Concussion treatment: Adolescent athletes 'prescribed' aerobic exercise recovered faster

Adolescent athletes who sustained concussions while playing a sport recovered more quickly when they underwent a supervised, aerobic exercise regimen, a study published Feb. 4 in JAMA Pediatrics has found.

The study, by University at Buffalo researchers and colleagues, is the first randomized clinical trial of a treatment in the acute phase after a sport-related concussion. The goal was to evaluate prescribed, progressive sub-symptom threshold exercise as a treatment within the first week of a concussion in adolescents after a few days of rest. Sub-symptom threshold exercise is physical activity that doesn't exacerbate symptoms.

The researchers followed 103 participants ages 13-18, with nearly the same number of males and females. All were seen within 10 days after sustaining a sport-related concussion at one of the UBMD Orthopaedics and Sports Medicine clinics in Western New York or at the Pan Am Clinic in Winnipeg.

Patients who followed the aerobic exercise program took on average 13 days to recover while those in the control group, who performed stretching exercises, took 17 days. In addition, fewer patients in the exercise program took longer than four weeks to recover than did patients in the control group.

"This research provides the strongest evidence yet that a prescribed, individualized aerobic exercise program that keeps the heart rate below the point where symptoms worsen is the best way to treat concussion in adolescents," said John J. Leddy, MD, first author, clinical professor of orthopaedics in the Jacobs School of Medicine and Biomedical Sciences at UB, and director of the UB Concussion Management Clinic at UBMD Orthopaedics and Sports Medicine.

The researchers plan to investigate if the treatment is also effective in adults with concussion.


No proven treatment
 
The researchers noted that there is no proven treatment for concussion, especially among adolescents, who typically take the longest to recover.

"Until now, nothing else has been proven in any way effective for treating concussion," said Barry S. Willer, PhD, senior author, director of research in the UB Concussion Management Clinic and professor of psychiatry in the Jacobs School. "This is the best evidence so far for a treatment that works."

The findings directly contradict the conventional approach to concussion, which often consists of nearly total rest, eliminating most physical and mental activities, including schoolwork.

"Telling a teenager to go home and basically do nothing is depressing," said Willer. "It can actually increase their physical and psychological symptoms, and we see that particularly among girls. But with our approach, you're saying, sure, you can return to school and you should start doing these exercises. Their chins are up, Mom and Dad are happy and so is the student."

The fact that all states have now passed laws requiring schools to make accommodations for students who have sustained concussions is also helpful, said Willer, so that the student can opt out of some activities during the school day, if necessary.


The proper 'dose' of exercise
 
To determine how much exercise each patient could sustain without exacerbating symptoms, the researchers had each one undergo the Buffalo Concussion Treadmill Test, developed by Leddy and Willer, to determine at what level their symptoms worsen. As the patient walks on a treadmill, the incline is gradually increased and the heart rate is recorded at the point where concussion symptoms intensify.

"We prescribed exercise at 80 percent of that threshold," Leddy explained, "so each patient's exercise 'dose' was individually tailored."

Patients were randomly assigned to the aerobic exercise group (52) or to a stretching group (51). Patients in both groups were sent home with a heart rate monitor so they could make sure they stayed below the threshold while exercising.

Both groups performed their assigned exercise for about 20 minutes each day and were required to report compliance and daily symptoms online. Those in the aerobic group either walked on a treadmill, rode a stationary bike, or walked either inside or out. Aside from the prescribed exercise, patients were advised to refrain from contact sports, gym class or team practice. They were given advice about getting schoolwork done and told to avoid excessive use of electronic devices, since that can also aggravate symptoms.

Each patient's condition was re-evaluated weekly and as symptoms improved, the "dose" of exercise or stretching was increased, according to the weekly treadmill test results.

Recovery was rigorously defined, requiring agreement among three independent criteria: the patient's reporting a normal (minimal) level of symptoms, a normal physical examination by a medical doctor, and the return of normal exercise tolerance on the Buffalo Concussion Treadmill Test. The physicians were blinded as to the group assignment of each participant.

One surprising finding was that only two participants out of 52 (4 percent) in the aerobic exercise group took longer than four weeks to recover compared to seven out of 51 (14 percent) in the stretching group. This did not reach statistical significance, but the scientific literature suggests, by contrast, that between 15 and 25 percent of adolescents who do not receive any treatment will be symptomatic past four weeks.

"Reducing the number of concussed adolescents who have delayed recovery has major implications," Willer said, noting that delayed recovery creates more difficulty with schoolwork, can lead to depression and puts additional demands on the health care system and its costs.


Expanding capacity for medically supervised exercise treatment
 
Michael J. Ellis, MD, co-author and medical director of the Pan Am Concussion Program in the Department of Surgery and Pediatrics at the University of Manitoba, said that for years, his clinic has been successfully using the Buffalo Concussion Treadmill Test and a medically supervised sub-symptom-threshold aerobic exercise program to treat professional, collegiate and elite adolescent athletes.

Expanding access to this treatment is now critical, he said.

"The results of this study suggest that we must build greater capacity within our health care systems to allow patients access to multidisciplinary concussion programs and clinics that have the medical expertise to carry out early targeted rehabilitation of acute concussion," he said.

Leddy and Willer are internationally known for their research into the best ways to diagnose and treat concussion, especially among adolescents, who are the most vulnerable age group for concussions and take the longest time to recover. They have led the emerging body of research findings that show that a patient's degree of exercise intolerance in the first week after injury, i.e., the lower the threshold of activity at which symptoms increase, is a key clinical indicator of how severe the concussion may be.

New wisdom about high cholesterol for adults aged 80 and older

Experts know that in adults younger than 65, having high cholesterol levels in your blood can raise your risk for heart attacks and strokes. However, in adults 80 years old and older, researchers have not--until now--thoroughly studied high cholesterol's impact on heart disease, your ability to function well, or your risk for death.

In fact, some research shows that a higher level of total cholesterol and a lower level of so-called "bad" cholesterol (also known as "low-density lipoprotein" or LDL cholesterol) might be helpful in protecting your ability to perform daily activities and preserving your life for longer.

What's more, it appears that having low cholesterol is linked to a higher risk of death from cancer, respiratory disease, and accidents in adults aged 80 and older. It also appears that the benefits of taking medications known as statins, which lower cholesterol, may lessen as people age. Researchers even have a phrase for this phenomenon. They call it the "risk factor paradox." This describes the fact that for adults aged 80 and older, having some conditions that are considered health risks in younger adults predicts better survival. These conditions include having higher total cholesterol, higher blood pressure, and higher body mass index (BMI, a ratio of body weight to height that helps determine whether you are overweight or obese).

"Triglycerides" are one type of blood fat that your body uses for energy. High levels of triglycerides can raise risks for heart disease in younger adults. However, we don't know as much about the risks to adults aged 80 and older, or whether high levels of triglycerides can affect their risks for disability or even death.

A team of researchers in China decided to learn more about whether current triglyceride-level guidelines make sense for people aged 80 and older. To do so, the team explored links between triglyceride levels and the ability to perform daily self-care activities, cognitive function (the ability to think and make decisions), and frailty (a condition associated with aging that increases the risks of poor health, falls, disability, and death. Signs of frailty include weakness, weight loss, and low activity levels.). Researchers also looked at whether triglyceride levels had an impact on death in a group of 930 Chinese adults aged 80 or older.
The researchers learned that for the oldest people in the study, having a higher triglyceride level was linked to a lower risk of cognitive decline, less of a reduction in the ability to perform daily tasks, less frailty, and lower risk for death.
The researchers said their results challenge current thinking that having high triglyceride levels is a risk factor for age-related chronic disorders and death. The researchers said their study suggested that, after the age of 80, taking medication to lower cholesterol may not have much--or any--benefit.

Patients with TMD and fibromyalgia report most benefit from self-care techniques

While oral appliances such as splints and bite guards are the most common treatment for facial pain from temporomandibular disorders (TMD), patients rate them as less helpful than self-care treatments, such as jaw exercises or warm compresses, finds a new study by researchers at NYU College of Dentistry.
The study, published in the journal Clinical Oral Investigations, suggests that self-care techniques should be the first line of treatment for muscle-related TMD.
TMD (sometimes called TMJ after the temporomandibular joint) is a group of common pain conditions that occur in the jaw joint and surrounding muscles. The muscular condition, called myofascial temporomandibular disorder (mTMD), affects over 10 percent of women. People with TMD often have other pain conditions; research shows that 7 to 18 percent of people with TMD also meet criteria for fibromyalgia, a condition characterized by widespread pain.
Dentists and patients use a variety of treatments to manage facial pain, including oral appliances, such as splints and bite guards, pain medications, such as nonsteroidal anti-inflammatory drugs, and self-care techniques, such as jaw exercises and warm compresses.
"Oral appliances are a common first-line treatment for TMD, despite mixed research results regarding their benefit. Even when oral splints have been found to have some benefit, they have not been found as effective for patients who also have widespread pain in the treatment of mTMD," said Vivian Santiago, assistant research scientist in the Department of Oral and Maxillofacial Pathology, Radiology, and Medicine at NYU College of Dentistry and the study's lead author.
In this study, the researchers examined what non-medication treatments women with mTMD use to manage their pain and how effective patients perceive the treatments to be. The researchers examined and interviewed a total of 125 women with mTMD, including 26 who had both mTMD and fibromyalgia, in order to determine whether treatment differed for patients with widespread pain.
The most common treatments reported were oral appliances (used by 59 percent of participants), physical therapy (54 percent), and at-home jaw exercises (34 percent). Less common treatments included acupuncture (20 percent), seeing a chiropractor (18 percent), trigger point injection (14 percent), exercise or yoga (7 percent), and meditation or breathing (6 percent). Participants often used more than one treatment (2.4 on average).
Participants reported the most improvement in their pain from common self-care activities, including jaw exercises, yoga or exercise, meditation, massage, and warm compresses, with over 84 percent reporting that these activities helped them at least a little. In contrast, only 64 percent of those who used oral appliances--the most popular treatment--reported that they helped at least a little. A small proportion of women who used oral appliances (11 percent) said that oral appliances made their pain worse, an area that warrants further research.
"Oral appliances did not outperform self-management care techniques in improving facial pain. Our results support the use of self-management as the first line of treatment for mTMD before considering more expensive interventions," said Karen Raphael, professor in the Department of Oral and Maxillofacial Pathology, Radiology and Medicine at NYU College of Dentistry and the study's co-author.
The researchers did not find significant differences between the number of treatments reported by women with and without fibromyalgia. While the use of alternative treatments, such as acupuncture and seeing a chiropractor, was reported more frequently among women with fibromyalgia and mTMD, they did not necessarily find more relief. Interestingly, physical therapy was used equally by women with and without fibromyalgia, but self-reported improvement tended to be higher for those with fibromyalgia.
"While fibromyalgia is diagnosed by a physician, usually a rheumatologist, TMD is usually diagnosed and treated by a dentist. Our research suggests that dentists should ask patients with facial pain about whether they also have widespread pain, as this could provide more information to help plan their treatment," said Santiago.
"Although clinical trials are critical for understanding treatment efficacy, our study highlights the importance of listening to people suffering with TMD to understand which treatments are the most beneficial," added Raphael.

The dangers of hidden fat: Exercise is your best defense against deep abdominal fat

Scientists know that the type of fat you can measure with a tape isn't the most dangerous. But what is the most effective way to fight internal, visceral fat that you cannot see or feel? The answer: exercise.
Researchers at UT Southwestern Medical Center analyzed two types of interventions - lifestyle modification (exercise) and pharmacological (medicine) - to learn how best to defeat fat lying deep in the belly. The study is published in Mayo Clinic Proceedings.

"Visceral fat can affect local organs or the entire body system. Systemically it can affect your heart and liver, as well as abdominal organs," said senior author and cardiologist Dr. Ian J. Neeland, Assistant Professor of Internal Medicine. "When studies use weight or body mass index as a metric, we don't know if the interventions are reducing fat everywhere in the body, or just near the surface."
To find out, the researchers evaluated changes in visceral fat in 3,602 participants over a 6-month period measured by a CT or MRI exam. Both exercise and medicines resulted in less visceral fat, but the reductions were more significant per pound of body weight lost with exercise.

"The location and type of fat is important. If you just measure weight or BMI, you can underestimate the benefit to your health of losing weight," said Dr. Neeland, a Dedman Family Scholar in Clinical Care. "Exercise can actually melt visceral fat."

Participants in exercise trials were 65 percent female, with a mean age of 54 and mean BMI at enrollment of 31. Exercise regimens were monitored, not self-reported. The majority of exercise trials were performed in the U.S. and Canada, while pharmacologic trials included the U.S., Canada, Sweden, Japan, and four multinational cohorts.

The medications used by study participants were FDA approved or in the FDA approval pipeline.

According to the Centers for Disease Control and Prevention, obesity affects nearly 40 percent of adult Americans. Dr. Neeland said researchers previously thought of fat as inert storage, but over the years this view evolved and fat is now seen as an active organ. "Some people who are obese get heart disease, diabetes, or metabolic syndrome - and others don't," Dr. Neeland said. "Our study suggests that a combination of approaches can help lower visceral fat and potentially prevent these diseases."

Simple guidelines to measure walking intensity

In an ongoing study exploring walking for health across the adult lifespan, University of Massachusetts Amherst kinesiology researchers found that walking cadence is a reliable measure of exercise intensity and set simple steps-per-minute guidelines for moderate and vigorous intensity.
Catrine Tudor-Locke, professor of kinesiology, and postdoctoral researchers Elroy Aguiar and Scott Ducharme concluded that for adults, age 21-40, walking about 100 steps per minute constitutes moderate intensity, while vigorous walking begins at about 130 steps per minute.

The research, published this month in the International Journal of Behavioral Nutrition and Physical Activity, offers walkers a concrete way to track their activity level without relying on exercise devices or complicated calculations about oxygen consumption or heart rate. It represents the first set of outcomes from Tudor-Locke's ongoing, five-year CADENCE-Adults study, funded with a $2.2 million grant from the NIH's National Institute on Aging. The study seeks to establish the relationship between walking cadence (steps per minute) and intensity (metabolic rate) across the adult lifespan, from age 21 to 85.

Using the study's initial results for younger adults, walkers can simply count their steps to determine their approximate exercise intensity. Counting steps for 15 seconds and multiplying by four, for example, will determine steps per minute.

"This research establishes a very practical method to measure the intensity of walking, one that is very easy to communicate and also rigorously validated by the science," says Tudor-Locke, a well-known expert on the steps-per-day question.
To ensure sex and age balance, researchers recruited 10 men and 10 women for each five-year age group between 21 and 40, for a total of 80 healthy participants. They performed a series of five-minute walks on a treadmill, with two-minute rests, as their cadence was hand-tallied and intensity (METs) was measured using a portable indirect calorimeter. Sessions began at .5 mph and increased in .5 mph increments until participants either began to run, reached 75 percent of their predicted maximum heart rate or reported a perceived exertion of "somewhat hard."
Federal guidelines call for 150 minutes of "moderate" or 75 minutes of "vigorous" exercise each week. Moderate intensity is defined as activity that requires 3 METs (metabolic equivalents of task), or three times the amount of oxygen that's consumed while sitting still. In the study, moderate-intensity walking began at about 2.7 mph and was equal to 3 METs. Vigorous walking was associated with 6 METs.
Aguiar said that the natural walking pace of 90 percent of the study participants was above the moderate-pace threshold. "If you just tell people to walk at their normal speed, they probably are going to walk above 100 steps per minute. Asking people to walk for exercise is a low-cost, low-skill, feasible activity choice which has the potential to drastically improve people's health," he says.
The research suggests a simple but powerful public health message: Just walk, as much as possible. "Our society has engineered movement out of our life," Aguiar says. "We have TVs, we have cars, we have remotes. It's clear that you can achieve the public health guidelines for physical activity through walking."
Researchers used two distinct analytical methods to determine the approximate walking cadence thresholds. They also found that after moderate intensity walking of 100 steps per minute was reached, each 10 steps-per-minute increase was associated with an increase in intensity of one MET. So, 4 METs is roughly equivalent to 110 steps per minute and 5 METs with 120 steps per minute.
Although the findings confirm data from previous research, the CADENCE-Adults study is the first calibration study to use a sex-and-age-balanced sampling approach, Tudor-Locke said. Future reports from the study may establish age-appropriate walking thresholds.

Common test for mental health understanding is biased, study finds

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How do clinicians rate how well a patient understands what other people are thinking and feeling? That is to say -- how does the patient assess another person's mental state?

An accurate tool is key for measuring treatment outcomes and carries profound consequences for the patient's mental and physical well-being.

To that end, psychologists determine a person's mental state understanding (MSU), which is based on the theory that success in the social world hinges upon our ability to decipher and infer the hidden beliefs, emotions, and intentions of others. A large body of research has demonstrated that being able to do so results in a number of positive social effects: increased popularity, improved interpersonal rapport, prosocial behavior, and the like.

Conversely, those who struggle with MSU experience a variety of negative effects: few friends, isolation, and the risk for severe psychiatric illness, such as schizophrenia spectrum disorders. The link between social isolation, psychiatric illness, and mortality is a strong one, hence the importance of a reliable assessment tool.

Problematic test

The National Institute for Mental Health (NIMH) recommends a test, called the Reading the Mind in the Eyes Task (RMET). Here, participants view 36 black and white photographs, originally selected from magazine articles, of solely the eyes of Caucasian female and male actors. Participants then decide which of four adjectives -- such as panicked, incredulous, despondent, or interested -- best describes the mental state expressed in the eyes (the correct answer has been generated through consensus ratings).

But there's a problem. Using data from more than 40,000 people, a new study published this month in Psychological Medicine concludes that the test is deeply flawed.

"It's biased against the less educated, the less intelligent, and against ethnic and racial minorities," says lead author David Dodell-Feder, an assistant professor of psychology at the University of Rochester. "It relies too heavily on a person's vocabulary, intelligence, and culturally-biased stimuli. That's particularly problematic because it's endorsed by the national authority in our field and therefore the most widely-used assessment tool."
What surprised the researchers most was that the difference in the performance of people of some races and certain levels of education was as large or even larger than the difference between neurotypical people and people with schizophrenia or autism -- two groups that exhibit well-documented, marked, and pervasive social difficulties.
The team, comprising Rochester's Dodell-Feder, and Harvard Medical School and McLean Hospital's Kerry Ressler and Laura Germine, studied 40,248 native-speaking or primarily English-speaking people between the ages of 10 to 70. Study participants completed one of five measures on TestMyBrain.org: either the RMET, or a shortened version of RMET, a multiracial emotion identification task, an emotion discrimination task, or a non-social/non-verbal processing speed task of digit symbol matching.
The scientists found that education, race, and ethnicity explained more of the variance in a person's RMET performance, and that the differences between levels of education, race, and ethnicity were more pronounced for the RMET -- compared to the other three tasks.
As a result, more highly educated, non-Hispanic, and white or Caucasian individuals performed best on the RMET. The researchers concluded that the RMET may be unduly influenced by social class and culture, hence posing a serious challenge to assessing correctly the mental state understanding in clinical populations, especially given the strong link between social status and psychiatric illness. The team also discovered that unlike on other tasks, the performance on the RMET improved across a person's lifespan.
"The findings are troubling because they suggest that the RMET task may not be appropriately assessing mental state understanding in certain groups of people," says Dodell-Feder, who also holds a secondary appointment in the Department of Neuroscience at the University of Rochester Medical Center.
On a practical level, false assessment can be costly -- monetarily and for the patient's health. Missed MSU impairments could lead researchers and clinicians to fail to identify someone at risk for social difficulties, leading them on a path towards mental and physical decline, the researchers warn.
On the other hand, detecting impairments where they do not exist, could lead to misidentifying someone as being at-risk for social difficulties, or worse, psychopathology, causing potential stigma and unnecessary and costly interventions. Alternatively, clinicians could incorrectly conclude that a treatment for social dysfunction is working when it is not, and vice versa.
So, should the RMET be thrown out entirely?
Not necessarily, says Dodell-Feder. One could keep the design of the task but use different stimuli that are multiracial and include different response options, which contain a less complicated vocabulary. Team member Germine is currently testing a new, multiracial version of the task. Another option would be to abandon it, or use it alongside other tasks that have been demonstrated to be valid cross-culturally, of which there are very few in the current literature.
"Either way, our findings show that it might be premature for NIMH to make strong recommendations regarding the use of certain tasks for measuring mental state understanding before we can thoroughly assess the validity of their usage across peoples," says Dodell-Feder.
The data analyzed in this study are available on the Open Science Framework repository at: https://osf.io/tn9vb/

Persistent sore throat could be larynx cancer warning

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GPs should consider larynx cancer when patients report a persistent sore throat, particularly when combined with other seemingly low-level symptoms.

A persistent sore throat combined with shortness of breath, problems swallowing or earache is a greater warning sign of laryngeal cancer than hoarseness alone, new research concludes.
Led by the University of Exeter, a study of more than 800 patients diagnosed with cancer of the larynx has found more than a five per cent risk of cancer from a persistent sore throat combined with one of these other symptoms. This compares with 2.7% risk for hoarseness alone.
The research, funded by NIHR and published today in BJGP aims to facilitate earlier detection of cancer, which is key in getting the best survival rates and health outcomes for patients. Currently, NICE guidelines recommend investigation for persistent hoarseness or an unexplained neck lump. The new research gives greater insight into the combinations of symptoms GPs should be alert to when deciding who should be investigated for cancer.
Professor Willie Hamilton, of the University of Exeter Medical School, is one of the authors. He said: "This research matters -- when NICE guidance for cancer investigation was published there was no evidence from GP practices to guide this -- nor to inform GPs. Crucially, hoarseness serious enough to be reported to GPs does warrant investigation. Furthermore, our research has shown the potential severity of some symptom combinations previously thought to be low-risk. "
The research was conducted using patient records for more than 600 GP practices as part of the UK's Clinical Practice Research Datalink.
Each year, more than 1,700 people were diagnosed with cancer of the larynx. Of those, 80 per cent were male. The number has risen by almost a third over the past 20 years, with tobacco and alcohol use strongly linked to the disease.
Lead author Dr Elizabeth Shephard, of the University of Exeter Medical School, said: "The UK still lags well behind the rest of Europe on cancer survival rate -- although our research is part of a body of work that is leading to significant improvements. Theres still some way to go and the results of this study really highlight the need to improve the current recommendations for all of the head and neck cancers -- which are either incomplete or absent."