Anne Mucha, PT, DPT, MS, NCSUPMC Centers for Rehab Services and

Sports Medicine Concussion ProgramPittsburgh, PA

Cara Troutman-Enseki, PT, DPT, OCS, SCS

University of Pittsburgh Medical Center Rooney Sports Medicine Complex/

Centers for Rehab ServicesPittsburgh, PA

Tim Rylander, PT, EdD(c), MPT, OCS, CBIS

Impact Physical Therapy & Chicago Recovery Room

Hinsdale, IL

PHYSICAL THERAPY MANAGEMENT OF

CONCUSSIONAdvanced Concussion

Management

Independent Study Course 28.1.3

CONTINUING PHYSICAL THERAPY EDUCATION

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

14

REFERENCES

1. Collins MW, Kontos AP, Okonkwo DO, et al. State-ments of agreement from the targeted evaluation andactive management (TEAM) approaches to treatingconcussion meeting held in Pittsburgh, October 15-16,2015. Neurosurgery. 2016;79(6):912-929.

2. Collins MW, Kontos AP, Reynolds E, Murawski CD, FuFH. A comprehensive, targeted approach to the clinicalcare of athletes following sport-related concussion. KneeSurg Sports Traumatol Arthrosc. 2014;22(2):235-246. doi:10.1007/s00167-013-2791-6. Epub 2013 Dec 12.

3. Elbin RJ, Sufrinko A, Schatz P, et al. Removal fromplay after concussion and recovery time. Pediatrics.

2016;138(3). pii: e20160910. doi: 10.1542/peds.2016-0910.

4. McCrory P, Meeuwisse W, Dvorak J, et al. Con-sensus statement on concussion in sport-the 5thinternational conference on concussion in sportheld in Berlin, October 2016. Br J Sports Med.2017. pii: bjsports-2017-097699. doi: 10.1136/bjsports-2017-097699. [Epub ahead of print]

5. Broglio SP, Cantu RC, Gioia GA, et al. National AthleticTrainers’ Association position statement: management ofsport concussion. J Athl Train. 2014;49(2):245-265. doi:10.4085/1062-6050-49.1.07. Epub 2014 Mar 7.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

15

6. Halstead ME, Walter KD, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report--sport-related concussion in children and adoles-cents. Pediatrics. 2010;126(3):597-615. doi: 10.1542/peds.2010-2005. Epub 2010 Aug 30.

7. National Collegiate Athletic Association. Concussion Di-agnosis and Management Best Practices. www.ncaa.org/sport-science-institute/concussion-diagnosis-and-man-agement-best-practices. Accessed August 1, 2017.

8. Giza CC, Griesbach GS, Hovda DA. Experience-de-pendent behavioral plasticity is disturbed following traumatic injury to the immature brain. Behav Brain Res. 2005;157(1):11-22.

9. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pi-nilla F. Voluntary exercise following traumatic brain in-jury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004;125(1):129-139.

10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute con-cussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223. doi: 10.1542/peds.2014-0966. Epub 2015 Jan 5.

11. Majerske CW, Mihalik JP, Ren D, et al. Concus-sion in sports: postconcussive activity levels, symp-toms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274. doi: 10.4085/1062-6050-43.3.265.

12. Grool AM, Aglipay M, Momoli F, et al. Associa-tion between early participation in physical activity following acute concussion and persistent post-concussive symptoms in children and adolescents. JAMA. 2016;316(23):2504-2514. doi: 10.1001/jama.2016.17396.

13. Maerlender A, Rieman W, Lichtenstein J, Condirac-ci C. Programmed physical exertion in recovery from sports-related concussion: a randomized pilot study. Dev Neuropsychol. 2015;40(5):273-278. doi: 10.1080/87565641.2015.1067706. Epub 2015 Jul 31.

14. Gagnon I, Galli C, Friedman D, Grilli L, Iver-son GL. Active rehabilitation for children who are slow to recover following sport-related con-cussion. Brain Inj. 2009;23(12):956-964. doi: 10.3109/02699050903373477.

15. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Ep-stein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21-27. doi: 10.1097/JSM.0b013e3181c6c22c.

16. Dematteo C, Volterman KA, Breithaupt PG, Claridge EA, Adamich J, Timmons BW. Exertion testing in youth with mild traumatic brain injury/concussion. Med Sci Sports Exerc. 2015;47(11):2283-2290. doi: 10.1249/MSS.0000000000000682.

17. Chrisman SP, Whitlock KB, Somers E, et al. Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth. NeuroRehabilitation. 2017;40(4):493-499.

18. Chou R, Huffman LH, American Pain Society, Ameri-can College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):492-504.

19. Wong JJ, Cote P, Shearer HM, et al. Clinical practice guidelines for the management of conditions related to traffic collisions: a systematic review by the OPTIMa Collaboration. Disabil Rehabil. 2015;37(6):471-489. doi: 10.3109/09638288.2014.932448. Epub 2014 Jun 25.

20. Ambrose KR, Golightly YM. Physical exercise as non-pharmacological treatment of chronic pain: Why and when. Best Pract Res Clin Rheumatol. 2015;29(1):120-130. doi: 10.1016/j.berh.2015.04.022. Epub 2015 May 23.

21. Manuel JC, Shilt JS, Curl WW, et al. Coping with sports injuries: an examination of the adolescent athlete. J Ado-lesc Health. 2002;31(5):391-393.

22. Leddy MH, Lambert MJ, Ogles BM. Psychological con-sequences of athletic injury among high-level competi-tors. Res Q Exerc Sport. 1994;65(4):347-354.

23. Ravindran AV, Balneaves LG, Faulkner G, et al. Ca-nadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Man-agement of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments. Can J Psychiatry. 2016;61(9):576-587. doi: 10.1177/0706743716660290. Epub 2016 Aug 2.

24. Milde-Busch A, Blaschek A, Borggrafe I, Heinen F, Straube A, von Kries R. Associations of diet and lifestyle with headache in high-school students: results from a cross-sectional study. Headache. 2010;50(7):1104-1114. doi: 10.1111/j.1526-4610.2010.01706.x. Epub 2010 Jun 7.

25. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26. doi: 10.1136/bjsports-2012-091941.

26. Management of Concussion/m TBI Working Group. VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury. J Rehabil Res Dev. 2009;46(6):CP1-68.

27. National Collegiate Athletic Association Sports Science Institute. Interassociation Consensus: Diagnosis and Management of Sport-Related Concussion Best Practices www.ncaa.org/sites/default/files/SSI_ConcussionBest-Practices_20170616.pdf. Accessed July 29, 2017.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

16

28. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, WillerBS. Return to full functioning after graded exerciseassessment and progressive exercise treatment of postcon-cussion syndrome. Rehabil Res Pract. 2012;2012:705309.doi: 10.1155/2012/705309. Epub 2012 Jan 16.

29. McCrory P, Meeuwisse WH, Aubry M, et al. Consensusstatement on concussion in sport: the 4th InternationalConference on Concussion in Sport held in Zurich,November 2012. Br J Sports Med. 2013;47(5):250-258.doi: 10.1136/bjsports-2013-092313.

30. Defense and Veterans Brain Injury Center (DVBIC).Progressive Return to Activity Following Acute Concus-sion/Mild TBI Clinical Suite. https://dvbic.dcoe.mil/material/progressive-return-activity-following-acute-con-cussionmild-tbi-clinical-suite. Accessed August 1, 2017.

31. Morin M, Langevin P, Fait P. Cervical spine involve-ment in mild traumatic brain injury: a review. J SportsMed (Hindawi Publ Corp). 2016;2016:1590161. doi:10.1155/2016/1590161. Epub 2016 Jul 26.

32. The International Classification of Headache Disorders,3rd ed (beta version). Cephalalgia. 2013;33(9):629-808.doi:10.1177/0333102413485658.

33. Racicki S, Gerwin S, DiClaudio S, Reinmann S, Don-aldson. Conservative physical therapy management forthe treatment of cervicogenic headache: a systematicreview. J Man Manip Ther. 2013;21(2):113-124.

34. Silberstein SD, US Headache Consortium. Practiceparameter: Evidence-based guidelines for migraine head-ache (an evidence-based review) Report of the QualityStandards Subcommittee of the American Academy ofNeurology. Neurology, 2000;55(6):754-762.

35. Biondi DM. Physical treatments for headache: a struc-tured review. Headache. 2005;45(6):738-746.

36. Hoving JL, Koes BW, de Vet HC, et al. Manual ther-apy, physical therapy, or continued care by a generalpractitioner for patients with neck pain. A randomized,controlled trial. Ann Intern Med. 2002;136(10):713-722.

37. Childs JD, Flynn TW, Fritz JM, et al. Screening forvertebrobasilar insufficiency in patients with neck pain:manual therapy decision-making in the presence ofuncertainty. J Orthop Sports Phys Ther. 2005:35(5):300-306.

38. Cook C, Brismee JM, Fleming R, Sizer Jr, PS. Identifierssuggestive of clinical cervical spine instability: a Delphistudy of physical therapists. Phys Ther. 2005; 85(9):895-906.

39. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA.Incidence of common postural abnormalities in the cer-vical, shoulder, and thoracic regions and their associationwith pain in two age groups of healthy subjects. PhysTher. 1992;72(6):425-431.

40. Marcus DA, Scharff L, Mercer S, Turk DC. Musculo-skeletal abnormalities in chronic headache: a controlled

comparison of headache diagnostic groups. Headache. 1999;39(1):21-27.

41. Ombregt L. Headache and vertigo of a cervical origin.In: Ombregt L. A system of orthopaedic medicine,3rd ed.London, UK: Churchill Livingstone Elsevier; 2013.

42. Neck Pain Guidelines: revision 2017: using the evi-dence to guide physical therapist practice. J OrthopSports Phys Ther. 2017;47(7):511-512. doi: 10.2519/jospt.2017.0507.

43. Son BC, Choi JG. Hemifacial pain and hemisensorydisturbance referred from occipital neuralgia caused bypathological vascular contact of the greater occipitalnerve. Case Rep Neurol Med. 2017;2017:3827369. doi:10.1155/2017/3827369. Epub 2017 Feb 26.

44. Heredia Rizo AM, Pascual-Vaca AO, Cabello MA,Blanco CR, Pozo FP, Carrasco AL. Immediate effects ofthe suboccipital muscle inhibition technique in cranio-cervical posture and greater occipital nerve mechano-sensitivity in subjects with a history of orthodontiause: a randomized trial. J Manipulative Physiol Ther.2012;35(6):446-453. doi: 10.1016/j.jmpt.2012.06.006.Epub 2012 Aug 14.

45. Reid SA, Rivett DA, Katekar MG, Callister R. Com-parison of mulligan sustained natural apophyseal glidesand maitland mobilizations for treatment of cervico-genic dizziness: a randomized controlled trial. Phys Ther.2014;94(4):466-476. doi: 10.2522/ptj.20120483. Epub2013 Dec 12.

46. Li Y, Peng B. Pathogenesis, diagnosis, and treatment ofcervical vertigo. Pain Physician. 2015;18(4):E583-595.

47. Kristjansson E, Treleaven J. Sensorimotor function anddizziness in neck pain: implications for assessment andmanagement. J Orthop Sports Phys Ther. 2009;39(5):364-377. doi: 10.2519/jospt.2009.2834.

48. Heikkila H, Johansson M, Wenngren BI. Effects of acu-puncture, cervical manipulation and NSAID therapy ondizziness and impaired head repositioning of suspectedcervical origin: a pilot study. Man Ther. 2000;5(3):151-157.

49. Reid SA, Rivett DA, Katekar MG, Callister R. Sus-tained natural apophyseal glides (SNAGs) are aneffective treatment for cervicogenic dizziness. Man Ther.2008;13(4):357-366. Epub 2007 Oct 22.

50. Gong W. Effects of cervical joint manipulation onjoint position sense of normal adults. J Phys Ther Sci.2013;25(6):721-723. doi: 10.1589/jpts.25.721. Epub2013 Jul 23.

51. O’Leary S, Falla D, Elliott JM, Jull G. Muscle dys-function in cervical spine pain: implications for as-sessment and management. J Orthop Sports Phys Ther.2009;39(5):324-333. doi: 10.2519/jospt.2009.2872.

52. Elliott JM, Noteboom JT, Flynn TW, Sterling M. Char-acterization of acute and chronic whiplash-associated dis-

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

17

orders. J Orthop Sports Phys Ther. 2009;39(5):312-323. doi: 10.2519/jospt.2009.2826.

53. Elliott J, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine (Phila Pa 1976). 2006;31(22):E847-855.

54. Elliott JM, O’Leary S, Sterling M, Hendrikz J, Pedler A, Jull G. Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash. Spine (Phila Pa 1976). 2010;35(9):948-954. doi: 10.1097/BRS.0b013e3181bb0e55.

55. O’Leary S, Jull G, Kim M, Vicenzino B. Specificity in retraining craniocervical flexor muscle performance. J Orthop Sports Phys Ther. 2007;37(1):3-9.

56. Jull GA, O’Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther. 2008;31(7):525-533. doi: 10.1016/j.jmpt.2008.08.003.

57. Falla D, O’Leary S, Farina D, Jull G. The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. Clin J Pain. 2012;28(7):628-634. doi: 10.1097/AJP.0b013e31823e9378.

58. Grimmer K. Measuring the endurance capacity of the cervical short flexor muscle group. Aust J Phys-iother. 1994;40(4):251-254. doi: 10.1016/S0004-9514(14)60461-X.

59. Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014;25:277-279.

60. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. 2007;25(3):404-412.

61. Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement con-trol--Part 2: case studies. Man Ther. 2008;13(3):266-275. doi: 10.1016/j.math.2007.11.002. Epub 2008 Jan 3.

62. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sports Med. 2015;34(2):213-231. doi: 10.1016/j.csm.2014.12.005. Epub 2015 Jan 24.

63. von Brevern M, Radtke A, Lezius F, et al. Epide-miology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715. Epub 2006 Nov 29.

64. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clini-cal practice guideline: benign paroxysmal positional ver-tigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi: 10.1177/0194599816689667.

65. Fife TD, Iverson DJ, Lempert T, et al. Practice param-eter: therapies for benign paroxysmal positional verti-

go (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-2074. doi: 10.1212/01.wnl.0000313378.77444.ac.

66. Balatsouras DG, Koukoutsis G, Aspris A, et al. Benign paroxysmal positional vertigo secondary to mild head trauma. Ann Otol Rhinol Laryngol. 2017;126(1):54-60. Epub 2016 Oct 25.

67. Geurts AC, Ribbers GM, Knoop JA, van Limbeek J. Identification of static and dynamic postural instability following traumatic brain injury. Arch Phys Med Rehabil. 1996;77(7):639-644.

68. Guskiewicz KM. Regaining balance and postural equi-librium. In: Prentice WE, ed. Rehabilitation Techniques in Sports Medicine. 3rd ed. Boston, MA: WCB Mc-Graw-Hill; 1999:107–133.

69. Guskiewicz KM, Riemann BL, Perrin DH, Nashner LM. Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc. 1997;29(7 Suppl):S213-221.

70. Peterson CL, Ferrara MS, Mrazik M, Piland S, Elliott R. Evaluation of neuropsychological domain scores and postural stability following cerebral concussion in sports. Clin J Sport Med. 2003;13(4):230-237.

71. Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. 2001;11(3):182-189.

72. Parker TM, Osternig LR, Lee HJ, Donkelaar P, Chou LS. The effect of divided attention on gait stability following concussion. Clin Biomech (Bristol, Avon). 2005;20(4):389-395. Epub 2005 Jan 28.

73. Catena RD, van Donkelaar P, Chou LS. Cognitive task effects on gait stability following concussion. Exp Brain Res. 2007;176(1):23-31. Epub 2006 Jul 7.

74. Catena RD, van Donkelaar P, Chou LS. The effects of attention capacity on dynamic balance control fol-lowing concussion. J Neuroeng Rehabil. 2011;8:8. doi: 10.1186/1743-0003-8-8.

75. Hain TC. Neurophysiology of vestibular rehabilitation. NeuroRehabilitation. 2011;29(2):127-141. doi: 10.3233/NRE-2011-0687.

76. Herdman SJ. Role of vestibular adaptation in ves-tibular rehabilitation. Otolaryngol Head Neck Surg. 1998;119(1):49-54.

77. Bittar RS, Lins EM. Clinical characteristics of patients with persistent postural-perceptual dizziness. Braz J Otorhinolaryngol. 2015;81(3):276-282. doi: 10.1016/j.bjorl.2014.08.012. Epub 2014 Sep 6.

78. Dieterich M, Staab JP. Functional dizziness: from phobic postural vertigo and chronic subjective dizzi-ness to persistent postural-perceptual dizziness. Curr Opin Neurol. 2017;30(1):107-113. doi: 10.1097/WCO.0000000000000417.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

18

79. Furman JM, Balaban CD, Jacob RG, Marcus DA. Migraine-anxiety related dizziness (MARD): a new dis-order? J Neurol Neurosurg Psychiatry. 2005;76(1):1-8.

80. Mihalik JP, Stump JE, Collins MW, Lovell MR, Field M, Maroon JC. Posttraumatic migraine characteristics in athletes following sports-related concussion. J Neurosurg. 2005;102(5):850-855.

81. Kontos AP, Elbin RJ, Lau B, et al. Posttraumat-ic migraine as a predictor of recovery and cogni-tive impairment after sport-related concussion. Am J Sports Med. 2013;41(7):1497-1504. doi: 10.1177/0363546513488751. Epub 2013 May 22.

82. Mihalik JP, Register-Mihalik J, Kerr ZY, Marshall SW, McCrea MC, Guskiewicz KM. Recovery of posttraumat-ic migraine characteristics in patients after mild traumat-ic brain injury. Am J Sports Med. 2013;41(7):1490-1496. doi: 10.1177/0363546513487982. Epub 2013 May 21.

83. Noseda R, Burstein R. Migraine pathophysiology: anato-my of the trigeminovascular pathway and associated neu-rological symptoms, CSD, sensitization and modulation of pain. Pain. 2013;154 Suppl 1:S44-53. doi: 10.1016/j.pain.2013.07.021.

85. Peroutka SJ. What turns on a migraine? A systemat-ic review of migraine precipitating factors. Curr Pain Headache Rep. 2014;18(10):454. doi: 10.1007/s11916-014-0454-z.

85. Ahn AH. Why does increased exercise decrease mi-graine? Curr Pain Headache Rep. 2013;17(12):379. doi: 10.1007/s11916-013-0379-y.

86. Kapoor N, Ciuffreda KJ. Vision disturbances follow-ing traumatic brain injury. Curr Treat Options Neurol. 2002;4(4):271-280.

87. Scheiman M, Gwiazda J, Li T. Non-surgical interven-tions for convergence insufficiency. Cochrane Database Syst Rev. 2011;(3):CD006768. doi: 10.1002/14651858.CD006768.pub2.

88. Ciuffreda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, Han ME. Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry. 2008;79(1):18-22.

89. Thiagarajan P, Ciuffreda KJ, Capo-Aponte JE, Ludlam DP, Kapoor N. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI): an inte-grative approach. NeuroRehabilitation. 2014;34(1):129-146. doi: 10.3233/NRE-131025.

90. Ellis MJ, Ritchie LJ, Koltek M, et al. Psychiatric outcomes after pediatric sports-related concus-sion. J Neurosurg Pediatr. 2015;16(6):709-718. doi: 10.3171/2015.5.PEDS15220. Epub 2015 Sep 11.

91. Max JE, Keatley E, Wilde EA, et al. Anxiety disorders in children and adolescents in the first six months after traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2011;23(1):29-39. doi: 10.1176/appi.neuro-psych.23.1.29.

92. Kontos AP, Covassin T, Elbin RJ, Parker T. Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Arch Phys Med Rehabil. 2012;93(10):1751-1756. doi: 10.1016/j.apmr.2012.03.032. Epub 2012 Apr 10.

93. Losoi H, Silverberg ND, Waljas M, et al. Recovery from mild traumatic brain injury in previously healthy adults. J Neurotrauma. 2016;33(8):766-776. doi: 10.1089/neu.2015.4070. Epub 2015 Dec 17.

94. Hou R, Moss-Morris R, Peveler R, Mogg K, Bradley BP, Belli A. When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury. J Neurol Neurosurg Psychiatry. 2012;83(2):217-223. doi: 10.1136/jnnp-2011-300767. Epub 2011 Oct 25.

95. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikoc-ka-Walus A, Schonberger M. Predictors of postconcus-sive symptoms 3 months after mild traumatic brain inju-ry. Neuropsychology. 2012;26(3):304-313. doi: 10.1037/a0027888. Epub 2012 Apr 2.

96. Lange RT, Iverson GL, Rose A. Depression strong-ly influences postconcussion symptom reporting following mild traumatic brain injury. J Head Trau-ma Rehabil. 2011;26(2):127-137. doi: 10.1097/HTR.0b013e3181e4622a.

97. Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma. 2009;66(2):289-296; discussion 296-297. doi: 10.1097/TA.0b013e3181961da2.

98. Emery CA, Barlow KM, Brooks BL, et al. A systematic review of psychiatric, psychological, and behavioural out-comes following mild traumatic brain injury in children and adolescents. Can J Psychiatry. 2016;61(5):259-269. doi: 10.1177/0706743716643741.

99. Rebar AL, Stanton R, Geard D, Short C, Duncan MJ, Vandelanotte C. A meta-meta-analysis of the effect of physical activity on depression and anxiety in non-clini-cal adult populations. Health Psychol Rev. 2015;9(3):366-378. doi: 10.1080/17437199.2015.1022901. Epub 2015 Jul 3.

100. Wegner M, Helmich I, Machado S, Nardi AE, Arias-Carrion O, Budde H. Effects of exercise on anxiety and depression disorders: review of meta- analyses and neurobiological mechanisms. CNS Neurol Disord Drug Targets. 2014;13(6):1002-1014.

101. Ravindran AV, Lam RW, Filteau MJ, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depres-sive disorder in adults. V. Complementary and alter-native medicine treatments. J Affect Disord. 2009;117 Suppl 1:S54-64. doi: 10.1016/j.jad.2009.06.040. Epub 2009 Aug 8.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

19

102. Cramer H, Anheyer D, Lauche R, Dobos G. A sys-tematic review of yoga for major depressive disorder. J Affect Disord. 2017;213:70-77. doi: 10.1016/j.jad.2017.02.006. Epub 2017 Feb 7.

103. Wang F, Lee EK, Wu T, et al. The effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. Int J Behav Med. 2014;21(4):605-617.

104. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368. doi: 10.1001/jamaint-ernmed.2013.13018.

105. Crowe K, McKay D. Efficacy of cognitive-behavior-al therapy for childhood anxiety and depression. J Anxiety Disord. 2017;49:76-87. doi: 10.1016/j.janx-dis.2017.04.001. Epub 2017 Apr 20.

106. Twomey C, O’Reilly G, Byrne M. Effectiveness of cog-nitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Fam Pract. 2015;32(1):3-15. doi: 10.1093/fampra/cmu060. Epub 2014 Sep 22.

107. Cox GR, Callahan P, Churchill R, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev. 2014;(11):CD008324. doi: 10.1002/14651858.CD008324.pub3.

108. Davidson JR. Major depressive disorder treatment guide-lines in America and Europe. J Clin Psychiatry. 2010;71 Suppl E1:e04. doi: 10.4088/JCP.9058se1c.04gry.

109. Strawn JR, Sakolsky DJ, Rynn MA. Psychopharma-cologic treatment of children and adolescents with anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-539. doi: 10.1016/j.chc.2012.05.003. Epub 2012 May 24.

110. Giza CC, DiFiori J. Pathophysiology of sports-related concussion: an update on basic science and translational research. Sports Health. 2011;3(1):46-51.

111. Towns SJ, Silva MA, Belanger HG. Subjective sleep quality and postconcussion symptoms following mild traumatic brain injury. Brain Inj. 2015;29(11):1337-1341. doi: 10.3109/02699052.2015.1045030. Epub 2015 Aug 7.

112. Sullivan KA, Edmed SL, Allan AC, Karlsson LJ, Smith SS. Characterizing self-reported sleep disturbance after mild traumatic brain injury. J Neurotrauma. 2015;32(7):474-486. doi: 10.1089/neu.2013.3284. Epub 2015 Feb 6.

113. Meehan WP, 3rd. Medical therapies for concussion. Clin Sports Med. 2011;30(1):115-124, ix. doi: 10.1016/j.csm.2010.08.003.

114. Kinnaman KA, Mannix RC, Comstock RD, Meehan WP 3rd. Management strategies and medication use for treating paediatric patients with concussions. Acta Pae-

diatr. 2013;102(9):e424-428. doi: 10.1111/apa.12315. Epub 2013 Jul 10.

115. 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(4):260-265. doi: 10.1097/HTR.0b013e318257fbc6.

116. Morgan CD, Zuckerman SL, Lee YM, et al. Predic-tors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 2015;15(6):589-598. doi: 10.3171/2014.10.PEDS14356. Epub 2015 Mar 6.

117. Petraglia AL, Maroon JC, Bailes JE. From the field of play to the field of combat: a review of the pharma-cological management of concussion. Neurosurgery. 2012;70(6):1520-1533; discussion 1533. doi: 10.1227/NEU.0b013e31824cebe8.

118. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmaco-therapies. Headache. 2015;55(1):3-20. doi: 10.1111/head.12499.

119. S ilberstein SD. Preventive migraine treatment. Continu-um (Minneap Minn). 2015;21(4 Headache):973-989. doi: 10.1212/CON.0000000000000199.

120. Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-720. doi: 10.2147/NDT.S33769. Epub 2013 May 17.

121. Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmaco-logical Treatments. Can J Psychiatry. 2016;61(9):540-560. doi: 10.1177/0706743716659417. Epub 2016 Aug 2.

122. Heyer GL, Idris SA. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concus-sion patients? Pediatr Neurol. 2014;50(5):464-468. doi: 10.1016/j.pediatrneurol.2014.01.040. Epub 2014 Jan 24.

123. Kristoffersen ES, Lundqvist C. Medication-overuse headache: a review. J Pain Res. 2014;7:367-378. doi: 10.2147/JPR.S46071. eCollection 2014.

124. Hawkins JR, Gonzalez KE, Heumann KJ. The ef-fectiveness of hyperbaric oxygen therapy as a treat-ment for postconcussion symptoms. J Sport Rehabil. 2017;26(3):290-294. doi: 10.1123/jsr.2015-0087. Epub 2016 Nov 11.

125. McGrane IR, Leung JG, St Louis EK, Boeve BF. Mela-tonin therapy for REM sleep behavior disorder: a critical review of evidence. Sleep Med. 2015;16(1):19-26. doi: 10.1016/j.sleep.2014.09.011. Epub 2014 Oct 13.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.

20

126. Costello RB, Lentino CV, Boyd CC, et al. The effec-tiveness of melatonin for promoting healthy sleep: a rapid evidence assessment of the literature. Nutr J. 2014;13:106. doi: 10.1186/1475-2891-13-106.

127. Ashbaugh A, McGrew C. The role of nutritional supplements in sports concussion treatment. Curr Sports Med Rep. 2016;15(1):16-19. doi: 10.1249/JSR.0000000000000219.

128. Teigen L, Boes CJ. An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine. Cephalalgia. 2015;35(10):912-922. doi: 10.1177/0333102414564891. Epub 2014 Dec 22.

129. Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized

controlled trial. Neurology. 1998;50(2):466-470.130. Sandor PS, Di Clemente L, Coppola G, et al. Efficacy of

coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology. 2005;64(4):713-715.

131. D’Onofrio F, Raimo S, Spitaleri D, Casucci G, Bussone G. Usefulness of nutraceuticals in migraine prophylaxis. Neurol Sci. 2017;38(Suppl 1):117-120. doi: 10.1007/s10072-017-2901-1.

132. Mucha A, Collins MW, Elbin RJ, et al. A brief Ves-tibular/Ocular Motor Screening (VOMS) assess-ment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. doi: 10.1177/0363546514543775. Epub 2014 Aug 8.

Ort

hopa

edic

Sec

tion,

APT

A, I

nc.

Dow

nloa

ded

from

ww

w.o

rtho

ptle

arn.

org

at th

e O

rtho

paed

ic S

ectio

n on

Sep

tem

ber

26, 2

018.

For

per

sona

l use

onl

y. N

o ot

her

uses

with

out p

erm

issi

on.

Cop

yrig

ht ©

201

8 O

rtho

paed

ic S

ectio

n, A

PTA

, Inc

. All

righ

ts r

eser

ved.