zurich, on 2008 and was designed as a formal consensus following the by the US of of the consensus can be at The principles the of a consensus development are not with any The was for the consensus and the were from clinical and research in the of concussion. not but were for their and understanding of this 4th International Conference on Concussion in Sport was held in Zurich, on November 2012 and the as for the 3rd consensus and authors were to an International of for of of related to and of will be made on the Concussion in Sport Group and with the of Sports consensus document the of and will to be to the development of new It provides an of issues that may be of to health care involved in the management of concussion. It is not as a standard of care and should not be as This document is a and is of a with the of a health care will on the and to is that this document will be and to 1 that is the subject of a that is in the of Sports all and of will be in those consensus that concussion is an evolving injury in the acute with clinical signs and symptoms, which may the injury in the Concussion is considered to be the complex injuries in sports to and The majority of concussions in sport occur without or neurologic present, is test or that can on for an diagnosis of concussion in the sporting of this evolving it is not to rule concussion when an injury with a neurologic such should be from the and for concussion by the or health care as It was recognized that a cognitive deficit is not for acute as it may not be present or not on is a clinical diagnosis based on the injury signs, and The majority of concussions referred to as occur without or neurologic In of concussion, the athlete might be without In concussions cannot be identified or by neuroimaging (eg, or Several tests are appropriate for use in the assessment of acute concussion in the sporting tests provide important on symptoms and functional that can incorporate into their but should not be used to and concussion in the athlete on the is a for the health care provider. this is often a rapid assessment in the of with a time and the athlete to A assessment of which more is in decisions for the The evaluation of concussion is often a the and of in a and of assessment and on these the evaluation is based on of assessment of symptoms, cognitive and and are often Concussion is often an evolving and signs and symptoms may be on the of an athlete of when is any suspicion for is A assessment of concussion is useful in the assessment of the athlete with suspected concussion but should not the of was that a variety of should be employed as part of the assessment of concussion to provide a more complete clinical for the clinical can be in a the use of a such as the A assessment is it is that further studies to be performed to this test should include an assessment of injury severity using the by and concussion this is symptom and symptom and balance function should be in any athlete suspected of a concussion. It is recommended that these be after a on the to the of or on the While it is noted that this timeframe is an nevertheless the that a of was important research should the for of tests such as the test and clinical time studies that these may be useful to the assessment of concussion. the for additional may for was further that the SCAT3 be for and and while a new tool be developed for concussions are with 1 or more symptoms, or cognitive deficits a of can be using symptom balance testing, and 3 can in the first after with The of symptoms and the of recovery can be which the of assessing all 3 as part of a comprehensive sports concussion assessment been by the Concussion in Sport Group as a of concussion are to tests and can play an important within the context of a and to concussion. Concussion management that use assessment to assist in clinical decision have been in professional sports, and Brief cognitive evaluation tools are the of these the in trained however, it should be noted that these are not for formal present, is to the routine use of number of exist to assess concussion but not motor assessment, technology, functional imaging and and head this exists for their in this and none have been as It will be important to the of these technologies is the of and after a concussion is of may be of further research to the outcome of and the and of is for those who are to may be of although the after injury for of this is for with clinical of or may be of There is a for studies the of a period, and for who have a symptoms are in of This may be in sports (eg, and (eg, In symptoms are not to concussion, and it is important to and may include formal testing and neuroimaging to structural injury. is to routine clinical use of neuroimaging or other of concussion in sport in which clinical recovery the should be in a by health care with in concussion. components of management after the of physical and cognitive include such as and of assessment of other of prolonged and of of a at a that not demonstrates that the number and severity of symptoms and previous concussions are with prolonged recovery or risk of Brief of or not outcome after concussion, although a should be in an athlete with prolonged longer to from and assessment batteries have to be in the are on the of and on outcome after concussion. Several are with prolonged recovery or risk of after concussion and have important for with concussion should be with the on to to In of concussion with (eg, a should also be such that the athlete not to sport new valid was provided to that the use of standard in or in can risk of concussion. was provided to an and concussion risk There was to that from and in were to be to from resulting in a head change in of to in professional and to in professional It also appears that be of head to and components to to their Given that a is for concussion and studies of are for and and the of rule should also be with studies, not assessing new rule or but also to or of was that a with an in It was further that was not related to concussions or to to contact present, are or studies to to the nature of the and pathologic that have been it is not to the or risk with any the that concussion or The to which or health or or medical or to this process is for in the present, the of in the studies should It was also recognized that it is important to the of and athletes from related to the of of as part of concussion is from Concussion tools but their and require further The is in attention to concussion, but to that the is of the as a concussion tool is more of is can use to assess and and use the to decision a defined the and of with evaluation, should be a of the concussion to have an on and Pocket Concussion Recognition Sports Concussion Assessment Tool version 3 Child SCAT3

Structured assessment instruments are particularly useful in screening for problems that often go undetected in older patients. In addition, such instruments can provide information about conditions and abilities or limitations that are not regularly assessed in standard clinical practice. Often, their administration is delegated to other health professionals, but these tools still provide useful information to the physician. Clinicians should view assessment instruments as they would any other clinical test. They should be familiar with the strengths, weaknesses, and precision of any test used and understand how best to use the test as an adjunct to clinical practice. In addition, clinicians must learn to focus on functional status, in terms of both assessment and outcome, in their care of older patients.

Identification of elderly individuals with low and high risk for future dementia has emerged as an important clinical and public health issue. To address this issue, we assessed neuropsychological performance in 317 initially nondemented elderly persons between 75 and 85 years of age and followed them for at least 4 years as part of the Bronx Aging Study. Four measures of cognitive function from the baseline assessment (delayed recall from the Buschke Selective Reminding Test, recall from the Fuld Object Memory Evaluation, the Digit Symbol subtest from the Wechsler Adult Intelligence Scale, and a verbal fluency score) can identify one subgroup with an 85% probability of developing dementia over 4 years and another with a 95% probability of remaining free of dementia. The model achieved an overall positive predictive value of 68%, or three times the base rate, for prediction of the development of dementia in our sample. The overall negative predictive value for prediction of absence of dementia was 88%. Baseline measures of cognitive function, often performed many years before the actual diagnosis of dementia, can provide important information about dementia risk. The group likely to develop dementia becomes a target for preventive or early therapeutic interventions, and the group unlikely to develop dementia can be reassured.

Despite agreement that dysnomia affects virtually every aphasic patient, there is no consensus about the purpose and effectiveness of techniques to treat it. Semantic feature analysis (SFA), a treatment technique designed to improve retrieval of conceptual information by accessing semantic networks, was used to treat aphasic dysnomia in a 57-year-old male who exhibited Broca's aphasia secondary to a left frontoparietal ischemic infarction. SFA was effective for improving confrontation naming and for generalized improvement to untreated pictures. However, no generalization to connected speech was seen on the measures of mean words per minute, mean correct information units per minute, or the percentage of all words that were correct information units.

The activity of the pyruvate dehydrogenase complex (PDHC) was reduced in affected areas of brain from patients with Huntington disease (caudate, putamen) and Alzheimer disease (frontal cortex) where choline acetyltransferase (CAT) activity was low. PDHC was also deficient in an area (Huntington hippocampus) where CAT was not significantly reduced. The activity of fumarase, an inner mitochondrial marker, was normal in all areas examined. The activities of PDHC and CAT correlated well in caudate, putamen, and amygdala but not in hippocampus or frontal cortex. Both total activity and activation of PDHC were below normal in fibroblasts from 4 patients with C-21 trisomy Down syndrome, who are at very high risk to develop Alzheimer disease. However, no abnormality of PDHC was detected in Huntington or Alzheimer fibroblasts. Deficiency of PDHC may play a role in the pathophysiology of Huntington and Alzheimer diseases, although it does not appear to be a primary defect. Loss of tissue oxidative capacity may relate to the reduction in cerebral metabolic rate and blood flow which are characteristic of many dementing illnesses.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the effects of stroke involvement of primary and secondary hemispheric motor systems and corticofugal tracts on arm and hand recovery. METHODS: Forty-one patients participating in an inpatient stroke rehabilitation database, admitted 17+/-2 (SEM) days after initial unilateral hemispheric ischemic stroke, with neuroimaging studies performed >48 hours after stroke and with minimal upper limb (UL) movement (admission Fugl-Meyer UL motor scores </=9; normal score, 58) were studied. Patients were divided into 3 groups according to their UL discharge Fugl-Meyer score: 0 to 9, no/poor recovery; 10 to 18, well-defined flexion-extension synergies; and >18, synergies+isolated movements. Lesions affecting the following structures were recorded: primary motor cortex, premotor area, supplementary motor area, anterior half of the middle third of corona radiata (secondary motor efferents), posterior half of the middle third of corona radiata (primary motor efferents), genu, anterior and posterior limbs of the internal capsule (PLIC), basal ganglia, and thalamus. chi(2) Analysis and ANOVA were used to study the significance of stroke location on UL motor recovery. RESULTS: The effect of involvement of primary, premotor, or supplementary motor areas on motor recovery did not reach statistical significance. Patients with purely cortical stroke were likely to recover UL isolated movement (3 of 4) compared with purely subcortical (1 of 17) or mixed cortical-subcortical stroke location (2 of 20) (P:=0.009). Of those with cortical, subcortical, or mixed cortical plus subcortical lesions sparing the PLIC, 5 of 13 recovered isolated UL movement (P:=0.01). Only 1 of 28 patients with involvement of the PLIC plus adjacent corona radiata, basal ganglia, or thalamus recovered isolated UL movement (P:=0.01). Patients with small lacunar strokes affecting only the PLIC did not have sufficient motor deficits 2 weeks after stroke to meet inclusion criteria. CONCLUSIONS: The probability of recovery of isolated UL movement decreases progressively with lesion location as follows: cortex, corona radiata, and PLIC. This is consistent with our current understanding of redundant cortical motor representation and convergence of corticofugal motor efferents as they pass through the corona radiata to the PLIC.

OBJECTIVE: To identify enduring prolonged neuropsychological effects of cerebral concussion in high school youth athletes. METHODS: High school athletes (n = 223) underwent baseline neuropsychological evaluation between 1999 and 2000, assigned to independent groups on the basis of concussion history: athletes with no concussion history or present medical and/or neuropsychological complaints (n = 82), symptom-free athletes who experienced one (n = 56) or two or more (n = 45) concussions (not in the prior 6 mo), and those who experienced a concussion 1 week before testing (n = 40). Main outcome measures included a structured clinical interview, demographic form, symptom checklist, the Repeatable Battery for the Assessment of Neuropsychological Status, and the Trail Making Tests A and B. Analyses of variance were used to determine between-group differences. RESULTS: Athletes with recent concussions performed significantly worse on measures of attention and concentration than youth athletes with no concussion history. Symptom-free athletes with a history of two or more concussions performed similar on testing to youth athletes who had just experienced a recent concussion. Similarly, cumulative academic grade point averages were significantly lower not only for youth athletes with two or more previous concussion groups, but for youth athletes who experienced recent concussions, suggesting that athletes with lower grade point averages may be more prone to concussion. CONCLUSION: There seem to be subtle yet significant prolonged neuropsychological effects in youth athletes with a history of two or more previous concussions.

Objectives N‐acetylcysteine (NAC) is a clinically approved thiol‐containing redox modulatory compound currently in trials for many neurological and psychiatric disorders. Although generically labeled as an “antioxidant,” poor understanding of its site(s) of action is a barrier to its use in neurological practice. Here, we examined the efficacy and mechanism of action of NAC in rodent models of hemorrhagic stroke. Methods Hemin was used to model ferroptosis and hemorrhagic stroke in cultured neurons. Striatal infusion of collagenase was used to model intracerebral hemorrhage (ICH) in mice and rats. Chemical biology, targeted lipidomics, arachidonate 5‐lipoxygenase (ALOX5) knockout mice, and viral‐gene transfer were used to gain insight into the pharmacological targets and mechanism of action of NAC. Results NAC prevented hemin‐induced ferroptosis by neutralizing toxic lipids generated by arachidonate‐dependent ALOX5 activity. NAC efficacy required increases in glutathione and is correlated with suppression of reactive lipids by glutathione‐dependent enzymes such as glutathione S ‐transferase. Accordingly, its protective effects were mimicked by chemical or molecular lipid peroxidation inhibitors. NAC delivered postinjury reduced neuronal death and improved functional recovery at least 7 days following ICH in mice and can synergize with clinically approved prostaglandin E 2 (PGE 2 ). Interpretation NAC is a promising, protective therapy for ICH, which acted to inhibit toxic arachidonic acid products of nuclear ALOX5 that synergized with exogenously delivered protective PGE 2 in vitro and in vivo. The findings provide novel insight into a target for NAC, beyond the generic characterization as an antioxidant, resulting in neuroprotection and offer a feasible combinatorial strategy to optimize efficacy and safety in dosing of NAC for treatment of neurological disorders involving ferroptosis such as ICH. Ann Neurol 2018;84:854–872

I used leg and arm paresis to predict outcome measured as extremity function in a prospective study of 75 consecutive hemiplegic patients admitted to an inpatient stroke rehabilitation unit. In each patient, extremity paresis was quantified according to the five-point scoring system advised by the Medical Research Council, upper extremity function was quantified using the Barthel Index subscore for feeding and dressing the upper body, and lower extremity function was quantified according to a five-point scoring of the ability to walk. Improvement was recorded for upper extremity function in 52% of the patients and for lower extremity function in 89%. Best extremity function was reached a mean +/- SEM of 9 +/- 3 and 10 +/- 4 weeks after stroke for the upper and lower extremities, respectively. In patients experiencing complete recovery, this occurred a mean +/- SEM of 7 +/- 2 weeks (for both upper and lower extremities) after the stroke. Only 8-11% of the patients with paresis scores of less than or equal to 2 regained independent extremity function after rehabilitation. Half of the patients with paresis scores of greater than or equal to 3 regained independent extremity function after rehabilitation, while the other half were able to perform extremity function with only minimal assistance. As predictors of extremity function, the Barthel Index subscore was slightly better (r = 0.64) than paresis score (r = 0.58). However, because evaluation of extremity paresis is easy, it appears to be useful as a preliminary predictor of outcome following stroke.

OBJECTIVE: To determine the relative risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration, silent aspiration, aspiration of 10% or greater on one or more barium test swallows, and aspiration of thick liquid or more solid consistencies in the subacute phase after stroke. DESIGN: Prospective, longitudinal cohort study. SETTING: Inpatient stroke rehabilitation unit. PATIENTS: There were 114 consecutive patients who met the following criteria: (1) stroke as defined by clinical history and neurological examination with compatible computed tomographic or magnetic resonance imaging scan; (2) age 20 to 90 years, inclusive; (3) no known history of significant oropharyngeal anomaly; and (4) videofluoroscopic evidence of dysphagia. Of 122 eligible patients, eight refused participation. MAIN OUTCOME MEASURES: Development of pneumonia, dehydration, and death. RESULTS: The relative risk for developing pneumonia was 6.95 times greater (P = .027) for those patients who aspirated compared with those who did not, 5.57 times greater (P = .012) for those who aspirated silently compared with those who coughed when aspirating or who did not aspirate, and 8.36 times greater (P = .002) for those who aspirated 10% or greater on one or more barium test swallows compared with those who aspirated less than 10% or did not aspirate. CONCLUSION: Aspiration, silent aspiration, and aspiration of 10% or greater on one or more barium test swallows during videofluoroscopic evaluation are associated with an increased risk of pneumonia, but not dehydration or death, during the subacute phase after stroke.

Chronic traumatic brain injury (CTBI) associated with boxing occurs in approximately 20% of professional boxers. Risk factors associated with CTBI include increased exposure (i.e., duration of career, age of retirement, total number of bouts), poor performance, increased sparring, and apolipoprotein (APOE) genotype. Clinically, boxers exhibiting CTBI will present with varying degrees of motor, cognitive, and/or behavioral impairments. The severe form of CTBI is referred to as dementia pugilistica. The diagnosis of CTBI is dependent upon documenting a progressive neurological condition that is consistent with the clinical symptomatology of CTBI attributable to brain trauma and unexplainable by an alternative pathophysiological process. Pathologically, CTBI shares many characteristics with Alzheimer's disease (i.e., neurofibrillary triangles, diffuse amyloid plaques, acetylcholine deficiency, and/or tau immunoreactivity). The mainstay of treatment of CTBI is prevention, however medications used in the treatment of Alzheimer's disease and/or parkinsonism may be utilized.