17 Bruce DA, Alavi A, Bilaniuk L, et al. Diffusecerebral swelling following head injuries inchildren: the syndrome of ‘malignant brainoedema’. J Neurosurg 1981;54(2):170–8.

18 Bruce DA. Delayed deterioration of consciousnessafter trivial head injury in childhood. Br Med J1984;289:715–6.

19 Pickles W. Acute general edema of the brain inchildren with head injuries. N Engl J Med1950;242:607–11.

20 Snoek JW, Minderhoud JM, Wilmink JT. Delayeddeterioration following mild head injury inchildren. Brain 1984;107:15–36.

21 McCrory P, Berkovic SF. Second impactsyndrome. Neurology 1998;50(3):677–84.

22 Kors E, Terwindt G, Vermeulen F, et al. Delayedcerebral edema and fatal coma after minor headtrauma: role of the CACNA1A calcium channelsubunit gene and relationship with familialhemiplegic migraine. Ann Neurol2001;49:753–60.

23 Bleiberg J. Consistency of within-day and across-day performance after mild brain injury.Neuropsychiatry Neuropsychol Behav Neurol1997;10(4):247–53.

24 Makdissi M, Collie A, Maruff P, et al.Computerised cognitive assessment of concussedAustralian rules footballers. Br J Sports Med2001;35(5):3543–60.

25 Rutter M, Chadwick O, Shafgfer D. Head injury.In: Rutter M, eds. Developmental neuropsychiatry.New York: Guilford Press, 1983:77–83.

26 Lovell M, Iverson G, Collins M, et al. Does loss ofconsciousness predict neuropsychologicaldecrements after concussion? Clin J Sport Med1999;9:193–9.

27 Gerberich SG, Priest JD, Boen JR, et al.Concussion incidences and severity in secondaryschool varsity football players. Am J Public Health1983;73(12):1370–5.

28 Albright J. Head and neck injuries in collegefootball. An eight year analysis. Am J Sports Med1985;13:147–52.

29 Guskiewicz KM, McCrea M, Marshall SW, et al.Cumulative effects associated with recurrentconcussion in collegiate football players. JAMA2003;290(19):2549–55.

30 Finch C, McIntosh A, McCrory P. What do under15 year old schoolboy rugby union players thinkabout protective headgear? Br J Sports Med2001;35:89–95.

31 Finch C, Mcintosh AS, McCrory P, et al. A pilotstudy of the attitudes of Australian Rulesfootballers towards protective headgear. J SciMed Sport 2003;6(4):505–11.

32 Liberman J, Stewart W, Wesnes K, et al.Apolipoprotein E e4 and short term recovery frompredominantly mild brain injury. Neurology2002;58:1038–44.

33 McCrory P, Johnston K, Meeuwisse W, et al.Evidence based review of sport relatedconcussion: basic science. Clin J Sport Med2001;11:160–6.

34 American Academy of Pediatrics. Themanagement of minor closed head injury inchildren. Pediatrics 1999;104(6):1407–15.

35 Davis G, McCrory P. The paediatric sport-relatedconcussion pilot study. Br J Sports Med 2004 (inpress).

36 Maddocks DL, Dicker GD, Saling MM. Theassessment of orientation following concussion inathletes. Clin J Sport Med 1995;5(1):32–5.

37 McCrea M, Kelly J, Randolph C, et al.Standardised assessment of concussion (SAC): onsite mental status evaluation of the athlete. J HeadTrauma Rehabil 1998;13:27–36.

38 Field M. Does age play a role in recovery fromsports-related concussion? A comparison of highschool and collegiate athletes. J Pediatr2003;142(5):546–53.

39 Collie A, Maruff P, McCrory P, et al. Statisticalprocedures for determining the extent of cognitivechange following concussion. Br J Sports Med2004;38(3):273–8.

40 Johnston K, McCrory P, Mohtadi N, et al.Evidence based review of sport-relatedconcussion – clinical science. Clin J Sport Med2001;11:150–60.

41 Collie A, Maruff P, McStephen M, et al. Theeffects of practice on the cognitive testperformance of neurologically normal individualsassessed at brief test-retest intervals. J IntNeuropsychol Soc 2003;9(3):419–28.

42 Collie A, Maruff P, Makdissi M, et al. CogSport:reliability and correlation with conventionalcognitive tests used in post concussion medicalevaluations. Clin J Sport Med 2003;13(1):28–33.

43 Teasdale G, Murray G, Anderson E. Risks ofacute traumatic intracranial complications inhematoma in children and adults: implications forhead injuries. Br Med J 1990;300:363–7.

44 Dacey RG Jr, Alves WM, Rimel RW, et al.Neurosurgical complications after apparentlyminor head injury. Assessment of risk in a seriesof 610 patients. J Neurosurg1986;65(2):203–10.

45 Hahn Y, McLone D. Risk factors in the outcome ofchildren with minor head injury. PediatrNeurosurg 1993;19:135–42.

Sport psychology and concussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sport psychology and concussion: newimpacts to exploreG A Bloom, A S Horton, P McCrory, K M Johnston. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

In recent years, there has been greatinterest in examining the psychologi-cal effects of athletic injuries. This has

also extended to interventions in whichcoping strategies have been suggested toenhance recovery. Concussive injuries,which are common to many sports, holdparticular problems in this regard. Forexample, a concussed athlete may beprone to experience isolation, pain,anxiety, and disruption of daily life asa result of the injury. This may be aproblem for individual sport athletes—for example, professional skiers—whodo not have the support of team matesto help them through their rehabilita-tion and recovery, as well as team sportathletes whose team mates may inad-vertently pressure them to return toplay.Besides the physical loss resulting

from an injury, there may also bepsychological distress. Commonlyreported emotion responses resulting

from athletic injury have includedanger, denial, depression, distress, bar-gaining, shock, and guilt.1–5 These areparticularly seen in career ending inju-ries. Such emotional distress can nega-tively affect the athletes’ recoveryprocess.

‘‘…concussed athletes in teamsports seem to have fewer long termproblems’’

Injured athletes have also reportedfeelings of isolation and loneliness.Researchers found that athletes pre-vented from participating in their activ-ity have lost contact with their team,coach, and friends.6 7 For example,Gould et al6 examined the emotionalreactions of US national team skiers toseason ending injuries and found that66.6% cited lack of attention and isola-tion as a source of stress during theirinjury. In another study of injured

athletes, Brewer et al2 surveyed 43 sportsmedicine practitioners to discover sideeffects of psychological distress. Theseside effects included exercise addiction,weight control problems, family adjust-ment, and substance abuse. These pro-blems have been reported individuallyas well as being associated with depres-sion and anxiety and have been shownto cause severe health complications.7

Injured athletes have reported differ-ent levels of satisfaction with the socialsupport they have received after injury.In particular, team mates have beenshown to have a greater affect on theemotional state of injured athletes thancoaches or medical professionals.8 Thisleads one to speculate that individualsport athletes may experience differentadjustment difficulties while recoveringfrom a concussion. This may alsosuggest why concussed athletes in teamsports seem to have fewer long termproblems, such as persistent post-con-cussive symptoms. In an environment inwhich team mates are likely to haveexperienced similar injuries, there is agreater corporate memory of such inju-ries and hence more reassurance as tothe likely recovery time frame andvalidation of subjective symptomsexperienced by the injured athlete.

UNIQUENESS OF CONCUSSIONINJURIESA number of unique characteristics ofconcussion injuries exist. Firstly, a con-cussion is an ‘‘invisible injury’’. This

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means there are no crutches, swelling,stitches, or other visual signs of theinjury. This makes it very difficult for acasual observer to identify the athlete asinjured. A second unique characteristicof concussion injuries is the overlap ofpost-concussive symptoms with psycho-logical responses to injury. A thirdproblem may be a loss of fitness(through loss of both aerobic andresistance training activity), particularlyif the post-concussive symptoms persist.A fourth problem, unique to profes-sional sport, is the relentless mediacommentary that typically occurs afterinjury. This increases pressure oninjured athletes to regain their sportingplace.

‘‘…it is often not considered accep-table to spend prolonged time reha-bilitating a concussion injury’’

Another issue surrounding concus-sion injuries is the lack of acceptanceor understanding of long term rehabili-tation. Whereas it is often considerednecessary to rehabilitate an orthopaedicinjury for a number of months, it isoften not considered acceptable to spendprolonged time rehabilitating a concus-sion injury. This may result in moreanxiety and frustration for the athleteand coach. Finally, concussion injuriesare unique because there is at present nostandard intervention technique. Formost other injuries, rehabilitative treat-ments are available—for example, phy-siotherapy, medication, exercise,surgery, etc. However, this is not thecase for concussion injuries; the athletemay leave the doctor with either nospecific management or at best a mini-mally structured treatment plan.

SOCIAL SUPPORT GROUPSIt is not uncommon for people who haveexperienced life events such as addic-tion, illness of a family member, injury,or a significant loss to have difficultydealing with the stress and anxiety oftheir situation. As a result of the distressencountered, different methods of cop-ing and psychological support have beendeveloped. Throughout the last 20 years,the role of social support in dealing withdisease has increased significantly.9

Support groups have been developed toeducate, prevent isolation, and help incoping.10 Positive outcomes from sup-port groups have been proven effectivefor sufferers of AIDS,11 12 cancer,13 obses-sive compulsive disorder,14 and preg-nancy loss,15 and families of criticallyill patients.16 It has also been shown thatgeneral social support is beneficial forathletes suffering from injuries.17 18 Asupport group for injured athletes may

also provide the same benefits as it hasfor non-athletic populations.Intervention strategies and psycholo-

gical rehabilitation techniques haveincluded imagery, relaxation, modelling,goal setting, positive self talk, socialsupport and support groups, pain man-agement, simulation training, educa-tion, stress management, and cognitivereconstruction.5 19–24 Social support andcommunication have been two mostcommonly suggested rehabilitation stra-tegies. Lynch22 stressed the importanceof the sport psychologist in encouragingathletes to discuss their experienceswith others. These interactions weredesigned to help reduce the injuredathlete’s feelings of isolation and lone-liness.

SOCIAL SUPPORT IN ATHLETICINJURY REHABILITATIONTwo distinct types of social support havebeen used during injury rehabilitation inan athletic setting: support groups andpeer modelling.4 5 Support groups forinjured athletes have allowed injuredathletes to come together to voice theirconcerns, share ideas about coping,learn vital performance enhancementstrategies, and realise that they are notalone.4 The goal is that athletes willsupport one another both mentally andphysically by helping deal with thedemands of rehabilitation and not par-ticipating in their sport.20

Numerous studies on non-athleticpopulations have been published show-ing the benefits of support groupsin reducing anxiety, depression, andisolation and enhancing copingstrategies.11–14 16 To date there have beenvery few academic sources that haveaddressed the use of support groups forathletic injury and only one for concus-sion.20–25 Granito et al20 offered anecdotalsupport for an injured athlete supportgroup programme, and Horton et al25

attempted to determine if participationin social support groups could reducenegative psychological side effects inconcussion. It was shown that partici-pants in the experimental concussedgroup improved their mood state, redu-cing effects such as anger, confusion,frustration, anxiety, depression, andisolation.Social support has also been proven to

have a significant effect on rehabilita-tion adherence. Udry18 reported that themost discriminating factor for rehabili-tation adherence was level of socialsupport. Athletes who perceived socialsupport for their rehabilitation hadbetter rehabilitation adherence, higherlevels of motivation, and adopted a goalmastery orientation towards their reha-bilitation.18

SUMMARYThe use of sport psychology techniquesin the management of concussion mayassist in solving some of the real andvery practical problems facing clinicians,namely certain aspects of the post-concussive syndrome and the influenceof anxiety and other adverse psycholo-gical states, which in turn may impacton injury outcome. Techniques derivedfrom other areas of psychology such aspeer modelling may be successfully usedin this setting.

Br J Sports Med 2004;38:519–521.doi: 10.1136/bjsm.2004.011999

Authors’ affiliations. . . . . . . . . . . . . . . . . . . . . .

G A Bloom, A S Horton, K M Johnston,McGill University, Montreal, CanadaP McCrory, University of Melbourne,Melbourne, Australia

Correspondence to: Dr Johnston, Department ofNeurosurgery, Kinesiology & PhysicalEducation, McGill University, McGill SportMedicine Centre, 475 Pine Ave West,Montreal, Quebec, Canada H2W 1S4;Karen.Johnston@mcgill.ca

REFERENCES1 Brewer BW, Linder DE, Phelps CM. Situational

correlates of emotional adjustment to athleticinjury. Clin J Sport Med 1995;5:241–5.

2 Brewer BW, Van Raalte JL, Linder DE. Role of thesport psychologist in treating injured athletes: asurvey of sports medicine providers. J Appl SportPsychol 1991;3:183–90.

3 Quinn AM, Fallon BJ. The changes inpsychological characteristics and reactions of eliteathletes from injury onset until full recovery. J ApplSport Psychol 1999;11:210–29.

4 Weiss MR, Troxel RK. Psychology of the injuredathlete. Athletic Training 1986;21:104–10.

5 Wiese DM, Weiss MR. Psychologicalrehabilitation and the physical injury: implicationsfor the sports medicine team. Sport Psychol1987;1:318–30.

6 Gould D, Udry E, Bridges D, et al. Stressencountered when rehabilitating from seasonending ski injuries. Sport Psychol1997;11:361–78.

7 Petitpas A, Danish SJ. Caring for injured athletes.In Murphy SM, ed. Sport psychologyinterventions. Champaign, IL: Human Kinetics,1995:225–81.

8 Udry E, Gould D, Bridges D, et al. People helpingpeople? Examining the social ties of athletescoping with burnout and injury stress. Journal ofSport and Exercise Psychology 1997;19:368–95.

9 Cohen S, Wills TS. Stress, social support, and thebuffering hypothesis. Psychol Bull1985;98:310–57.

10 Kates N. Support groups in psychiatry: anuntapped resource. Can J Psychiatry1995;40:367–8.

11 DiPasquale JA. The psychological effects ofsupport groups on individuals infected by theAIDS virus. Cancer Nurs 1990;13:278–85.

12 Ribble D. Psychological support groups forpeople with HIV infection and AIDS. Holist NursPract 1989;3:52–62.

13 Deans G, Bennett-Emslie GB, Weir J, et al.Cancer support groups: who joins and why?Br J Cancer 1988;58:670–4.

14 Broatch JW. Obsessive-compulsive disorders:adding value to treatment through patient supportgroups. Int Clin Psychopharmacol1996;11:89–94.

15 Bonno C. Peer support network. In: Woods J,Esposito J, eds. Pregnancy loss: medical

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therapeutics and practical considerations. LosAngeles: Williams & Wilkins, 1987:225–47.

16 Acorn S. Head-injured survivors: caregiversand support groups. J Adv Nurs1993;18:39–45.

17 Green SL, Weinberg RS. Relationships amongathletic identity, coping skills, social support, andthe psychological impact of injury in recreationalparticipants. J Appl Sport Psychol2001;13:40–59.

18 Udry E. Social support: exploring its role in thecontext of athletic injury. Journal of SportRehabilitation 1996;5:151–63.

19 Gilbourne D, Taylor AH. From theory topractice: the integration of goal perspectivetheory and life development approacheswithin an injury-specific goal-setting program.Journal of Applied Sport Psychology1998;10:124–39.

20 Granito VJ, Hogan JB, Varnum LK. Theperformance enhancement group: integratingsport psychology and rehabilitation. J Athl Train1995;30:328–31.

21 Ievleva L, Orlick T. Mental links to enhancedhealing: an exploratory study. Sport Psychology1991;5:25–40.

22 Lynch GP. Athletic injuries and the practicingsport psychologist: practical guidelines forassisting athletes. Sport Psychology1988;2:161–7.

23 Smith AM. Psychological impact of injuries inathletes. Sports Med 1996;6:391–405.

24 Taylor J, Taylor S. Psychological approaches tosports injury rehabilitation. Gaithersburg, MD:Aspen Publications, 1997.

25 Horton AS, Bloom GA, Johnston KM. The impactof support groups on the psychological state ofathletes experiencing concussions.Med Sci SportsExerc 2002;34:99.

Manual therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

To treat or not to treat: new evidencefor the effectiveness of manual therapyM M Sran. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Manual therapy has been shown to be effective for certainconditons but more research is needed to identify other suitablepatients

Recent randomised clinical trialsfound manual therapy to be moreeffective than other methods of

conservative management for low backand neck pain.1–5 On the other hand,some randomised clinical trials,6–13 sys-tematic reviews,14 and meta-analyses15

concluded that there was no evidencethat spinal manipulative therapy issuperior to other standard treatmentsfor patients with low back or neck pain.This provides the clinician with aShakespearean quandary—to treat ornot to treat using manual therapies?Therefore this leader addresses thequestion: what explains these appar-ently inconsistent data?.

DEFINITIONS AND SEARCHSTRATEGYThe term manual therapy has manyconnotations, but for this leader itincludes manually performed assess-ment and treatment methods (whichcan include joint, neural tissue, and/ormuscle techniques). The term manipu-lation is typically used to describe smallamplitude thrust techniques performedwith speed.16

I searched Medline, Cinahl, andEmbase databases for randomised clin-ical trials comparing spinal manual jointtechniques (mobilisation with or with-out manipulation) or manipulation onlywith other conservative treatments forback or neck pain. Only studies pub-lished as full papers, in English,between 1 January 1998 and 31December 2003 were included. Pilotstudies were not included. Table 1 out-

lines search strategies for each database.Thirteen studies met the criteria(table 2). One study of bone setting byFinnish folk healers who lacked formaleducation17 was excluded as all otherstudies involved formally educated pro-fessionals.Examining the trials for homogeneity

revealed that the mean age of partici-pants was similar among the studiesand most participants were white(except for two studies6 11). Thus factorsrelated to the population studied did notappear to explain the conflicting results.There were, however, at least fourfactors that differed among the inter-ventions that constituted manual ther-apy, and I focus on these differences tosee whether they explain the conflictingoutcomes.

DIFFERENCES IN MANUALTHERAPY THAT MAY EXPLAINSTUDY FINDINGSWhether or not the study usedmanual therapy or manipulationonlyFour of the 13 studies reported betterresults in the manual therapy groupthan the other group(s).1–4 Five of theremaining nine studies used manipula-tion only, and all but one5 reported nosignificant difference or a poorerresponse than the other group(s).7 8 10 11

Use of a variety of manual therapytechniques, rather than joint manipula-tion alone, appears to yield betterresults. For example, Jull et al3 studiedthe effectiveness of manual therapydelivered by physical therapists, specificexercise therapy delivered by physicaltherapists, combined manual and spe-cific exercise therapy, and a controlgroup, for treatment of cervicogenicheadache. At the 12 month follow up,both manual therapy and specific exer-cise groups had significantly reducedheadache frequency and intensity, neckpain, and disability. In this study,3

manual therapy included both lowvelocity cervical joint mobilisation tech-niques and high velocity manipulationtechniques. These results are relevant tophysical therapists with postgraduatecertification in manual therapy, as theyare well trained in both of thesetechniques. Similarly, Hoving et al2

Table 1 Search strategy

Database MeSH headings Limits

Medline Manipulation, orthopaedic HumanManipulation, chiropractic EnglishManipulation, osteopathic 1998–2003Physical therapy techniquesMusculoskeletal manipulationsComparative study(Back or neck) and pain

Cinahl Manual therapy EnglishChiropractic Clinical trialChiropractic manipulation 1998–2003Manipulation, orthopaedicOsteopathy(Back or neck) and pain

Embase Manipulative medicine Human(Back or neck) and pain English

1998–2003

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