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Gene therapy in sport
R J Trent and I E Alexander
Br. J. Sports Med. 2006;40;4-5
doi:10.1136/bjsm.2005.021709
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2 EDITORIAL
Bone mass The conundrum posed by the effec-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tiveness of rest insertion lies with its
contradiction of the   bigger the stimu-
lus, the bigger the response  principle.
Building bone mass through exercise: The potential mechanisms underlying
the effectiveness of rest insertion are
could less be more? numerous and may range from simple
amplification of standard pathways to
activation of alternative signalling path-
T S Gross, S Srinivasan
ways. Given the difficulty associated
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
with defining specific biochemical
mechanotransduction pathways in vivo,
Insertion of a rest interval between loading events greatly
we have begun to explore this question
amplifies the response of bone to loading
from a different perspective, using
approaches of complex adaptive system
biology to identify particular aspects of
vast literature supports the sen- elderly populations has been the incom- cellular activation that may explain the
11
sitivity of bone to mechanical plete elucidation of specific bone
effectiveness of rest inserted loading.
Aloading. When mechanical load- mechanotransduction pathways. In vivo Complex adaptive (biological) systems
ing is acutely diminished, as occurs with
studies of bone adaptation have clearly are characterised by internal heteroge-
paralysis or other forms of disuse, bone
confirmed that bone is responsive to a neity, hierarchical structure, non-linear
1
mass is rapidly degraded. Alternatively,
variety of specific aspects of mechanical interactions, and high degrees of con-
bone is also capable of substantial
loading such as magnitude and serial nectivity within and between parts of
6 7
augmentation following long term exer-
bouts of activity. Although the benefit the system. Approaches used to analyse
2
cise. In combination, these observations
of increased loading or activity even- such systems are typically inductive and
suggest that mechanical loading of the
tually plateaus, few would argue that are premised on the observation that
skeleton is essential for maintenance of
the greater the stimulus, the bigger the local interactions (such as generation
bone homoeostasis and holds potential
response of the tissue. Substantial pro- and/or perception of signalling mole-
to serve as a substantial anabolic stimu-
cules by adjacent osteocytes) are capable
gress has been made in studying the
lus. Given the extremely debilitating
molecular events underlying this path- of inducing emergent system behaviours
nature of bone loss pathologies and
way, including identification of numer- (such as osteoblast activity days or
nascent development stage of anabolic
weeks after the loading event).
ous second messengers, transcription
interventions capable of enhancing ske-
In this context, we have examined
factors, and signal transduction genes,
letal mass and morphology at both
how rest inserted stimuli may be per-
the regulation of which is rapidly altered
trabecular and cortical sites, examina-
ceived by osteocytes by an agent based
in various bone cells by mechanical
tion of how mechanical loading induces
modelling technique that is uniquely
stimuli. However, mechanotransduction
bone formation continues to be an area
within bone remains a largely unre- suited to studying counterintuitive and
of substantial study.
emergent phenomena. The model pre-
solved area of research.
dicted that inserting a rest interval
  & high magnitude loading is not between load cycles enhances and sus-
  & rest insertion serves to reduce
practical for those seniors acutely in tains signalling activity within osteocy-
the amount and magnitude of
need of bone augmentation  tic networks. This augmented signalling
mechanical loading required for an
arose by a combination of more effi-
intervention to be perceived as
ciently exploiting the dynamics of sec-
The most efficacious exercise inter-
stimulatory, even in the aged skele-
ond messenger generation and
ventions have exposed young develop-
ton 
depletion and by augmenting intercel-
ing skeletons to dynamic impact loads
3
lular communication within the osteo-
such as those induced by jumping. The
Our recent efforts in this area have
cyte network. Thus the model suggests
success of such a regimen stems, in part,
focused on developing strategies to
that the osteogenic potency of rest
from the enhanced ability of the devel-
  trick  bone into perceiving that mild
inserted stimuli emerges from real time
oping skeleton to respond to mechanical
loading activities, such as walking, are
activity induced within the cellular
stimuli compared with an aged skele-
4 stimulatory for bone accretion. If suc-
syncytium of the bone during the brief
ton and, we would argue, the inter-
cessful, such an approach could greatly
time that is, seconds that the skele-
mittent nature of activities such as
broaden the use of exercise to build
ton is subjected to loading. The agent
jumping. However, although impact
bone mass. In a recent series of in vivo
based modelling approach also holds
exercise interventions may serve to
studies, our group (and others) have
potential for expansion to examine
augment peak skeletal strength and
observed that the insertion of a rest
transduction of specific signalling mole-
thereby serve as a potential prophylaxis
interval between each loading event
cules for example, Ca2+ or ATP or
for future osteopenias, high magnitude
greatly amplifies the response of bone
enhanced diffusion of these factors as
loading is not practical for those seniors
to loading. This strategy is capable of
might be achieved by rest inserted
acutely in need of bone augmentation.
transforming a brief (100 second) low
loading. Pending further studies and
Exercise that is accessible for this
magnitude regimen that is normally
population, such as the relatively mild experimental validation, it appears that
ignored by bone into one that is potently
skeletal loading that might be generated biological mechanisms of rest insertion
osteogenic. As well, it appears that rest may lie at the level of altering how
by walking or resistance exercise, is not
perceived as a stimulus for bone forma- insertion serves to reduce the amount osteocytes behave within the context of
5
tion. and magnitude of mechanical loading their local cellular neighbourhood.
It is quite likely that a primary required for an intervention to be The specific signalling pathways
contributor to the poor efficacy of perceived as stimulatory, even in the underlying the effectiveness of rest
8 10
exercise interventions in adult and aged skeleton. insertion may prove elusive. However,
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EDITORIAL 3
11 Gross TS, Poliachik SL, Ausk BJ, et al. Why rest
Competing interests: none declared
it is our belief that this strategy may
stimulates bone formation: a hypothesis based on
yield positive clinical results without
complex adaptive phenomenon. Exerc Sport Sci
exact knowledge of its mechanism. In Rev 2004;32:9 13.
this context, our complexity based REFERENCES
approach may provide a tool to optimise
1 Leblanc AD, Schneider VS, Evans HJ, et al. Bone
mineral loss and recovery after 17 weeks of bed
rest inserted loading waveforms and to
rest. J Bone Miner Res 1990;5:843 50.
design strategies that compensate for
2 Haapasalo H, Kannus P, Sievanen II, et al. Long-
potential variations associated with fac-
COMMENTARY
term unilateral loading and bone mineral density
tors such as age or genetic background.
and content in female squash players. Calcif Tiss
Int 1994;54:29 55.
With future optimisation, rest insertion
Dynamic mechanical loading has been shown
3 Petit MA, McKay HA, MacKelvie KJ, et al. A
holds the potential to enable more bone
to actively influence the adaptive activities of
randomized school-based jumping intervention
accretion with less exercise compared
bone in many animal studies and clinical
confers site and maturity-specific benefits on bone
with current repetitive loading strate- structural properties in girls: a hip structural observations. This report reviews recent
analysis study. J Bone Miner Res 2002;17:363 72.
studies on rest insertion between loading
gies. Whereas cyclic aerobic exercise
4 Rubin CT, Bain SD, McLeod KJ. Suppression of the
events, which amplifies the response of bone
undoubtedly confers numerous physio-
osteogenic response in the aging skeleton. Calcif
to loading, and suggests that the adaptation
logical and psychological benefits
Tissue Int 1992;50:306 13.
of bone to mechanical loading may be
5 Pruitt LA, Taaffe DR, Marcus R. Effects of a one-
beyond the skeleton, a rest inserted
triggered by specific mechanical stimuli, but
year high-intensity versus low-intensity resistance
exercise regimen, in our view, holds
not necessarily correlate with the   magni-
training program on bone mineral density in
greatly enhanced potential for utilisa- tude  per se. The authors further develop a
older women. J Bone Miner Res
model and examine the cellular signalling
tion in a couch potato era of substan- 1995;10:1788 95.
pathway to predict the signalling activity in
6 Rubin CT, Lanyon LE. Regulation of bone mass by
tially diminished physical fitness.
the osteocytic networks. This is an interesting
mechanical strain magnitude. Calcif Tissue Int
Br J Sports Med 2006;40:2 3.
1985;37:411 17. approach to explaining how bone is sensitive
doi: 10.1136/bjsm.2004.016972 7 Robling AG, Burr DB, Turner CH. Partitioning a
to novel mechanical intervention at the
daily mechanical stimulus into discrete loading
cellular level. The high anabolic response to
bouts improves the osteogenic response to
. . . . . . . . . . . . . . . . . . . . . . rest insertion of loading may also be sup-
loading. J Bone Miner Res 2000;15:1596 602.
ported by the mechanotransduction pathway,
Authors affiliations
8 LaMothe JM, Zernicke RF. Rest insertion
in which rest insertion would improve the
T S Gross, S Srinivasan, University of
combined with high-frequency loading enhances
fluid saturation caused by continuous loading
Washington, Seattle, WA, USA osteogenesis. J Appl Physiol 2004;96:1788 93.
and enhance perfusion in bone. This work
9 Lee KC, Jessop H, Suswillo R, et al. The adaptive
provides valuable insight into the mechanism
response of bone to mechanical loading in female
Correspondence to: Dr Gross, Department of
of bone adaptation and potential design of
transgenic mice is deficient in the absence of
Orthopaedics and Sports Medicine, University
therapeutic strategies for clinical applica-
oestrogen receptor-alpha and -beta. J Endocrinol
of Washington, 1959 NE Pacific St, Box
2004;182:193 201. tions.
356500, Seattle, WA 98195-6500, USA;
10 Srinivasan S, Agans SC, King KA, et al. Enabling
[e-mail]
bone formation in the aged skeleton via rest- Y-X Qin
inserted mechanical loading. Bone SUNY at Stony Brook, New York, NY, USA;
Accepted 12 July 2005 2003;33:946 55. [e-mail]
Exercise for chronic disease can be biased for many reasons, such as
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . genetic selection bias and inability to
control for all confounding lifestyle
3
factors. However, it has been widely
Benefits of exercise therapy for chronic accepted that an epidemiological obser-
vational study with supportive data
from studies on disease mechanisms
diseases
provides enough evidence for exercise
recommendations in disease prevention.
U M Kujala
Conclusive evidence for the benefits of
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
exercise in the treatment of patients
with chronic disease using the limited
Evidence on the benefits of exercise therapy for chronic diseases
resources of the healthcare system
based on randomised controlled trials is accumulating
should optimally be based on well
1
designed RCTs. Recently, the number
of RCTs evaluating the effects of physi-
cal exercise therapy for specific diseases
egular physical activity is one FROM PREVENTION TO
has increased substantially, allowing
means of decreasing disability and
TREATMENT
disease specific systematic reviews
R
increasing the number of indepen- Traditionally physical activity has been
including meta-analyses.
dently living elderly people, as well as
regarded as a powerful tool in the
decreasing the costs of the healthcare
prevention of certain chronic diseases,
system. On the basis of a recent review
even though this has been confirmed in MAIN FINDINGS OF SYSTEMATIC
2
of the results of randomised controlled only a very few cases by RCTs. When REVIEWS BASED ON RCTS
trials (RCTs), there is accumulating the strength of evidence for the use of The most consistent finding of the
evidence that, in patients with chronic exercise in health care is evaluated, data studies is that exercise capacity or
disease, exercise therapy is effective in from epidemiological observational fol- muscle strength can be improved in
increasing fitness and correcting some low ups, studies on the mechanisms of patients with different diseases without
risk factors for the development of disease, and controlled clinical trials are having detrimental effects on disease
1 1
disease complications. used. Observational follow up studies progression. Severe complications in
www.bjsportmed.com
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4 LEADER
3
the exercise trials were rare. In some exercise therapy may have a beneficial smoking are also important, as is the
diseases, such as osteoarthritis, pain effect on the long term progression of optimal medication.
1
symptoms may also be reduced. Most specific diseases. However, there is a
Br J Sports Med 2006;40:3 4.
RCTs are too short to document disease need for RCTs with long term follow
doi: 10.1136/bjsm.2005.021717
progression. Studies on patients with ups, including documentation, of such
4
Correspondence to: Dr Kujala, Department of
coronary heart disease, as well as outcomes as survival rate, rate of hospi-
Health Sciences, University of Jyvaskyla, PO
5
studies on patients with heart failure, tal admission, and healthcare costs.
Box 35, Jyvaskyla, Finland; urho.kujala@sport.
show that exercise groups have a some-
jyu.fi
what reduced all-cause mortality. The
CLINICAL PRESCRIPTION OF
Accepted 1 August 2005
clinically very significant findings
EXERCISE
include that exercise therapy has bene-
Competing interests: none declared
Doctors prescribing exercise therapy have
ficial effects on all metabolic syndrome
to know the basics of exercise physiology
components and is highly beneficial for
and training principles. Also, tailoring of a
1 6
patients with type 2 diabetes mellitus. REFERENCES
programme depends on the disease and
1 Kujala UM. Evidence for exercise therapy in the
its stage, the baseline fitness level of the
treatment of chronic disease based on at least
STUDY QUALITY IS IMPORTANT patient, and the goals of the programme
three randomized controlled trials: summary of
Before the results are considered, the set together with the patient. published systematic reviews. Scand J Med Sci
Sports 2004;14:339 45.
methodological quality of the individual The available RCTs include a large
2 Kesäniemi YA, Danforth E, Jensen MD, et al.
7 8
RCTs should be critically analysed. variety of effective training programmes.
Dose-response issues concerning physical activity
Biased results from poorly designed Most patients seem to benefit from low
and health: an evidence-based symposium. Med
Sci Sports Exerc 2001;33:S351 8.
and reported trials can mislead decision to moderate intensity aerobic exercise.
3 Kujala UM, Kaprio J, Koskenvuo M. Modifiable
making. It should be taken into account Detailed conclusions on the dose-
risk factors as predictors of all-cause-mortality:
that exercise trials cannot usually be response of exercise therapy in the
the roles of genetics and childhood environment.
Am J Epidemiol 2002;156:985 93.
properly blinded, which may lessen the treatment of specific diseases cannot be
4 Taylor RS, Brown A, Ebrahim S, et al.
reliability of the results. In addition to drawn from the available RCTs. We have
Exercise-based rehabilitation for patients with
other quality criteria, we have to keep in to remember that the beneficial results of
coronary heart disease: systematic review and
meta-analysis of randomized controlled trials.
mind that generalisability may be a exercise therapies for patients with
Am J Med 2004;116:682 92.
problem as some RCTs include patients chronic disease shown by RCTs are based
5 Smart N, Marwick TH. Exercise training for
that are not representative of the gen- on carefully planned and followed exer-
patients with heart failure: a systematic review of
eral population of patients with regard cise interventions in patients whose factors that improve mortality and morbidity.
Am J Med 2004;116:693 706.
to age and coexisting diseases. This is clinical status has first been examined
6 Boule NG, Haddad E, Kenny GP, et al. Effect of
typically seen in RCTs on coronary heart to take into account possible risks.
exercise on glycemic control and body mass in
disease and heart failure. Unlike the prevention of disease in young type 2 diabetes mellitus. A meta-analysis of
controlled clinical trials. JAMA
The fact that most trials are of short healthy people, the therapeutic range of
2001;286:1218 27.
duration means that some benefits, physical activity for patients with chronic
7 Altman DG, Schulz KF, Moher D, et al. The
such as increases in physical fitness, disease may be limited. In exercise
revised CONSORT statement for reporting
randomized trials: explanation and elaboration.
are reached within weeks or months. therapy, long term adherence is a general
Ann Intern Med 2001;134:663 94.
However, specific RCTs are usually too problem. Exercise consultations face to
8 Van Tulder M, Furlan A, Bombardier C, et al.
short to provide conclusive evidence on face or by telephone can be used to
Updated method guidelines for systematic reviews
9
in the Cochrane Collaboration Back Review
the effects of exercise therapy on the maintain high physical activity levels.
Group. Spine 2003;28:1290 9.
true progression of disease. RCTs on the Also, whereas we look for evidence of the
9 Kirk A, Mutrie N, MacIntyre P, et al. Increasing
effects of exercise on lipid risk factors, benefits of exercise therapy from RCTs
physical activity in people with type 2 diabetes.
Diabetes Care 2003;26:1186 92.
blood pressure levels, and glucose specifically investigating the effects of
6 10 Leon AS, Sanchez OA. Response of blood lipids
homoeostasis, as well as sporadic long exercise, in clinical work we have to bear
to exercise alone or combined with dietary
term follow ups of disease progres- in mind that correction of other modifi-
intervention. Med Sci Sports Exerc
4 5 10
sion, support the conclusion that able risk factors such as diet and 2001;33:S502 15.
Gene therapy The transfer of genetic material into
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cells can be undertaken in many ways,
most commonly using a viral vector. For
this, viruses are genetically engineered
Gene therapy in sport
to remove infectious potential while
retaining the capacity to carry a ther-
R J Trent, I E Alexander apeutic gene(s) into selected target cells.
The inserted sequences can encode a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
missing or mutant product as might
occur in the case of cancer, or alterna-
The potential benefits of gene therapy for sports injuries are
tively could be used to inhibit a foreign
counterbalanced by the potential for gene doping
protein as would be found in HIV
infection. Viral vectors have been
uman gene therapy involves the missing or mutant genes could be derived from a number of different
insertion of DNA (or RNA) into replaced or repaired. Today, gene ther- viruses. Some, such as the adenovirus,
H are associated with relatively mild
somatic cells to produce a ther- apy has broader applications, with trials
apeutic effect. Gene therapy was first covering many clinical problems includ- human infections, whereas others are
envisaged as an approach to treating ing genetic diseases, cancer, infections associated with more serious disease, for
genetic disorders. In this scenario, such as HIV, and degenerative diseases. example HIV. Certain viral properties
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LEADER 5
with the potential for harm to be passed
Table 1 Human gene therapy studies with potential application to sport
on to an athlete s children.
Model Status Today, the risks for gene doping are
much greater than the taking of tradi-
Muscular dystrophy Using animals with muscular dystrophy caused by mutations in the dystrophin
tional chemical products. Those
gene, it is possible with gene therapy to inject into muscle a functional
4
dystrophin gene. The effects observed include a reduction in contraction involved in sport should be sufficiently
induced injury, and an increase in muscle bulk.
informed of the risks, as well as likely
Muscular atrophy The National Aeronautics and Space Administration (NASA) in the United
future benefits of gene therapy. As the
States has shown that space travel can produce skeletal muscle atrophy.
technology improves, many of the com-
Experimental studies are now underway to determine the preventive effects of
5
plications may be avoided, and so
IGF1 in a retroviral vector given regularly by intramuscular injection.
Rheumatoid arthritis Phase I studies show little toxicity when inflammatory molecules such as
ongoing assessment of the potential for
interleukin 1 are inhibited by intra-articular injection of gene therapy
gene doping will be necessary. Detecting
6
products.
gene doping cheats will be possible
using the standard assays as well as
through the identification of gene vec-
tors or their products. The bypassing of
various metabolic pathways through the
insertion of genes may lead to changes
are particularly useful for gene therapy, future time be used to treat sporting
in gene expression profiles, and this
such as the capacity to permanently injuries (table 1).
may open up another approach to
integrate introduced genetic sequences
detecting gene doping.
into the host cell genome.
GENE DOPING IN SPORT
Apart from viruses, there are numer-
Br J Sports Med 2006;40:4 5.
Sports men and women and sporting
ous physicochemical methods for intro-
doi: 10.1136/bjsm.2005.021709
administrators faced with the prospect
ducing DNA (or RNA) into somatic cells.
of drug cheating and blood doping now
. . . . . . . . . . . . . . . . . . . . . .
The most relevant in the context of sport 7
need to consider gene doping. Although
Authors affiliations
involves direct injection of DNA that has
therapeutic benefit from gene therapy is
R J Trent, Department of Molecular and
been formulated with a chemical carrier
difficult to achieve, gene doping is
Clinical Genetics, Royal Prince Alfred Hospital
for more efficient uptake by cells. None
paradoxically more feasible because a
in the Central Clinical School, University of
of the physicochemical approaches has
very large output from the introduced
Sydney, NSW, Australia
been successful in human trials, as the
gene may not be required, and the I E Alexander, Gene Therapy Research Unit,
levels of gene transfer achieved are
The Children s Hospital, Westmead and
desired effect need only be short term.
insufficient for therapeutic benefit.
Children s Medical Research Institute, Sydney,
Regular injections at the time of sport-
NSW, Australia
The results in gene therapy have
ing events may suffice. Gene doping is
generally been disappointing despite
further simplified as it would not be
1
over 1000 clinical trials since 1990. Correspondence to: Professor Trent,
necessary to have the transferred gene
Department of Molecular and Clinical Genetics,
Only two diseases have been success-
regulated so that its output corresponds
Royal Prince Alfred Hospital in the Central
fully treated by gene therapy. Both are
to specific cellular requirements as
Clinical School, University of Sydney, NSW
forms of severe combined immunodefi-
might be the case for treating disease. 2050, Australia; [e-mail]
2 3
ciency, SCID-X1 and ADA-deficiency.
Genes of relevance to doping such as
Competing interests: none declared
Unfortunately, success has come at a
growth hormone, insulin-like growth
cost, with three of 18 infants with SCID-
factor I, and erythropoietin have been
X1 treated developing leukaemia. This
cloned, and so are readily available.
REFERENCES
has now been shown to have been
They could be used as an alternative
1 Gene therapy clinical trials worldwide. http://
caused by insertional mutagenesis,
way to produce a range of performance www.wiley.co.uk/genmed/clinical (accessed 19
Oct 2005).
which had previously been considered
enhancing agents. The risks of taking
2 Cavazzana-Calvo M, Hacein-Bey S, de Saint
a remote theoretical risk associated with
these substances in the form of tradi-
Basile G, et al. Gene therapy of human severe
the integrating gene transfer technology
tional chemicals are known, and so
combined immunodeficiency (SCID)-X1 disease.
Science 2000;288:669 72.
used. decisions about risk versus benefit are
3 Aiuti A, Vai S, Mortellaro A, et al. Immune
At present, there are three limitations straightforward. The same cannot be
reconstitution in ADA-SCID after PBL gene therapy
to gene therapy: (a) gene transfer said for gene doping, as there continue
and discontinuation of enzyme replacement. Nat
Med 2002;8:423 5.
technologies are not efficient enough to be many unknowns in this form of
4 DelloRusso C, Scott JM, Hartigan-O Connor D, et
for most applications; (b) therapeuti- cellular intervention. Effects cannot be
al. Functional correction of adult mdx mouse
cally useful integrating gene transfer predicted, and so the sportsperson tak-
muscle using gutted adenoviral vectors expressing
full-length dystrophin. Proc Natl Acad Sci USA
ing this route for cheating does not have
technologies carry unresolved risks; (c)
2002;99:12979 84.
there remains an inadequate under- control of the product. Random integra-
5 NASA Exploration Systems Mission Directorate
standing of the biology of therapeuti- tion of vector sequences, for example,
Education Outreach. http://weboflife.nasa.gov/
currentResearch/currentResearchFlight/
could produce complications such as
cally relevant target cell populations.
geneTherapy.htm (accessed 19 Oct 2005).
acute leukaemia or other forms of
6 Evans CH, Robbins PD, Ghivizzani SC, et al.
cancer. Finally, unlike taking a drug,
Gene transfer to human joints: progress toward a
GENE THERAPY AND SPORTING gene therapy of arthritis. Proc Natl Acad Sci USA
gene transfer is not easy to reverse, and
2005;102:8698 703.
INJURIES so any untoward effects may be long
7 Haisma HJ. Gene doping: a report from the
There are a number of models illustrat- term. There is also a small risk of
Netherlands Centre for Doping Affairs. http://
ing how gene therapy may at some inadvertent gene transfer to germ cells www.genedoping.com (accessed 19 Oct 2005).
www.bjsportmed.com
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6 LEADER
Concussion and presentations of traumatic brain
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . injury, including mild, moderate, and
severe cerebral concussion, as well as
the more severe but less common head
Research based recommendations on injuries that can cause damage to the
brain stem and other vital centres of the
brain.
management of sport related
(2) The colloquial term   ding  should
not be used to describe a sport related
concussion: summary of the National
concussion. This stunned confusional
state is a concussion most often
Athletic Trainers Association position
reflected by the athlete s initial confu-
sion, which may disappear within min-
statement
utes, leaving no outward observable
signs and symptoms. Use of the term
K M Guskiewicz, S L Bruce, R C Cantu, M S Ferrara, J P Kelly,
  ding  generally carries a connotation
M McCrea, M Putukian, T C Valovich McLeod
that diminishes the seriousness of the
injury. If an athlete shows concussion-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
like signs and reports symptoms after a
Sport related concussion should always be treated seriously and contact to the head, the athlete has, at
the very least, sustained a mild concus-
systematically
sion and should be treated for a
concussion.
(3) To detect deteriorating signs and
13 38
port related concussion has physician referral and home care,
symptoms that may indicate a more
39 40
received considerable attention in youth athletes, and protective equip-
serious head injury, the ATC should be
41
S ment have also provided clinicians
both the lay media and medical
able to recognise both the obvious signs
literature in recent years. As a result, with a better understanding of how
(fluctuating levels of consciousness,
better to manage sport related concus-
clinicians, coaches, parents, and athletes
balance problems, memory and concen-
sion.
at all levels of competition are becoming
tration difficulties, etc) and common
educated about the necessity to treat To provide certified athletic trainers
self reported symptoms (headache, ring-
(ATCs), doctors, and other medical
concussions seriously. In time, this will
ing in the ears, nausea, etc).
help to create a safer playing environ- professionals with a comprehensive list
(4) The ATC should play an active role
ment for athletes at all levels of compe- of recommendations for managing con-
in educating athletes, coaches, and
cussions, the National Athletic Trainers
tition. Despite an array of complexities
parents about the signs and symptoms
Association (NATA) formed a commit-
associated with studying sport related
associated with concussion, as well as
tee charged with developing a research
concussion, new scientific research and
the potential risks of playing while still
based position statement derived from
clinically based literature have provided
symptomatic.
these most recent studies. The recom-
sports medicine professions with a
(5) The ATC should document all
mendations are intended for the treat-
wealth of updated information on the pertinent information surrounding the
ment of concussed athletes at the youth,
treatment of sport related concussion. concussive injury, including, but not
high school, collegiate, and elite levels.
For example, there is now sufficient limited to, (a) mechanism of injury,
The writing committee consisted of a
literature supporting the notion that (b) initial signs and symptoms, (c) state
team doctor, a neurosurgeon, a neurol-
of consciousness, (d) findings on serial
once you experience a concussion, you
ogist, a neuropsychologist, and four
testing of symptoms, neuropsychologi-
are more likely to sustain future con-
1 2
ATCs.
cal function, and postural stability (not-
cussions ; and a strong likelihood
The following summary includes
ing any deficits compared with
exists that the symptoms following
recommendations that can be found in
baseline), (e) instructions given to the
these repeat concussions may be more
1 3
the full article published in the Journal of
athlete and/or parent, (f) recommenda-
serious and resolve at a slower rate.
Athletic Training 2004;39:278 95. The full
tions provided by the physician, (g) date
Several recent research papers and con-
text and complete reference list for this
and time of the athlete s return to
sensus statements indicate the necessity
peer reviewed position statement is also
participation, and (h) relevant informa-
to use a systematic approach to evaluat-
available at http://www.pubmedcentral.
tion on the player s history of prior
ing the severity and duration of all
nih.gov and http://www.nata.org/
concussion and associated recovery pat-
possible signs and symptoms after a
publicinformation/position.htm.
tern(s).
concussion, and to be cautious of not
The summary statement is organised
returning players to competition too
4 16 into the following sections: Defining
quickly. Loss of consciousness and
EVALUATING AND MAKING THE
and recognising the concussion;
amnesia are two important parameters
RETURN TO PLAY DECISION
Evaluating and making the return to
associated with cerebral concussion, but
(6) ATCs and team physicians working
play decision; Concussion assessment
headaches, dizziness/balance deficits,
together should agree on a philosophy
tools; When to refer to a physician;
concentration deficits, and feeling   slo-
for managing sport related concussion
1 2 6 9 14 17 When to disqualify an athlete; Special
wed down  are more common.
before the start of the athletic season.
considerations for young athletes; Home
20
Extensive research has also been
Currently three approaches are com-
care; Equipment issues.
conducted on neuropsychological test-
monly used: (a) grading the concussion
17 19 34
ing and postural stability test-
at the time of the injury; (b) deferring
20 35 37
ing, both of which are considered DEFINING AND RECOGNISING
final grading until all symptoms have
to be key markers for tracking recovery THE CONCUSSION resolved; or (c) not using a grading
after cerebral concussion. Recent con- (1) The ATC should develop a high scale but rather focusing attention on
cussion publications on topics such as sensitivity for the various mechanisms the athlete s recovery by symptoms,
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LEADER 7
neurocognitive testing, and postural to establish the individual athlete s cerebral dysfunction in order to reduce
stability testing. After deciding on an   normal  pre-injury performance and the possibility of making false positive
approach, the ATC-physician team to provide the most reliable benchmark and false negative errors, which could
should be consistent in its use regardless against which to measure recovery. lead to clinical decision-making errors.
of the athlete, sport, or circumstances Baseline testing also controls for extra- (17) As is the case with all clinical
surrounding the injury. neous variables (attention deficit dis- instruments, results from assessment
measures to evaluate concussion should
(7) For athletes playing sports with a order, learning disabilities, age,
be integrated with all aspects of the
high risk of concussion, baseline cogni- education, etc) and for the effects of
tive and postural stability testing should previous concussion, while also evaluat- injury evaluation for example, physi-
cal examination, neurological evalua-
be considered. In addition to the con- ing the possible cumulative effects of
tion, neuroimaging, player s history,
cussion injury assessment, the evalua- recurrent concussions.
tion should also include an assessment etc for the most effective approach to
(13) The use of objective concussion
of the cervical spine and cranial nerves injury management and return to play
assessment tools will help ATCs in more
to identify any cervical spine or vascular decision making. Decisions about an
accurately identifying deficits caused by
intracerebral injuries. athlete s return to play should never be
injury and recovery from injury and
(8) The ATC should record the time of based solely on the use of any one test.
protect players from the potential risks
the initial injury and document serial
associated with prematurely returning
assessments of the injured athlete, not- to competition and sustaining a repeat
WHEN TO REFER TO A PHYSICIAN
ing the presence or absence of signs and
concussion. The concussion assessment
(18) The ATC or team physician should
symptoms of injury. The ATC should
battery should include a combination of
monitor an athlete with a concussion at
monitor vital signs and level of con-
tests for cognition, postural stability,
five minute intervals from the time of
sciousness every five minutes after a
and self reported symptoms known to
the injury until the athlete s condition
concussion until the athlete s condition
be affected by concussion.
completely clears or the athlete is
improves. The athlete should also be
(14) A combination of brief screening referred for further care. Coaches should
monitored over the next few days after
tools appropriate for use on the side- be informed that in situations when a
the injury for the presence of delayed
line for example, standardised assess- concussion is suspected but an ATC or
signs and symptoms and to assess
ment of concussion (SAC), balance error physician is not available, their primary
recovery.
scoring system (BESS), symptom check- role is to ensure that the athlete is
(9) Concussion severity should be
list and more extensive measures for immediately seen by an ATC or physician.
determined by paying close attention
example, neuropsychological testing, (19) An athlete with a concussion
to the severity and persistence of all
computerised balance testing to eval- should be referred to a physician on the
signs and symptoms, including the
uate more precisely recovery later after day of injury if he or she lost conscious-
presence of amnesia (retrograde and
injury is recommended. ness, experienced amnesia lasting
anterograde) and loss of consciousness,
longer than 15 minutes, or meets any
(15) Before instituting a concussion
as well as headache, concentration
of the criteria outlined in appendix B.
neuropsychological testing battery, the
problems, dizziness, blurred vision, etc.
(20) A team approach for the assess-
ATC should understand the test s user
It is recommended that ATCs and
ment of concussion should be used to
requirements, copyright restrictions,
physicians consistently use a symptom
include a variety of medical specialties.
and standardised instructions for
checklist similar to the one provided in
administration and scoring. All evalua- In addition to family practice or general
appendix A.
medicine physician referrals, the ATC
tors should be appropriately trained in
(10) In addition to a thorough clinical
should secure other specialist referral
the standardised instructions for test
evaluation, formal cognitive and pos-
sources within the community. For
administration and scoring before
tural stability testing is recommended to
example, neurologists are trained to
embarking on testing or adopting an
assist in objectively determining injury
assist in the management of patients
instrument for clinical use. Ideally, the
severity and readiness to return to play.
experiencing persistent signs and symp-
sports medicine team should include a
No one test should be used solely to
toms, including sleep disturbances.
neuropsychologist, but in reality, many
determine recovery or return to play, as
Similarly, a neuropsychologist should
ATCs may not have access to a neuro-
concussion presents in many different
be identified as part of the sports
psychologist for interpretation and con-
ways.
medicine team for assisting athletes
sultation, nor the financial resources to
(11) Once symptom-free or asympto-
who require more extensive neuro-
support a neuropsychological testing
matic, the athlete should be reassessed
psychological testing and for interpret-
program. In this case, it is recommended
to establish that cognition and postural
ing the results of neuropsychological
that the ATC use screening instruments
stability have returned to normal for
tests.
(SAC, BESS, symptom checklist) that
that player, preferably by comparison
(21) A team approach should be used
have been developed specifically for use
with pre-injury baseline test results. The
in making return to play decisions after
by sports medicine clinicians without
return to play decision should be made
concussion. This approach should
extensive training in psychometric or
after an incremental increase in activity
involve input from the ATC, physician,
standardised testing and that do not
with an initial cardiovascular challenge,
athlete, and any referral sources. The
require a special license to administer or
followed by sport specific activities that
assessment of all information including
interpret.
do not place the athlete at risk of
the physical examination, imaging
(16) ATCs should adopt for clinical
concussion. The athlete can be released
studies, objective tests, and exertional
use only, those neuropsychological and
to full participation as long as no
efforts should be considered before
postural stability measures with popula-
recurrent signs or symptoms are pre-
making a return to play decision.
tion specific normative data, test-retest
sent.
reliability, clinical validity, and suffi-
cient sensitivity and specificity estab- WHEN TO DISQUALIFY AN
CONCUSSION ASSESSMENT lished in the peer reviewed literature. ATHLETE
TOOLS These standards provide the basis for (22) Athletes who are symptomatic at
(12) Baseline testing on concussion how well the test can distinguish rest and after exertion for at least
assessment measures is recommended between those with and without 20 minutes should be disqualified from
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8 LEADER
returning to participation on the day of prospective investigations to determine similar to the one presented in appendix
the injury. Exertional exercises should the acute and long term effects of C, and it should be used consistently for
include sideline jogging followed by recurrent concussion in younger ath- all concussions.
sprinting, sit ups, push ups, and any letes are warranted.
sport specific, non-contact activities (or (28) Because damage to the maturing
positions or stances) the athlete might brain of a young athlete can be cata- EQUIPMENT ISSUES
(34) The ATC should enforce the stan-
need to perform on returning to parti- strophic (almost all reported cases of
cipation. Athletes who return on the second-impact syndrome are in young dard use of helmets for protecting
same day because symptoms resolved athletes), younger athletes (under the against catastrophic head injuries and
quickly (,20 minutes) should be mon- age of 18 years) should be managed reducing the severity of cerebral con-
itored closely after they return to play. more conservatively, using stricter cussions. In sports that require helmet
They should be repeatedly re-evaluated return to play guidelines than those protection (football, lacrosse, ice hockey,
on the sideline, after the practice or used to manage concussion in the more baseball/softball, etc), the ATC should
game, and again at 24 and 48 hours mature athlete. ensure that all equipment meets either
after the injury to identify any delayed the National Operating Committee on
onset of symptoms.
Standards for Athletic Equipment
HOME CARE
(23) Athletes who experience loss of
(NOCSAE) or American Society for
(29) An athlete with a concussion
consciousness or amnesia should be
Testing and Materials (ASTM) stan-
should be instructed to avoid taking
disqualified from participating on the
dards.
drugs except acetaminophen after the
day of the injury.
(35) The ATC should enforce the
injury. Acetaminophen and other drugs
(24) The decision to disqualify from
standard use of mouthguards for pro-
should only be given at the recommen-
further participation on the day of a
tection against dental injuries, even
dation of a physician. In addition, the
concussion should be based on a com-
though the scientific evidence support-
athlete should be instructed to avoid
prehensive physical examination,
ing their use for reducing concussive
ingesting alcohol, illicit drugs, or other
assessment of self reported post-concus-
injury is not yet convincing.
substances that might interfere with
sion signs and symptoms, functional
(36) At this time, the ATC should
cognitive function and neurological
impairments, and the athlete s history
neither endorse nor discourage the use
recovery.
of concussions. If assessment tools such
of soccer headgear for protecting against
(30) Any athlete with a concussion
as the SAC, BESS, neuropsychological
concussion or the consequences of
should be instructed to rest, but com-
test battery, and symptom checklist are
cumulative, subconcussive impacts to
plete bed rest is not recommended. The
not used, a seven day symptom-free
the head. Currently, no scientific evi-
athlete should resume normal activities
waiting period before returning to par-
dence supports the use of headgear in
of daily living as tolerated, while avoid-
ticipation is recommended. Some cir-
soccer for reducing concussive injury to
ing activities that potentially increase
cumstances, however, will warrant even
the head.
symptoms. Once he or she is asympto-
more conservative treatment (see
matic, the athlete may resume a graded
recommendation 25).
programme of physical and mental
Br J Sports Med 2006;40:6 10.
(25) ATCs should be more conserva-
exertion, without contact or risk of
doi: 10.1136/bjsm.2005.021683
tive with athletes who have a history of
concussion, up to the point at which
concussion. Athletes with a history of
. . . . . . . . . . . . . . . . . . . . . .
post-concussion signs and symptoms
concussion are at increased risk of
recur. If symptoms appear, the exertion Authors affiliations
sustaining subsequent injuries, as well
K M Guskiewicz, Department of Exercise and
level should be scaled back to allow
as slow recovery of self reported post-
Sport Science, University of North Carolina at
maximal activity without triggering
concussion signs and symptoms, cogni-
Chapel Hill, Chapel Hill, NC, USA
symptoms.
tive dysfunction, and postural instability
S L Bruce, California State University of
(31) An athlete with a concussion
after subsequent injuries. In athletes Pennsylvania, California, PA, USA
should be instructed to eat a well
R C Cantu, Emerson Hospital, Concord, MA,
with a history of three or more concus-
balanced diet that is nutritious in both
USA and Neurological Sports Injury Center,
sions who are experiencing slow recov-
quality and quantity.
Brigham and Women s Hospital, Boston, MA,
ery, temporary or permanent
(32) An athlete should be awakened
USA
disqualification from contact sports
during the night to check on deteriorat- M S Ferrara, Exercise and Sport Science,
may be indicated.
ing signs and symptoms only if he or she University of Georgia, Athens, GA, USA
J P Kelly, University of Colorado School of
experienced loss of consciousness, had
Medicine, Denver, CO, USA
SPECIAL CONSIDERATIONS FOR prolonged periods of amnesia, or was
M McCrea, Waukesha Memorial Hospital,
YOUNG ATHLETES still experiencing significant symptoms
Waukesha, WI, USA
(26) ATCs working with younger (pae- at bedtime. The purpose of the wake ups
M Putukian, Princeton University, Princeton,
diatric) athletes should be aware that is to check for deteriorating signs and
NJ, USA
recovery may take longer than in older symptoms, such as decreased levels of
T C V McLeod, Department of Sport Health
athletes. In addition, these younger consciousness or increasing headache,
Care, Arizona School of Health Sciences,
athletes are maturing at a relatively fast which could indicate a more serious
Mesa, AZ, USA
rate and will probably require more head injury or a late onset complication
frequent updates of baseline measures such as an intracranial bleed.
Correspondence to: Dr Guskiewicz,
compared with older athletes. (33) Oral and written instructions for
Department of Exercise and Sport Science,
(27) Many young athletes experience home care should be given to the athlete University of North Carolina at Chapel Hill,
Chapel Hill, NC 27599-8700, USA; gus@
sport related concussion. ATCs should and to a responsible adult for example,
email.unc.edu
play an active role in helping to educate parents or roommate who will observe
young athletes, their parents, and coa- and supervise the athlete during the Competing interests: none declared
ches about the dangers of repeated acute phase of the concussion while at
The authors represent the writing team of the
concussions. Continued research into home or in the dormitory. The ATC and
National Athletic Trainers Association position
the epidemiology of sport related physician should agree on a standard
statement on management of sport related
concussion in young athletes and concussion home instruction form concussion. J Athl Train 2004;39:278 95.
www.bjsportmed.com
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LEADER 9
2001: recommendations for the improvement of
Appendix A
safety and health of athletes who may suffer
concussive injuries. Br J Sports Med
2002;36:6 10.
Graded symptom checklist (GSC)
5 Bailes JE, Hudson V. Classification of sport-
related head trauma: a spectrum of mild to severe
Time of 2 3 h 24 h 48 h 72 h
injury. J Athl Train 2001;36:236 43.
Symptom injury after injury after injury after injury after injury
6 Cantu RC. Posttraumatic retrograde and
anterograde amnesia: pathophysiology and
Blurred vision
implications in grading and safe return to play.
Dizziness
J Athl Train 2001;36:244 8.
Drowsiness
7 Giza CC, Hovda DA. The neurometabolic cascade
Excess sleep
of concussion. J Athl Train 2001;36:228 35.
Easily distracted
8 Guskiewicz KM, Cantu RC. The concussion
Fatigue
puzzle: evaluation of sport-related concussion.
Feel   in a fog 
Am J Med Sports 2004;6:13 21.
Feel   slowed down 
9 Kelly JP. Loss of consciousness: Pathophysiology
Headache
and implications in grading and safe return to
Inappropriate emotions
play. J Athl Train 2001;36:249 52.
Irritability 10 Lovell MR, Iverson GL, Collins MW, et al. Does
Loss of consciousness loss of consciousness predict neuropsychological
decrements after concussion? Clin J Sport Med
Loss or orientation
1999;9:193 8.
Memory problems
11 Lovell MR, Collins MW, Iverson GL, et al.
Nausea
Recovery from mild concussion in high school
Nervousness
athletes. J Neurosurg 2003;98:296 301.
Personality change
12 Lovell MR, Collins MW, Iverson GL, et al. Grade
Poor balance/coord.
1 or   ding  concussions in high school athletes.
Poor concentration
Am J Sports Med 2004;32:47 54.
Ringing in ears
13 McCrory P. What advice should we give to
Sadness
athletes postconcussion? Br J Sports Med
Seeing stars
2002;36:316 18.
Sensitivity to light
14 McCrory P, Ariens T, Berkovic SF. The nature and
Sensitivity to noise
duration of acute concussive symptoms in
Sleep disturbance
Australian football. Clin J Sport Med
Vacant stare/glassy eyed
2000;10:235 8.
Vomiting
15 Oliaro S, Anderson S, Hooker D. Management
of cerebral concussion in sports: the athletic
trainer s perspective. J Athl Train
Note: the GSC should be used not only for the initial evaluation but for each subsequent follow up
2001;36:257 62.
assessment until all signs and symptoms have cleared at rest and during physical exertion. In lieu of
16 Practice parameter: the management of
simply checking each symptom present, the ATC can ask the athlete to grade or score the severity of the
concussion in sports (summary statement).
symptom on a scale of 0 6, where 0 = not present, 1 = mild, 3 = moderate, and 6 = most severe.
Report of the Quality Standards Subcommittee of
the American Academy of Neurology. Neurology
1997;48:581 5.
17 Collins MW, Iverson GL, Lovell MR, et al. On-field
Appendix B
predictors of neuropsychological and symptom
deficit following sports-related concussion.
Physician referral checklist Clin J Sport Med 2003;13:222 9.
18 Erlanger D, Kaushik T, Cantu R, et al. Symptom-
based assessment of the severity of a concussion.
Day of injury referral
J Neurosurg 2003;98:477 84.
1. Loss of consciousness on the field
19 Erlanger D, Saliba E, Barth JT, et al. Monitoring
2. Amnesia lasting longer than 15 minutes
resolution of postconcussion symptoms in athletes:
3. Deterioration of neurological function*
preliminary results of a web-based
4. Decreasing level of consciousness*
neuropsychological test protocol. J Athl Train
5. Decrease or irregularity in respirations*
2001;36:280 7.
6. Decrease or irregularity in pulse*
20 McCrea M, Guskiewicz KM, Barr W, et al. Acute
7. Increase in blood pressure
effects and recovery time following concussion in
8. Unequal, dilated, or unreactive pupils*
collegiate football players: the NCAA Concussion
9. Cranial nerve deficits
Study. JAMA 2003;290:2556 63.
10. Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding*
21 Barr WB, McCrea M. Sensitivity and specificity of
11. Mental status changes: lethargy, difficulty maintaining arousal, confusion, agitation*
standardized neurocognitive testing immediately
12. Seizure activity*
following sports concussion. J Int Neuropsychol
13. Vomiting
Soc 2001;7:693 702.
14. Motor deficits subsequent to initial on-field assessment
22 Bleiberg J, Cernich AN, Cameron K, et al.
15. Sensory deficits subsequent to initial on-field assessment Duration of cognitive impairment after sports
16. Balance deficits subsequent to initial on-field assessment concussion. Neurosurgery 2004;54:1073 80.
23 Collie A, Darby D, Maruff P. Computerised
17. Cranial nerve deficits subsequent to initial on-field assessment
cognitive assessment of athletes with sports
18. Post-concussion symptoms that worsen
related head injury. Br J Sports Med
19. Additional post-concussion symptoms as compared with those on the field
2001;35:297 302.
20. Athlete is still symptomatic at the end of the game (especially at high school level)
24 Collie A, Maruff P, Makdissi M, et al.
Delayed referral (after the day of injury)
CogSport: reliability and correlation with
1. Any of the findings in the day of injury referral category
conventional cognitive tests used in
2. Post-concussion symptoms worsen or do not improve over time
postconcussion medical evaluations. Clin J Sport
3. Increase in the number of post-concussion symptoms reported
Med 2003;13:28 32.
4. Post-concussion symptoms begin to interfere with the athlete s daily activities (sleep disturbances,
25 Collins MW, Field M, Lovell MR, et al.
cognitive difficulties)
Relationship between postconcussion headache
and neuropsychological test performance in high
*Requires the athlete be transported immediately to the nearest emergency department.
school athletes. Am J Sports Med
2003;31:168 73.
26 Collins MW, Grindel SH, Lovell MR, et al.
school football players. Am J Sports Med
Relationship between concussion and
REFERENCES
2000;28:643 50.
neuropsychological performance in college
1 Guskiewicz KM, McCrea M, Marshall SW, et al.
3 Iverson GL, Gaetz M, Lovell MR, et al. Cumulative
football players. JAMA 1999;282:964 70.
Cumulative effects of recurrent concussion in
effects of concussion in amateur athletes. Brain
27 Collins MW, Lovell MR, Iverson GL, et al.
collegiate football players: the NCAA Concussion
Injury 2004;18:433 43. Cumulative effects of concussion in high school
Study. JAMA 2003;290:2549 55.
4 Aubry M, Cantu R, Dvorak J, et al. Summary and athletes. Neurosurgery 2002;51:1175 81.
2 Guskiewicz KM, Weaver NL, Padua DA, et al.
agreement statement of the First International 28 Daniel JC, Olesniewicz MH, Reeves DL, et al.
Epidemiology of concussion in collegiate and high
Conference on Concussion in Sport, Vienna Repeated measures of cognitive processing
www.bjsportmed.com
Downloaded from bjsm.bmj.com on 4 February 2007
10 LEADER
31 McCrea M. Standardized mental status
Appendix C
assessment of sports concussion. Clin J Sport Med
2001;11:176 81.
Concussion home instructions 32 McCrea M. Standardized mental status testing on
________________________________________________________________________________________ the sideline after sport-related concussion. J Athl
I believe that __________________________ sustained a concussion on ________________________. To Train 2001;36:274 9.
33 McCrea M, Kelly JP, Randolph C, et al. Immediate
make sure he/she recovers, please follow the following important recommendations:
neurocognitive effects of concussion.
1. Please remind________________________________ to report to the athletic training room tomorrow
Neurosurgery 2002;50:1032 42.
at ____________________ for a follow-up evaluation.
34 Pottinger L, Cullum M, Stallings RL. Cognitive
2. Please review the items outlined on the enclosed Physician Referral Checklist. If any of these problems
recovery following concussion in high school
develop prior to his/her visit, please call_____________________at ___________________ or contact
athletes. Arch Clin Neuropsychol
the local EMS. Otherwise, you can follow the instructions outlined below.
1999;14:39 40.
35 Guskiewicz KM, Ross SE, Marshall SW. Postural
It is OK to: There is NO need to: Do NOT:
stability and neuropsychological deficits after
l l l
Use acetaminophen (Tylenol) for Stay in bed Drink alcohol concussion in collegiate athletes. J Athl Train
l l 2001;36:263 73.
headaches Check eyes with flashlight Eat or drink, spicy
l l 36 Peterson CL, Ferrara MS, Mrazik M, et al. An
Eat a light diet Wake up every hour foods or drinks
analysis of domain score and posturography
l l
Use ice pack on head & neck as Test reflexes
following cerebral concussion. Clin J Sport Med
needed for comfort
2003;13:230 7.
l
Return to school
37 Riemann BL, Guskiewicz KM. Effects of mild head
l
Go to sleep
injury on postural stability as measured through
l
Rest (no strenuous activity or sports)
clinical balance testing. J Athl Train
Special recommendations: 2000;35:19 25.
_____________________________________________________________________________________ 38 de Kruijk JR, Leffers P, Meerhoff S, et al.
Effectiveness of bed rest after mild traumatic brain
_____________________________________________________________________________________
injury: a randomised trial of no versus six days of
Recommendations provided to: __________________________________________________________
bed rest. J Neurol Neurosurg Psychiatry
Recommendations provided by: ________________Date: ________________ Time: ________________
2002;73:167 72.
Please feel free to contact me if you have any questions. I can be reached at: ___________________
39 Adams J, Frumiento C, Shatney-Leach L, et al.
Signature: ___________________________________ Date: ___________________________________
Mandatory admission after isolated mild closed
head injury in children: is it necessary? J Pediatr
Surg 2001;36:119 21.
40 Field M, Collins MW, Lovell MR. Does age play
a role in recovery from sports related concussion?
efficiency in adolescent athletes: implications for following sports-related mild traumatic brain
A comparison of high school school and
monitoring recovery from concussion. injury. Clin J Sport Med 2001;11:23 31.
collegiate athletes. Am J Pediatr
Neuropsychiatry Neuropsychol Behav Neurol 30 Makdissi M, Collie A, Maruff P, et al.
2003;142:546 53.
1999;12:167 9. Computerised cognitive assessment of concussed 41 Halstead DP. Performance testing updates in
29 Echemendia R, Putukian M, Mackin RS, et al. Australian Rules footballers. Br J Sports Med head, face, and eye protection. J Athl Train
Neuropsychological test performance prior to and 2001;35:354 60. 2001;36:322 7.
11th European Forumon Quality Improvement in Health Care
26 28 April 2006, Prague, Czech Republic
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