Journal of concussion最新文献

{"title":"Visuomotor adaptation learning not affected by repeated sport-related concussion","authors":"W. Stokes, J. Stilling, M. Anaya, Matthew A. Statton, M. S. St. Pierre, P. Celnik, G. Cantarero","doi":"10.1177/20597002221130658","DOIUrl":"https://doi.org/10.1177/20597002221130658","url":null,"abstract":"Sports-related concussions (SRC) have been associated with emotional, cognitive, and affective symptoms including a negative impact on motor-based learning. However, no study has assessed the impact of SRC on cerebellar-based motor learning. Cerebellar-based motor learning was assessed in three different groups of athletes with different SRC history: athletes with no history of SRC: athletes in the acute stage of SRC (within two weeks of injury), and athletes in the chronic stage of SRC (over one year after injury). We used a visuomotor adaptation task (VAT) to measure both explicit strategy-based learning and implicit error-based learning. We found that there was no difference in cerebellar dependent motor learning in SRC and non-SRC athletes. These findings suggest that the cerebellum may be more resilient to damage from SRCs than the motor cortex.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48118249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Applying knowledge translation frameworks, approaches and principles to co-create a dissemination plan: Optimizing the spread of a pediatric concussion guideline","authors":"C. Provvidenza, S. Kingsnorth, Jennifer Dawson, A. Ledoux, R. Zemek, N. Reed","doi":"10.1177/20597002221116239","DOIUrl":"https://doi.org/10.1177/20597002221116239","url":null,"abstract":"Background Clinical practice guidelines are evidence-based statements that assist healthcare professionals with improving patient care. Achieving guideline aims depends on successful knowledge translation (KT) and includes dissemination and implementation efforts. Dissemination efforts are important precursors to implementation, help to maximize awareness and reach of best practices, and prepare for evidence adoption. This article shares the application of KT frameworks, approaches and principles in the creation of a dissemination plan and KT products for the Living Guideline for Pediatric Concussion Care. The target audience for dissemination are healthcare professionals delivering clinical care to patients between 5–18 years. Methods Guided by the Framework for Knowledge Transfer and an integrated KT (iKT) approach, 46 concussion experts participated in an iKT workshop and knowledge board activity to: 1) establish a Living Guideline dissemination plan; 2) identify products to share the Living Guideline; and, 3) prepare for Living Guideline implementation planning. Post-workshop, a snowball approach invited knowledge users including educators and youth/young adults with lived experience in concussion via interviews and focus groups, to expand upon the dissemination plan and recommended products. Results The dissemination plan yielded a reach of nearly 42,000 Living Guideline page views from September, 2019-January, 2022. Dissemination efforts included 13 multi-media interviews, over 40 activities (e.g. webinars), and 28 engagement emails to help raise awareness. Eight KT products were developed to foster sharing and use of the Living Guideline, with over 3000 downloads across all KT products. Conclusions Applying an iKT approach alongside appropriate frameworks and principles allowed for interaction and partnership building, resulting in the development of a robust dissemination plan and essential KT products. By showing the breadth and impact of the KT activities undertaken, it is hoped that the concussion community will explore how KT practices can bolster efforts to drive evidence into practice and optimize concussion care.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45567251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Post-traumatic headache: Pathophysiology and management - A review","authors":"A. Blumenfeld, J. McVige, Kerry Knievel","doi":"10.1177/20597002221093478","DOIUrl":"https://doi.org/10.1177/20597002221093478","url":null,"abstract":"Background Post-traumatic headache (PTH) is a common secondary headache due to traumatic brain injury. In the past, significant research has been conducted to understand the pathophysiology and treatment options for PTH. However, PTH still lacks evidence-based treatment, and most of the management depends on the primary phenotype observed in the patient. Objective The main objective of this review is to provide a single reference that covers the current understanding of the pathophysiology and the treatment options available for PTH. Methods A detailed literature search on PubMed was performed, and a narrative review was prepared. Results The pathophysiology of PTH is multifactorial. Acute PTH may be attributed to increased peripheral pain sensitization with impaired pain inhibiting pathways. Chronic or persistent PTH may be due to a chronic inflammatory response and peripheral as well as central sensitization. The mechanism responsible for the transition of acute to persistent PTH is unknown. The migraine-like phenotype is reported to be the most prevalent headache type seen in PTH. New targets for preventive treatment have been identified in recent years, such as neuropeptides like calcitonin-gene-related peptide (CGRP), nitric oxide, and glutamate. The preventive pharmacological and non-pharmacological strategies employed for migraine (e.g. anti-CGRP monoclonal antibodies, onabotulinumtoxinA, physical therapy, cognitive and behavioral treatment, and neurostimulation techniques) have shown in preliminary studies that they are potentially efficacious, but large, randomized, double blind, placebo controlled trials are needed to further establish these as treatment options for PTH. Conclusions The lack of evidence-based treatment for PTH has created a need for future large trials to confirm the safety and efficacy of the currently employed treatments.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42230677","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Longitudinal assessment of hemodynamic alterations after mild traumatic brain injury in adolescents: Selected case study review","authors":"C. Thibeault, Amber Y. Dorn, S. Radhakrishnan, R. Hamilton","doi":"10.1177/20597002211065855","DOIUrl":"https://doi.org/10.1177/20597002211065855","url":null,"abstract":"Alterations in the neurovasculature after traumatic brain injury (TBI) represents a significant sequelae. However, despite theoretical and empirical evidence supporting the near-ubiquity of vascular injury, its pathophysiology remains elusive. Although this has been shown for all grades of TBI, the vascular changes after injuries with the broad mild traumatic brain injuries (mTBI) classification, remain particularly difficult to describe. Our group has previously demonstrated hemodynamic alterations in mTBI by utilizing transcranial Doppler ultrasound and cerebrovascular reactivity in a cross-sectional study. That work identified a phasic progression of deviations over varying days post-injury. These phases were then characterized by a set of inverse models that provided a hypothetical process of hemodynamic dysfunction after mTBI. This model set provides a framework with the potential for guiding clinical treatment over the course of recovery. However, it is still unclear if individual patients will progress through the phases of dysfunction similar to that found at the population level. The work presented here explores six individual patients with high-density data collected during their post-injury recovery. Breath-hold index (BHI) was found to be the most robust feature related to mTBI longitudinally. All six subjects exhibited BHI recovery curves that followed the population model's progression. The changes in pulsatile features lacked the universality of BHI, but were present in subjects with higher self-reported symptom scores and longer periods of recovery. This work suggests neurovascular dysfunction after an mTBI may be a robust phenomenon. Additionally, the capabilities of TCD in capturing these changes highlights its potential for aiding clinicians in monitoring patient's recovery post mTBI.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46102708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Concussion-reporting behaviors among high school athletes in Ireland: Applying the theory of planned behavior","authors":"L. Sullivan, L. Pursell, M. Molcho","doi":"10.1177/2059700221992951","DOIUrl":"https://doi.org/10.1177/2059700221992951","url":null,"abstract":"Background Sport-related concussion is a significant public health issue, especially among children and adolescents. A growing body of evidence suggests that athletes who do not immediately report concussion and continue to play while concussed take longer to recover than their counterparts. Yet, many child and adolescent athletes do not immediately report concussion symptoms to a responsible adult. Aim This study examined the utility of the Theory of Planned Behavior (TPB) in predicting concussion reporting intentions and in-season reporting behaviors among high school, Gaelic Athletic Association (GAA) athletes in the Republic of Ireland. Methods High school GAA athletes aged 12-18 years completed surveys at baseline and at three-month follow-up. Concussion-related perceived behavioral control (PBC), attitudes, subjective norms, and reporting intentions were assessed at baseline. In-season concussion reporting behaviors were assessed at three-month follow-up. Hierarchical linear regression models were used to examine the relationship between the constructs of the TPB and baseline reporting intentions. Logistic regression models were used to examine the relationship between the constructs of the TPB and in-season reporting behaviors. All data were collected during the 2016–2017 academic year. Results A total of 153 adolescent athletes were included (n = 102 [66.7%] females; Mage = 14.4 years, [SD = 1.6]). Consistent with the TPB, results revealed that PBC and reporting intentions contributed to the prediction of in-season reporting behaviors. Reporting intentions, in turn, were strongly influenced by PBC, attitudes, and subjective norms. PBC was the strongest predictor of concussion reporting intentions and in-season reporting behaviors; the stronger the athletes’ PBC, the stronger their reporting intentions and the more likely they were to have reported concussion symptoms during the current season. Conclusion Although the findings from the current study must be interpreted cautiously given the small sample size, the findings suggest that the TPB has some utility in the prediction of concussion reporting intentions and reporting behaviors. However, our findings suggest that the TPB should not be used in isolation; other models that incorporate personal factors and environmental constraints may be needed to better our understanding of concussion reporting intentions and behaviors among high school athletes. Concussion education programs that include strategies to enhance PBC over concussion reporting may help improve concussion reporting behaviors among high school athletes.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/2059700221992951","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43141916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prolonged concussion effects: Constellations of cognitive deficits detected up to year after injury","authors":"Daniel Leeds, Annie Nguyen, Christopher J D'Lauro, J. Jackson, Brian R. Johnson","doi":"10.1177/20597002211006585","DOIUrl":"https://doi.org/10.1177/20597002211006585","url":null,"abstract":"Concussions are associated with an array of physical, emotional, cognitive, and sleep symptoms at multiple timescales. Cognitive recovery occurs relatively quickly – five-to-seven days on average. Yet, recent evidence suggests that some neurophysiological changes can be identified one year after a concussion. To that end, we examine more nuanced patterns in cognitive tests to determine whether cognitive abilities could identify a concussion within one-year post injury. A radial-basis (non-linear boundary) support vector machine classifier was trained to use cognitive performance measures to distinguish participants with no prior concussion from participants with prior concussion in the past year. After incorporating only 10 cognitive measures, or all 5 composite measures from the neurocognitive assessment (Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)), over 90% accuracy was achieved in identifying both participants without prior concussions and participants with concussions in the past year, particularly when relying on non-linear patterns. Notably, classification accuracy stayed relatively constant between participants who had a concussion early or late in the one-year window. Thus, with substantial accuracy, a prior concussion can be identified using a non-linear combination of cognitive measures. Cognitive effects from concussion linger one-year post-injury, indicating the importance of continuing to follow concussion patients for many months after recovery and to take special note of constellations of cognitive abilities.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/20597002211006585","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48963917","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The care of the concussed pediatric patient prior to presentation to primary care pediatrician versus concussion specialists: Implications for management","authors":"B. Taubman, A. Michael Luciani, David B Gealt, Thomas P Drake, Philip T. Cochetti, J. Farrar","doi":"10.1177/2059700221998921","DOIUrl":"https://doi.org/10.1177/2059700221998921","url":null,"abstract":"Objective Absent adequate randomized control trials to inform appropriate treatment for concussion in pediatric patients, guidelines have been developed based on expert opinion and observational data that may not apply to all groups. This study examines differences in the previous clinical care between concussed patients who present in pediatric practice and specialty clinics. Differences found might influence treatment recommendations for each setting. Study design Prospective data collected from a pediatric practice in 2011 to 2013 were compared to chart review data from two specialty clinics between 2015 and 2017. In all three groups patients 11–19 years of age with an ICD9 billing code for concussion were included if they met the 4th International Consensus definition of concussion. Patients were excluded if hospitalized or had abnormal CNS imaging. Results The time between injury and presentation was substantially longer in specialty clinic patients versus those seen in the primary pediatric care office. (median 10 vs. 2 days-p < 0.001) Primary care patients presenting had higher rates of immediate rest after injury, 61.4% vs 27.9% (p < 0.001). More specialty clinic patients had been seen in the emergency departments prior to presentation (47.5% vs. 18.8% p < 0.001) regardless of rest status at presentation to the office. Conclusion Several differences in previous clinical care between the groups were found. These included the time of presentation from injury, rates of cognitive rest both immediate and non-immediate, and emergency department visits. These differences may have implications for management recommendations. Accordingly, the appropriate treatment for patients seen by the primary pediatric care physicians may be different from those referred to specialty care. Given these findings randomized controlled trails should be conducted independently in both groups of patients.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/2059700221998921","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48706655","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patients with chronic mild or moderate traumatic brain injury have abnormal longitudinal brain volume enlargement more than atrophy","authors":"David E. Ross, John D Seabaugh, Jan M. Seabaugh, Jennifer Plumley, Junghoon Ha, Jason A Burton, Andrew Vandervaart, Ryan Mischel, Alyson Blount, Daniel Seabaugh, Katherine Shepherd, J. Barcelona, A. Ochs","doi":"10.1177/20597002211018049","DOIUrl":"https://doi.org/10.1177/20597002211018049","url":null,"abstract":"Introduction Many studies have found brain atrophy in patients with traumatic brain injury (TBI), but most of those studies examined patients with moderate or severe TBI. A few recent studies in patients with chronic mild or moderate TBI found abnormally large brain volume. Some of these studies used NeuroQuant®, FDA-cleared software for measuring MRI brain volume. It is not known if the abnormal enlargement occurs before or after injury. The purpose of the current study was to test the hypothesis that it occurs after injury. Methods 55 patients with chronic mild or moderate TBI were compared to NeuroQuant® normal controls (n > 4000) with respect to MRI brain volume change from before injury (time 0 [t0], estimated volume) to after injury (t1, measured volume). A subset of 36 patients were compared to the normal controls with respect to longitudinal change of brain volume after injury from t1 to t2. Results The patients had abnormally fast increase of brain volume for multiple brain regions, including whole brain, cerebral cortical gray matter, and subcortical regions. Discussion This is the first report of extensive abnormal longitudinal brain volume enlargement in patients with TBI. In particular, the findings suggested that the previously reported findings of cross-sectional brain volume abnormal enlargement were due to longitudinal enlargement after, not before, injury. Abnormal longitudinal enlargement of the posterior cingulate cortex correlated with neuropathic headaches, partially replicating a previously reported finding that was associated with neuroinflammation.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/20597002211018049","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44571278","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Changes in working memory-related cortical responses following pediatric mild traumatic brain injury: A longitudinal fMRI study","authors":"Athena Stein, K. Iyer, A. Khetani, K. Barlow","doi":"10.1177/20597002211006541","DOIUrl":"https://doi.org/10.1177/20597002211006541","url":null,"abstract":"Persistent post-concussion symptoms (PPCS) lasting longer than 4 weeks affect 25% of children with mild traumatic brain injury (mTBI) or concussion. Working memory (WM) problems are a common complaint in children with PPCS. Despite normal function on traditional neuropsychological tests, these children exhibit aberrant cortical responses within the dorsolateral prefrontal cortex (dlPFC) and default mode network (DMN) regions – both of which are implicated in WM. Using a prospective, longitudinal cohort study design, we investigated changes in cortical fMRI responses within the dlPFC and DMN during an nback WM task at two timepoints: one and two months post-injury. Across these timepoints, the primary outcome was change in cortical activations (increase in BOLD) and deactivations (decrease in BOLD) of both dlPFC and DMN. Twenty-nine children (mean age 15.49 ± 2.15; 48.3% male) with fMRI scans at both timepoints were included, following data quality control. Student’s t-tests were used to examine cortical activations across time and task difficulty. ANCOVA F-tests examined cortical responses after removal of baseline across time, task difficulty and recovery. Volumes of interest (5 mm sphere) were placed in peak voxel regions of the DMN and dlPFC to compare cortical responses between recovered and unrecovered participants over time (one-way ANOVA). Between one and two months post-injury, we found significant increases in dlPFC activations and significant activations and deactivations in the DMN with increasing task difficulty, alongside improved task performance. Cortical responses of the DMN and bilateral dlPFC displayed increased intensity in recovered participants, together with improved attention and behavioural symptoms. Overall, our findings suggest evidence of neural compensation and ongoing cognitive recovery from pediatric TBI over time between one and two months post injury in children with PPCS. These results highlight the wider and persisting implications of mTBI in children, whose maturing brains are particularly vulnerable to TBI.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/20597002211006541","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46777844","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Concussion in cricket: Clinical findings using Sport Concussion Assessment Tool and recovery timeframes","authors":"Laura M Lallenec, A. Saw, A. Kountouris, R. Saw, J. Orchard","doi":"10.1177/2059700221993322","DOIUrl":"https://doi.org/10.1177/2059700221993322","url":null,"abstract":"Objectives To retrospectively review data of concussed and non-concussed elite cricket athletes following head impact to describe which clinical features on the day of injury are associated with concussion diagnosis. A secondary aim was to describe the recovery time of concussed athletes. Design Retrospective cohort study. Methods This study reviewed five seasons of Sport Concussion Assessment Tool (SCAT) data and clinical records for elite male and female cricket athletes who sustained a head impact during a cricket match or training. Results Data from 30 concussed and 37 non-concussed athletes were compared. Symptoms of ‘don’t feel right’ and ‘feeling slowed down’ had the strongest clinical utility for a concussion diagnosis post head impact. Concussed athletes reported a significantly lower ‘percent of normal’ (median 60%, IQR 60–90%) compared to athletes who sustained a non-concussive head impact (median 99%, IQR 95–100%, p = 0.003). No other component of the SCAT distinguished concussed from non-concussed athletes on day of injury. Concussed athletes typically experienced symptom resolution within 2–8 days and completed a graded return to play protocol within 4–14 days. No differences in SCAT findings or recovery times were observed between genders. Conclusion The SCAT may be used as a clinical tool to assist in diagnosis of concussionin elite cricket athletes. The components of the SCAT with the greatest clinical utility on day of injury were athlete-reported symptoms and ‘percent of normal’. Concussed cricket athletes typically complete their graded return to play protocol within 14 days however individualised management is paramount.","PeriodicalId":92541,"journal":{"name":"Journal of concussion","volume":"5 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/2059700221993322","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65509126","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}