Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes?

Characteristics and Outcomes for Delayed Diagnosis of Concussion in Pediatric Patients Presenting to the Emergency Department

BACKGROUND

Concussions are common pediatric injuries. Previous studies have found concussed youth may be underdiagnosed in the emergency department (ED), but outcomes for those with delayed diagnosis have yet to be described.

OBJECTIVE

Our aim was to compare visit characteristics and outcomes of patients who present to the ED with head injury who receive immediate vs. delayed diagnosis.

METHODS

Retrospective chart review of patients aged 6 to 18 years diagnosed with concussion on their first ED or urgent care (UC) visit and patients requiring a second visit for diagnosis between July 1, 2017 and June 20, 2019. We compared demographic information, ED or UC visit features, and recovery outcomes using χ² tests, Student's t-tests, and Wilcoxon rank-sum tests.

RESULTS

Overall, we included 85 patients with delayed concussion diagnosis and 159 with immediate diagnosis. Those with immediate diagnosis had more symptoms inquired at initial visit (5 vs. 4; p = 0.003) and a higher likelihood of receiving concussion-specific physical examinations (80% vs. 36.5%; p < 0.001); 76.5% of delayed diagnosis patients had at least 1 symptom at follow-up visit that was not inquired about at initial visit. Those with delayed diagnosis had more medical visits during recovery (3 vs. 2; p < 0.001), longer average time to symptom resolution (21 vs. 11 days; p = 0.004), and a higher likelihood of having persistent concussion symptoms (odds ratio 2.9; 95% confidence interval 1.4-5.9).

CONCLUSIONS

Concussed children evaluated acutely for head injury who do not receive an immediate diagnosis may be at risk for persistent symptoms. Performance of a concussion-specific physical examination and use of a standardized symptom scale may aid in identification of concussed youth acutely.

THE EFFECT OF AEROBIC EXERCISE ON ADOLESCENT ATHLETES POST-CONCUSSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Adolescent athletes are experiencing an increased number of concussions. There is currently a debate within the medical community regarding the most effective and safe treatment approach for this population, post-concussion. Interventions currently range from cognitive and physical rest to various types of physical activity, including aerobic exercise. While there are systematic reviews that focus on rest as the main intervention, there are no other systematic reviews that focus on the effects of aerobic exercise on concussion recovery in adolescent athletes.

Purpose

The aim of this systematic review and meta-analysis was to investigate the effectiveness of aerobic exercise on concussion recovery for adolescent athletes compared to an alternate intervention.

Study Design

Systematic Review and Meta-Analysis.

Methods

A computer-based search (population: adolescent athletes with concussions, intervention: aerobic exercise, comparator: non-aerobic interventions, outcome: symptom severity and recovery time) was performed. Databases including PubMed, CINAHL, SPORTdiscus, ProQuest, and Scopus were searched up to December 2019 for randomized controlled trials published since 1965. A hand search of relevant articles and exploration of grey literature was also completed. Data were extracted for the following information: interventions prescribed, outcome measures, and overall results of the study. A meta-analysis was performed for aerobic interventions using standardized mean difference as the summary measure of effect.

Results

Five studies, which all held a moderate to low risk of bias according to the PEDro scale, met the inclusion criteria for this systematic review and meta-analysis. Overall results favored aerobic exercise for both acute and prolonged recovery symptoms as demonstrated by a decrease in symptom severity and improved recovery time. The meta-analysis revealed a moderate effect size in favor of the intervention group (SMD: 0.51, CI: 0.02, 0.81, p=0.00) when looking at the three outcome measures combined: Post-Concussion Symptom Scale, Post-Concussion Symptom Inventory, and recovery time.

Conclusion

The results of this systematic review and meta-analysis indicate that there is currently moderately significant evidence in support of implementing an aerobic exercise program for adolescent athletes with both acute and prolonged recovery concussion symptoms. Additional higher quality studies are needed to continue to study the effectiveness of aerobic exercise in post-concussion treatment of adolescents.

Level of Evidence

1a.

Attention-Deficit/Hyperactivity Disorder and Outcome After Concussion: A Systematic Review

OBJECTIVE

To synthesize the literature and conduct a gap analysis on the association between attention-deficit/hyperactivity disorder (ADHD) and clinical outcome from sport-related concussion.

METHOD

The electronic search for this systematic review (PROSPERO ID: CRD42019128281) was conducted in February 2019 using terms related to concussion, sports/athletics, and predictors/modifiers of outcome to search the PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science databases. Eligible studies evaluated the association between ADHD and outcome from sport-related concussion. Of 4014 studies screened, 359 full-text articles were reviewed, with 14 studies ultimately included, involving 3623 participants (n = 359 [9.9%] with ADHD).

RESULTS

Study samples were primarily from specialty medical clinics (57.1%) and high school or college athletic groups (28.6%). Only 2 studies reported a statistically significant association between ADHD and worse clinical outcome. Of these, 1 included 13 participants with ADHD and the other included only 8 participants with ADHD. Only 1 previous study in this review was designed specifically to examine ADHD and prolonged concussion recovery, and that study did not report a statistically significant association.

CONCLUSION

There is not a clear association between ADHD and worse clinical outcome from concussion. However, eligible studies had limitations in research design, and nearly all studies were underpowered and evaluated the association between ADHD and concussion outcome as a secondary focus rather than the primary research question, precluding definitive conclusions. The association between ADHD and clinical outcomes remains unclear, and future research specifically examining ADHD and concussion recovery is needed.

The Economic Burden of Pediatric Postconcussive Syndrome

OBJECTIVE

To estimate the direct costs of pediatric postconcussive syndrome (PCS).

DESIGN

Retrospective cohort study.

SETTING

Subspecialty sports medicine clinics of a large pediatric tertiary care network in the United States.

PATIENTS

One hundred fifty-four patients aged 5 to 18 years with PCS, evaluated between 2010 and 2011.

ASSESSMENT OF INDEPENDENT VARIABLES

Direct costs included visits to sports medicine clinic, visio-vestibular therapy, homebound education, subspecialist referral, and prescription-only medications (amantadine and amitriptyline), all measured beginning at 28 days after injury.

MAIN OUTCOME MEASURES

Postconcussive syndrome was defined as persistence beyond 28 days from injury.

RESULTS

The cost incurred by each PCS patient for sports medicine visits was $1575, for visio-vestibular therapy was $985, for homebound tutoring was $55, for prescription medications was $22, and for subspecialist referral was $120, totaling $3557 per patient, with a 95% confidence interval range of $2886 to $4257.

CONCLUSIONS

Given the high economic costs of PCS determined in this study, therapies that mitigate this syndrome may have the potential to be cost-effective and even cost saving.

Concussion Symptom Treatment and Education Program: A Feasibility Study

OBJECTIVE

To evaluate the feasibility and potential benefits of a manualized, brief cognitive-behavioral therapy-based intervention program for children and adolescents with persistent postconcussive symptoms.

SETTING

Two outpatient pediatric concussion programs in the United States.

PARTICIPANTS

Patients aged 8 to 17 years who sustained concussions between 2 and 12 months prior to enrollment.

DESIGN

Pre-/postretrospective study.

MAIN MEASURES

SCAT-3; HBI; PedsQL 4.0 Generic Core Scales; and RCADS.

RESULTS

Thirty children and adolescents completed the treatment program. Self- and parent-reported postconcussive symptoms, quality of life, and internalizing symptoms significantly improved with treatment. Mixed-effects models revealed a significant decline in self-reported postconcussive symptoms across treatment sessions, a = -2.07, SE = 0.25, P < .001. The largest change occurred between sessions 2 and 3, following the session focusing on concussion psychoeducation and sleep hygiene (estimated mean change between sessions 2 and 3 = -4.72, P < .0001).

CONCLUSIONS

Our findings indicate that a 6-session manualized cognitive behavioral intervention is feasible to initiate in an outpatient clinic 1 to 12 months following a pediatric mild traumatic brain injury. With a manualized format, clinicians at most levels of training should be able to implement this treatment manual and flexibly adapt as needed when working with children and adolescents who are experiencing delayed symptom recovery following concussion.

Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery

INTRODUCTION

Novel research suggests that children engaging in physical activity during recovery from concussion may recover more rapidly.

OBJECTIVE

To determine if level of physical activity at presentation to a rehabilitation-based concussion specialty clinic predicted days from injury to recovery.

DESIGN

Retrospective cohort.

SETTING

A concussion sub-specialty clinic at an academic institution.

PATIENTS

Retrospective review of medical records between September 2015 and February 2017 identified 178 children ages 6-17 years (mean age = 13.7 years; standard deviation [SD] = 2.7 years) who presented within 60 days of concussion and were ultimately deemed recovered and cleared to progress to full return to high-risk activities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical activity at initial visit was classified as none-to-light (79%) versus moderate-to-heavy (21%). A doubly robust, inverse probability of exposure weighted linear regression model was used to examine the relationship between physical activity level and days to recovery, while adjusting for 10 demographic and clinical variables.

RESULTS

Children participating in moderate-to-heavy activity at initial evaluation in concussion clinic averaged recovery 21 days quicker (95% confidence interval [CI] -27.1, -15.5, P < .001) than children who were engaging in none-to-light activity. This finding did not change when removing children who were deemed recovered at the first visit (who may have initiated physical activity after becoming asymptomatic).

CONCLUSIONS

These data add to growing evidence that progressive physical activity during recovery from concussion does not appear to be harmful. Physical activity represents a modifiable variable in recovery, and physicians can potentially expedite symptomatic recovery by recommending noncontact physical activity as tolerated during concussion recovery.

Persistent post-concussive symptoms: A model of predisposing, precipitating, and perpetuating factors

While the majority of individuals make full recovery within a short period following mild traumatic brain injury (mTBI), some continue to experience a more chronic course of symptoms termed persistent post-concussive symptoms (PPCS). Previous models and conceptualizations of PPCS have typically not differentiated the time at which factors present across the injury timeline spectrum or have considered a limited array of contributory factors. In the current review, PPCS are examined within the predisposing, precipitating, and perpetuating (PPP) model, which has been applied to explain other syndromes resulting in a clear framework to explain, disseminate, and further research the specified condition. Previous PPCS models are reviewed and integrated into this comprehensive model, as well. To do so, a literature review was completed which included previous PPP models applied to other conditions, other PPCS models, and more recent findings of factors related to PPCS. This new iteration and application of the PPP model more clearly, completely, and validly identifies contributing factors to PPCS. Future prevention, early identification, clearer questions for future research, and treatment of PPCS is possible with clarity provided by this model.

Management of mild traumatic brain injury

Mild traumatic brain injury (TBI) is common and associated with a range of diffuse, non-specific symptoms including headache, nausea, dizziness, fatigue, hypersomnolence, attentional difficulties, photosensitivity and phonosensitivity, irritability and depersonalisation. Although these symptoms usually resolve within 3 months, 5%–15% of patients are left with chronic symptoms. We argue that simply labelling such symptoms as ‘postconcussional’ is of little benefit to patients. Instead, we suggest that detailed assessment, including investigation, both of the severity of the ‘mild’ injury and of the individual symptom syndromes, should be used to tailor a rehabilitative approach to symptoms. To complement such an approach, we have developed a self-help website for patients with mild TBI, based on neurorehabilitative and cognitive behavioural therapy principles, offering information, tips and tools to guide recovery: www.headinjurysymptoms.org.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population

OBJECTIVES

To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education.

DESIGN

Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit.

SETTING

Three military treatment facilities.

PARTICIPANTS

Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury.

RESULTS

Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time.

CONCLUSIONS

Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents

OBJECTIVE

This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI).

METHODS

A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors.

RESULTS

Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045).

DISCUSSION

Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Effect of Exercise Recommendation on Adolescents With Concussion

We examined the effect of a noncontact, subsymptom exacerbation early exercise recommendation on recovery from sports-related concussion. Retrospective analysis of adolescents, 10-17 years old, with symptomatic concussion, within 30 days of injury was performed. Time to recovery was measured between the early exercise group and a comparison group. A total of 187 patients studied-112 in the exercise group and 75 in the comparison group; 55% were male (n = 103). The exercise group had a significantly longer duration of concussion symptoms (18.5 days vs 14, P = .002), although both groups recovered within the expected time to recovery for concussion. When analyzed separately, males experienced longer time to recovery from injury (19 days vs 14, P = .003), than females, respectively (18 days vs 14.5, P = .18). Recommendation of early exercise resulted in significantly longer recovery from concussion in male adolescents but had no significant effect in female adolescents; both groups recovered within the expected time frame.

Rehabilitation Utilizing Controlled Aerobic Activity in Patients With a Concussion: A Critically Appraised Topic

Clinical Scenario: A sport-related concussion is a common injury to the brain that may cause a variety of symptoms ranging in duration and severity. The mainstay of treatment for concussion has been rest, followed by a stepwise return to activity. This recovery process may be lengthy when symptoms persist. Aerobic exercise conducted at subsymptom and submaximal intensities has been proposed as a potential intervention for symptoms following a concussion. Therefore, the purpose of this critically appraised topic is to examine the safety of varying aerobic exercise intensities in patients with a concussion. Focused Clinical Question: Are subsymptom and submaximal exercise programs safe when implemented in a population with a symptomatic sports-related concussion when compared with traditional rest? Summary of Key Findings: Four randomized controlled trials were included for critical appraisal. The 4 studies investigated supervised and controlled aerobic exercise as early as within 1 week of with a concussion; all studies conclude that exercise is safe and may be of benefit to individuals with a concussion. Two studies support the use of submaximal exercise as a therapeutic intervention for adolescents with persistent concussion symptoms. Clinical Bottom Line: The authors conclude that controlled exercise performed within the symptom or exertion threshold of patients with concussion is safe compared with rest. It was noted that symptom changes may occur; however, the changes did not have a negative impact on long-term recovery. This research should ease concerns about prescribing physical activity when an athlete with concussion is still experiencing lingering symptoms. While specific parameters of the activity performed have not been described in detail, the individualization of each exercise program was stressed. Strength of Recommendation: Grade A.

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild's 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Relationships between Post-Concussion Sleep and Symptom Recovery: A Preliminary Study

Post-concussion sleep disturbances can be debilitating and may influence days to symptom recovery; however, evidence is minimal. The purpose of this study was to explore relationships between days to symptom recovery and aspects of sleep, as measured by actigraphy and subjective sleep questionnaires in a concussed sample. Thirty-one college students were physician-diagnosed with a concussion and asked to complete a daily sleep symptom checklist. Participants (n = 14) were excluded based on lack of compliance/early termination (22.6%), recorded <5 nights of data (12.9%), and protracted recoveries (3.2%). Final concussed sample included 17 college-aged students (varsity student-athletes, n = 5; university students, n = 12). A wrist-worn ActiGraph GT9X Link was provided during initial evaluation (within 72 h post-injury) and worn continuously until symptom recovery (follow-up evaluation; 14.3 ± 5.9 days post-injury). The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) also were completed at follow-up. Pearson's correlations were conducted to determine relationships between days to symptom recovery and actigraphy sleep outcomes (sleep onset latency, wake after sleep onset (WASO_norm), total sleep time, sleep efficiency (SE), and number of awakenings) across recovery stages (2-3 days post-injury, mid-point, and end). Spearman's rho correlations were used to determine relationships between subjective sleep (PSQI global), sleepiness (ESS total), and sleep cluster symptom severity and days to symptom recovery. At recovery mid-point, individuals who were awake longer throughout the night (24.1 ± 9.0%) and/or were less efficient at sleeping (73.7 ± 9.7%) took longer to recover (WASO_norm: r = 0.58, p = 0.015; SE: r = -0.51, p = 0.035). Poorer post-concussion sleep quality (based on PSQI) was correlated with longer recovery (r_s = 0.70, p = 0.001). Post-concussion sleep-wake disturbances at recovery mid-point and overall poorer sleep quality may be associated with longer symptom recovery. Our findings provide preliminary guidance on identifying those who may be at risk for longer recoveries based on poorer sleep post-injury.

The symptom experience of adolescents with concussion

PURPOSE

The incidence of concussions in adolescents has increased in recent years. Concussion causes an array of symptoms that can interfere with the daily life of an adolescent, yet the symptoms and recovery vary greatly. Concussion management is based on expert consensus guidelines but they are not specific for adolescents and it is unclear how adolescents actually manage their symptoms. This study aimed to describe the symptom experience of adolescents with a concussion and their self-management strategies.

DESIGN AND METHODS

The study used a qualitative design to explore the symptom experiences of adolescents. Ten adolescents aged 14-17 years were recruited from a concussion clinic. Using a semi-structured interview, adolescents were asked about their concussion symptoms, the interference with their daily life, and their symptom self-management strategies. Data were analyzed using descriptive statistics and content analysis.

RESULTS

Adolescents reported 17 different symptoms they experienced following their concussion. All of the adolescents reported a headache but descriptions varied. The symptoms interfered with many aspects of their daily life including school and activities. The majority of the school responses were related to difficulties attending school and learning (n = 21). The self-management strategies were organized into 11 categories. The most common strategies fell under three categories: rest (n = 20), controlling the environment (n = 20), and using motivational thoughts and activities (n = 9).

PRACTICE IMPLICATIONS

This study indicates that adolescents experience multiple symptoms after their concussion and use a variety of strategies to manage the symptoms. Each adolescent had a unique symptom experience, highlighting the need for developing personalized concussion management plans. Nurses can coordinate the development of management plans and provide education about managing concussion symptoms and promoting recovery.

Survey of Child Neurologists on Management of Pediatric Post-traumatic Headache

Traumatic brain injury causes significant morbidity in youth, and headache is the most common postconcussive symptom. No established guidelines exist for pediatric post-traumatic headache management. We aimed to characterize common clinical practices of child neurologists. Of 95 practitioners who completed our survey, most evaluate <50 pediatric concussion patients per year, and 38.9% of practitioners consistently use International Classification of Headache Disorders criteria to diagnose post-traumatic headache. Most recommend nonsteroidal anti-inflammatory drugs as abortive therapy, though timing after injury and frequency of use varies, as does the time when providers begin prophylactic medications. Amitriptyline, topiramate, and vitamins/supplements are most commonly used for prophylaxis. Approach to rest and return to activities varies; one-third recommend rest for 1 to 3 days and then progressive return, consistent with current best practice. With no established guidelines for pediatric post-traumatic headache management, it is not surprising that practices vary considerably. Further studies are needed to define the best, evidence-based management for pediatric post-traumatic headache.

An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents

BACKGROUND AND PURPOSE

Physical therapy (PT) is a management strategy increasingly recognized to facilitate recovery after concussion. The purpose of this study was to investigate the safety and outcomes of multimodal impairment-based PT at varying time points after injury in youth diagnosed with concussion.

METHODS

Data were extracted retrospectively from medical records for patients who received PT for concussion-related impairments. Patient records were categorized into 3 cohorts on the basis of the timing of PT implementation: 0-20 days following injury (early intervention), 21 to 41 days following injury (middle intervention), and 42 or more days following injury (late intervention). The primary outcome measure was Post-Concussion Symptom Inventory score from the beginning to the end of the PT episode of care. Additional outcome measures included number of PT sessions, duration of PT episode of care (days), and occurrence of unplanned visits to a health care provider.

RESULTS

A total of 120 patient records (mean age of 14.77 years) were analyzed. Thirty-three, 39, and 48 individuals were categorized into the early, middle, and late intervention cohorts, respectively. There were no significant differences between intervention cohorts with regard to symptom change on the Post-Concussion Symptom Inventory from the beginning to the end of the PT episode of care, unplanned health care visits, number of PT sessions, or duration of PT episode of care.

DISCUSSION AND CONCLUSIONS

Early initiation of PT may be safe and tolerable. Future prospective studies are needed to explore the efficacy of PT services administered early following injury to help characterize an optimal care plan for youth following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A210).

Sport-Related Concussion Evaluation and Management

Concussion is a challenging and controversial medical diagnosis that can test even the most seasoned practitioner. Knowledge on this topic is ever evolving. It was not so long ago that grading guidelines were based on loss of consciousness and amnesia. Medicine has seen a renaissance of discovery over the past 20 years in concussion evaluation and management. A PubMed search for "concussion" between 1990 and 2000 produced just over 1000 articles and that same search including the last 18 years expands to over 10,000 publications. The most recent knowledge and recommendations are discussed based on the published evidence.

What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don't Have to Choose

Objectives: Return to School (RTS) and Return to Activity/Play (RTA) protocols are important in concussion management. Minimal evidence exists as to sequence and whether progression can occur simultaneously. Experts recommend that children/youth fully return to school before beginning RTA protocols. This study investigates recovery trajectories of children/youth while following RTA and RTS protocols simultaneously, with the following objectives: (1) to compare rates and patterns of progression through the stages of both protocols; (2) to evaluate symptom trajectories of youth post-concussion while progressing through stages of RTS and RTA; and (3) to propose a new model for concussion management in youth that involves the integration of Return to Activity and Return to School protocols. Methods: In a 3-year prospective-cohort study of 139 children/youth aged 5-18 years with concussive injury, self-reported symptoms using PCSS and stage of protocols were evaluated every 48 h using electronic surveys until full return to school and activity/sport were attained. Information regarding school accommodation and achievement was collected. Results: Sample mean age is 13 years, 46% male. Youth are returning to school with accommodations significantly quicker than RTA (p = 0.001). Significant negative correlations between total PCSS score and stage of RTS protocol were found at: 1-week (r = -0.376, p < 0.0001; r = -0.317, p = 0.0003), 1-month (r = -0.483, p < 0.0001; r = -0.555, p < 0.0001), and 3-months (r = -0.598, p < 0.0001; r = -0.617, p < 0.0001); indicating lower symptom scores correlated with higher guideline stages. Median full return to school time is 35 days with 21% of youth symptomatic at full return. Median return time to full sport competition is 38 days with 15% still symptomatic. Sixty-four percent of youth reported experiencing school problems during recovery and 30% at symptom resolution, with 31% reporting a drop in their grades during recovery and 18% at study completion. Conclusions: Children/youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during stages 1-3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. There is much to be learned with further research needed in this area.

The Future of Concussion

Over the past 2 decades, concussion care is increasingly in demand as research and media attention shed light on the importance of proper diagnosis and medical management to prevent complex, potentially disabling sequelae. The purpose of this review is to discuss the future of clinical concussion care across selected topics under the broad themes of diagnosis/assessment, intervention/treatment, and patient characteristics/presentations with the intent to direct clinicians' attention to important anticipated developments in the field. The current status of biomarkers, clinical settings, models of clinical concussion, return-to-activity, clinical subpopulations, treatment approaches, patient perceptions of injury, and social media are reviewed along with predictions for future developments.

Treatment of Pediatric Concussion

Concussions have gained attention in medical literature, legal literature, and lay media over the past several years as a public health affecting children, particularly those who do not improve in the first few days after an injury. We discuss strategies for acute management immediately after a concussion and an introduction to medical and non-medical options for treatment of the complex symptoms that persist in some patients with concussions. We examine the role of rest and exercise during recovery. We briefly discuss the role of the multidisciplinary approach to concussion in a setting that engages multiple specialists. Finally, we address policy changes related to sport-concussions and their efficacy in improving long term outcomes.

Activity Level During Acute Concussion May Predict Symptom Recovery Within an Active Duty Military Population

OBJECTIVE

To evaluate the impact on symptom resolution of activity acutely following a concussion and the role of acute-phase symptoms on this relationship among active duty service members (SMs).

SETTING

Three military installations.

PARTICIPANTS

Sixty-two SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment.

DESIGN

Longitudinal design with data collected within 72 hours of injury (baseline, n = 62) and at 1 week (n = 57), 1 month (n = 50), 3 months (n = 41), and 6 months (n = 40) postinjury.

MAIN MEASURES

Baseline activity level using a 60-item Activity Questionnaire. Symptom level at baseline and during follow-up using Neurobehavioral Symptoms Inventory.

RESULTS

Significant interaction (Pi < .05) was found, with significant main effects (P < .05) limited to SMs with elevated baseline symptomatology. Among these participants, greater baseline total activity was significantly related to greater vestibular symptoms at 1, 3, and 6 months (β = .61, .63, and .59, respectively). Significant associations were also found for particular types of baseline activity (eg, physical; vestibular/balance; military-specific) and symptoms at 1, 3, and/or 6 months postinjury.

CONCLUSION

These results provide support for clinical guidance that symptomatic SMs, particularly those with high levels of acute symptoms, may need to avoid excessive activity acutely following concussion.

Activity Level and Type During Post-acute Stages of Concussion May Play an Important Role in Improving Symptoms Among an Active Duty Military Population

Background: Previous research demonstrates that early rest and gradual increases in activity after concussion can improve symptoms; however, little is known about the intensity and type of activity during post-acute time periods-specifically months post-injury-that may promote optimal recovery in an active duty service member (SM) population. Objective: The objectives of this study were to investigate how activity level and type at the post-acute stages of concussion (at 1 and 3 month[s] post-injury) impact subsequent symptoms among SMs, and how this relationship might differ by the level of symptoms at the time of injury. Methods: Participants included 39 SMs ages 19-44 years from 3 military installations who were enrolled within 72 h after sustaining a concussion. Linear regression was used to evaluate whether the association between activity level at 1 or 3 month(s) post-injury (as measured by a multi-domain Activity Questionnaire) and subsequent symptoms at 3 and/or 6 months (as measured by the Neurobehavioral Symptom Inventory) varied by the level of symptoms at acute stages of concussion. Partial correlation was used to evaluate relationships that did not differ by acute symptom level. Symptoms at the time of activity assessment (1 or 3 month[s]) were accounted for in all models, as well as activity level at acute stages of concussion. Results: Greater physical and vestibular/balance activity at 1 month were significantly correlated with lower symptoms at 3 months, but not at 6 months post-injury. There were no significant associations found between activity (total or by type) at 3 months and symptoms at 6 months. The association between activity level at either 1 or 3 months and subsequent symptoms at 3 and/or 6 months did not differ by the level of acute symptoms. Conclusion: The intensity and type of activities in which SMs engage at post-acute stages of concussion may impact symptom recovery. Although low levels of activity have been previously shown to be beneficial during the acute stage of injury, higher levels of activity may provide benefit at later stages. These findings provide support for the importance of monitoring and managing activity level beyond the acute stage of concussion.

Advice to Rest for More Than 2 Days After Mild Traumatic Brain Injury Is Associated With Delayed Return to Productivity: A Case-Control Study

Objectives: Recent expert agreement statements and evidence-based practice guidelines for mild traumatic brain injury (mTBI) management no longer support advising patients to “rest until asymptomatic,” and instead recommend gradual return to activity after 1–2 days of rest. The present study aimed to: (i) document the current state of de-implementation of prolonged rest advice, (ii) identify patient characteristics associated with receiving this advice, and (iii) examine the relationship between exposure to this advice and clinical outcomes.

Methods: In a case-control design, participants were prospectively recruited from two concussion clinics in Canada's public health care system. They completed self-report measures at clinic intake (Rivermead Post-concussion Symptom Questionnaire, Personal Health Questionnaire-9, and Generalized Anxiety Disorder-7) as well as a questionnaire with patient, injury, and recovery characteristics and the question: “Were you advised by at least one health professional to rest for more than 2 days after your injury?”

Results: Of the eligible participants (N = 146), 82.9% reported being advised to rest for more than 2 days (exposure group). This advice was not associated with patient characteristics, including gender (95% CI odds ratio = 0.48–2.91), race (0.87–6.28) age (0.93–1.01), a history of prior mTBI(s) (0.21–1.20), or psychiatric problems (0.40–2.30), loss of consciousness (0.23–2.10), or access to financial compensation (0.50–2.92). In generalized linear modeling, exposure to prolonged rest advice predicted return to productivity status at intake (B = −1.06, chi-squared(1) = 5.28, p = 0.02; 64.5% in the exposure group vs. 40.0% in the control were on leave from work/school at the time of clinic intake, 19.8 vs. 24% had partially returned, and 11.6 vs. 24% had fully returned to work/school). The exposure group had marginally (non-significantly) higher post-concussion, depression, and anxiety symptoms.

Conclusions: mTBI patients continue to be told to rest for longer than expert recommendations and practice guidelines. This study supports growing evidence that prolonged rest after mTBI is generally unhelpful, as patients in the exposure group were less likely to have resumed work/school at 1–2 months post-injury. We could not identify patient characteristics associated with getting prolonged rest advice. Further exploration of who gets told to rest and who delivers the advice could inform strategic de-implementation of this clinical practice.

When Is It Safe to Drive after Mild Traumatic Brain Injury/Sports-related Concussion?

Driving an automobile has inherent danger, and driving after mild traumatic brain injury (mTBI)/sports-related concussion (SRC) can make this task even more hazardous. There is evidence to suggest that restriction from driving for the first 24 to 48 h after mTBI/SRC is probably reasonable. However, after the first 48 h have passed, there is insufficient evidence to make a recommendation regarding return to driving. Clinicians need to weigh the evidence and make decisions on how to advise their patients on a case by case basis. Further research is required to provide a standardized recommendation.

Feasibility and Effects of the CO–OP Approach™ in Postconcussion Rehabilitation

OBJECTIVE. We determined the feasibility and effects of the Cognitive Orientation to daily Occupational Performance (CO–OP) ApproachTM on activity performance and satisfaction, symptoms, and mood of adolescents with persistent postconcussion symptoms.

METHOD. In a prospective case series, 3 participants with persistent symptoms 3 mo after concussion and difficulties resuming activities were taught to use a metacognitive strategy (Goal–Plan–Do–Check) to work toward occupation-based goals in a 7-wk intervention (10 sessions, 30–60 min each). Participants were assessed pre- and postintervention and at 3-mo follow-up. Feasibility was determined by positive changes on study measures, ease of administration, and acceptability to participants.

RESULTS. Clinically significant, positive changes were found in participants’ activity performance and satisfaction. All participants had decreases in symptoms and improved mood scores at posttest.

CONCLUSION. The CO–OP Approach to rehabilitation for youth postconcussion is feasible and may make a positive contribution to recovery.

Concussions in Sports

Although concussions are common, they are complex, variable, and not entirely understood in terms of pathophysiology and treatment. The incidence of concussion is expected to continue to rise with the increased participation of youth in sports and improved awareness. The role of orthopedic surgeons in concussion management is murky. However, the existing literature does provide a foundation from which orthopedic surgeons who are exposed to concussed patients can function. [Orthopedics. 2019; 42(1):12-21.].

Effects of Media Sensationalization on Cognitive Performance and Post Concussive Symptoms

OBJECTIVES

The current study aimed to examine if televised media about mild traumatic brain injury (mTBI) framed in a sensationalized manner had a negative impact on cognitive functioning and persistent mTBI symptoms.

METHODS

One hundred two participants (M Age=37.16; SD=22.61) with a history of post-acute mTBI, recruited through a community research registry and an undergraduate recruitment system, were included in this study. Participants were assessed with a measure of health literacy, the Short Test of Functional Health Literacy in Adults (S-TOFHLA), and randomized to watch either a sensationalized or non-sensationalized news clip focused on mTBI. They were then assessed with the Paced Auditory Serial Addition Test (PASAT), Rivermead Post Concussion Symptoms Questionnaire (RPQ), Patient Reported Outcome Measures Information System (PROMIS) Depression scale, and the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders 5th edition (PCL-5).

RESULTS

Bayesian analyses indicated that sensationalized media-alone (β PASAT=-0.08; β RPQ=-0.08) or in the context of covariates (β PASAT=-0.11; β RPQ=-0.14)-was not a strong predictor of PASAT score or post-concussion syndrome symptom severity.

CONCLUSIONS

Although media sensationalization of mTBI symptoms is not desirable, this study suggests that one brief exposure to sensationalized information may not have a meaningful immediate impact on the cognitive functioning or symptom reporting of individuals with a history of mTBI. Future research should examine long-term and downstream effects of sensationalized media reporting in samples with greater diversity of TBI history. (JINS, 2019, 25, 90-100).

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

A review of the effects of physical activity and sports concussion on brain function and anatomy

Physical activity has been associated with widespread anatomical and functional brain changes that occur following acute exercise or, in the case of athletes, throughout life. High levels of physical activity through the practice of sports also lead to better general health and increased cognitive function. Athletes are at risk, however, of suffering a concussion, the effects of which have been extensively described for brain function and anatomy. The level to which these effects are modulated by increased levels of fitness is not known. Here, we review literature describing the effects of physical activity and sports concussions on white matter, grey matter, neurochemistry and cortical excitability. We suggest that the effects of sports concussion can be coufounded by the effects of exercise. Indeed, available data show that the brain of athletes is different from that of healthy individuals with a non-active lifestyle. As a result, sports concussions take place in a context where structural/functional plasticity has occurred prior to the concussive event. The sports concussion literature does not permit, at present, to separate the effects of intense and repeated physical activity, and the abrupt removal from such activities, from those of concussion on brain structure and function.

Rehabilitation modality and onset differentially influence whisker sensory hypersensitivity after diffuse traumatic brain injury in the rat

BACKGROUND

As rehabilitation strategies advance as therapeutic interventions, the modality and onset of rehabilitation after traumatic brain injury (TBI) are critical to optimize treatment. Our laboratory has detected and characterized a late-onset, long-lasting sensory hypersensitivity to whisker stimulation in diffuse brain-injured rats; a deficit that is comparable to visual or auditory sensory hypersensitivity in humans with an acquired brain injury.

OBJECTIVE

We hypothesize that the modality and onset of rehabilitation therapies will differentially influence sensory hypersensitivity in response to the Whisker Nuisance Task (WNT) as well as WNT-induced corticosterone (CORT) stress response in diffuse brain-injured rats and shams.

METHODS

After midline fluid percussion brain injury (FPI) or sham surgery, rats were assigned to one of four rehabilitative interventions: (1) whisker sensory deprivation during week one or (2) week two or (3) whisker stimulation during week one or (4) week two. At 28 days following FPI and sham procedures, sensory hypersensitivity was assessed using the WNT. Plasma CORT was evaluated immediately following the WNT (aggravated levels) and prior to the pre-determined endpoint 24 hours later (non-aggravated levels).

RESULTS

Deprivation therapy during week two elicited significantly greater sensory hypersensitivity to the WNT compared to week one (p < 0.05), and aggravated CORT levels in FPI rats were significantly lower than sham levels. Stimulation therapy during week one resulted in low levels of sensory hypersensitivity to the WNT, similar to deprivation therapy and naïve controls, however, non-aggravated CORT levels in FPI rats were significantly higher than sham.

CONCLUSION

These data indicate that modality and onset of sensory rehabilitation can differentially influence FPI and sham rats, having a lasting impact on behavioral and stress responses to the WNT, emphasizing the necessity for continued evaluation of modality and onset of rehabilitation after TBI.

The Role of Physical Activity in Recovery From Concussion in Youth: A Neuroscience Perspective

BACKGROUND AND PURPOSE

Concussion is a major public health concern and one of the least understood neurological injuries. Children and youth are disproportionally affected by concussion, and once injured, take longer to recover. Current guidelines recommend a period of physical and cognitive rest with a gradual progressive return to activity. Although there is limited high-quality evidence (eg, randomized controlled trials) on the benefit of physical activity and exercise after concussion, most studies report a positive impact of exercise in facilitating recovery after concussion. In this article we characterize the complex and dynamic changes in the brain following concussion by reviewing recent results from neuroimaging studies and to inform physical activity participation guidelines for the management of a younger population (eg, 14-25 years of age) after concussion.

SUMMARY OF KEY POINTS

Novel imaging methods and tools are providing a picture of the changes in the structure and function of the brain following concussion. These emerging results will, in the future, assist in creating objective, evidence-based pathways for clinical decision-making. Until such time, physical therapists should be aware that current neuroimaging evidence supports participation in physical activity after an initial and brief period of rest, and consider how best to incorporate exercise into rehabilitation to enhance recovery following concussion.

RECOMMENDATIONS FOR CLINICAL PRACTICE

It is important that physical therapists understand the neurobiological impact of concussion injury and recovery, and be informed of the scientific rationale for the recommendations and guidelines for engagement in physical activity.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A205).

Placebo Effects in Traumatic Brain Injury

In recent years, several randomized controlled trials evaluating pharmaceutical treatments for traumatic brain injury (TBI) have failed to demonstrate efficacy over placebo, with both active and placebo arms improving at comparable rates. These findings could be viewed in opposing ways, suggesting on the one hand failure of the tested outcome, but on the other, representing evidence of robust placebo effects in TBI. In this article, we examine several of the primary psychological processes driving placebo effects (verbal suggestion, cognitive re-framing, interpersonal interactions, conditioning, therapeutic alliance, anxiety reduction) as well as placebo neurobiology (top-down cortical regulation, reward system activation, dopaminergic and serotonergic neurotransmission). We then extrapolate from the literature to explore whether something inherent in TBI makes it particularly responsive to placebos. Viewed as such here, placebos may indeed represent a powerful and effective treatment for a variety of post-TBI complaints.

Near Point of Convergence and Gait Deficits in Adolescents After Sport-Related Concussion

OBJECTIVE

To prospectively examine gait characteristics of participants acutely after concussion with and without receded near point of convergence (NPC), compared with healthy controls.

DESIGN

Cross-sectional study.

SETTING

Sports-medicine clinic.

PARTICIPANTS

Patients examined after concussion (n = 33; mean ± SD = 7.2 ± 3.1 days) and a group of uninjured athletes (n = 31) completed a Postconcussion Symptom Scale, underwent NPC testing, and single/dual-task gait assessments.

INDEPENDENT VARIABLES

Near point of convergence was defined as the patient-reported diplopia distance when a fixation target moved toward the nose. Receded NPC was defined as a distance >5 cm from the tip of the nose.

MAIN OUTCOME MEASURES

Spatiotemporal gait characteristics in single-task and dual-task conditions were evaluated with analysis of variance; correlations were calculated between NPC and gait measures.

RESULTS

Eighteen of 33 (55%) patients with concussion presented with receded NPC. Those with receded NPC exhibited slower gait speed (single-task = 1.06 ± 0.14 m/s vs 1.19 ± 0.15 m/s; dual-task = 0.80 ± 0.13 m/s vs 0.94 ± 0.13 m/s; P = 0.003) and shorter stride lengths (single-task = 1.11 ± 0.10 m vs 1.24 ± 0.11 m; dual-task = 0.97 ± 0.11 m vs 1.09 ± 0.11 m; P = 0.001) than healthy controls. Near point of convergence was moderately correlated with dual-task average walking speed for the normal NPC group (ρ = -0.56; P = 0.05). Postconcussion Symptom Scale scores did not significantly differ between groups (27 ± 18 vs 28 ± 16).

CONCLUSIONS

After concussion, adolescents with receded NPC exhibited significant gait-related deficits compared with healthy controls, whereas those with normal NPC did not. Vergence and gross motor system dysfunction may be associated after concussion. Gait and vergence measures may contribute useful information to postconcussion evaluations.

Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion

Objective

To determine whether earlier time to initiation of aerobic exercise following acute concussion is associated with time to full return to (1) sport and (2) school or work.

Methods

A retrospective stratified propensity score survival analysis of acute (≤14 days) concussion was used to determine whether time (days) to initiation of aerobic exercise post-concussion was associated with, both, time (days) to full return to (1) sport and (2) school or work.

Results

A total of 253 acute concussions [median (IQR) age, 17.0 (15.0–20.0) years; 148 (58.5%) males] were included in this study. Multivariate Cox regression models identified that earlier time to aerobic exercise was associated with faster return to sport and school/work adjusting for other covariates, including quintile propensity strata. For each successive day in delay to initiation of aerobic exercise, individuals had a less favourable recovery trajectory. Initiating aerobic exercise at 3 and 7 days following injury was associated with a respective 36.5% (HR, 0.63; 95% CI, 0.53–0.76) and 73.2% (HR, 0.27; 95% CI, 0.16–0.45) reduced probability of faster full return to sport compared to within 1 day; and a respective 45.9% (HR, 0.54; 95% CI, 0.44–0.66) and 83.1% (HR, 0.17; 95% CI, 0.10–0.30) reduced probability of faster full return to school/work. Additionally, concussion history, symptom severity, LOC deleteriously influenced concussion recovery.

Conclusion

Earlier initiation of aerobic exercise was associated with faster full return to sport and school or work. This study provides greater insight into the benefits and safety of aerobic exercise within the first week of the injury.

Returning Adolescents to Driving after Sports-Related Concussions: What Influences Physician Decision-Making

OBJECTIVE

To determine which data collected on an initial patient clinic visit for a sports-related concussion (SRC) might influence physicians to clear an adolescent to return to drive (RTD) after injury.

STUDY DESIGN

Retrospective cohort study of 189 adolescents with a SRC referred to a hospital-based concussion clinic between June 1, 2015, and May 31, 2016. Subjects were ≥16 years with a valid driver's license (median age = 16, IQR [16, 17]). Concussion evaluations included Post-Concussion Symptom Scale, modified Balance Error Scoring System, and postinjury computerized neurocognitive testing (CNT). Clearance for RTD was the main outcome. Statistical comparisons were conducted with Mann-Whitney U and χ² tests and logistic regression.

RESULTS

In multivariable analysis, odds of being fully cleared to drive were 5.9-fold greater among patients who were administered CNT. Stated symptoms of "headache" and "sensitivity to light" were statistically significantly associated with RTD clearance. For a subset of 113 individuals undergoing CNT, each additional 10-millisecond decrease in simple reaction time was associated with 9% greater odds of being cleared to drive. Each additional 10-millisecond decrease in choice reaction time was associated with 4% greater odds of being cleared to drive.

CONCLUSIONS

CNT and associated reaction time measures may facilitate a physician's objective decision-making. Making a RTD determination for adolescents recovering from an SRC should be a core component of a physician's assessment.

Predicting Fatigue 12 Months after Child Traumatic Brain Injury: Child Factors and Postinjury Symptoms

OBJECTIVES

Fatigue is a common and persisting symptom after childhood brain injury. This study examined whether child characteristics and symptomatology preinjury or 6 months postinjury (pain, sleep, and mood, inattention) predicted fatigue at 12months postinjury.

METHODS

Parents of 79 children (0-18 years) rated fatigue at 12 months after injury on a multidimensional scale (general, sleep/rest, and cognitive). Demographic and clinical data were collected at injury. Parents rated child sleep, pain, physical/motor function, mood, and inattention at injury (preinjury description), and 6 months postinjury. Children were divided into two traumatic brain injury severity groups: mild TBI (n=57) and moderate/severe TBI (n=27). Hierarchical regression models were used to examine (i) preinjury factors and (ii) symptoms 6 months postinjury predictive of fatigue (general, sleep/rest, and cognitive) at 12 months postinjury.

RESULTS

Sleep/rest fatigue was predicted by preinjury fatigue (7% of variance) and psychological symptoms preinjury (10% of variance). General fatigue was predicted by physical/motor symptoms (27%), sleep (10%) and mood symptoms (9%) 6 months postinjury. Sleep/rest fatigue was predicted by physical/motor symptoms (10%), sleep symptoms (13%) and mood symptoms (9%) 6 months postinjury. Cognitive fatigue was predicted by physical/motor symptoms (17%) 6 months postinjury.

CONCLUSIONS

Preinjury fatigue and psychological functioning identified those at greatest risk of fatigue 12 months post-TBI. Predictors of specific fatigue domains at 12 months differed across each of the domains, although consistently included physical/motor function as well as sleep and mood symptoms postinjury. (JINS, 2018, 24, 224-236).

Posttraumatic Headache

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61-e68.].

Neurologic benefits of sports and exercise

Traumatic brain injury (TBI) is associated with several pathophysiologic changes, including: neurostructural alterations; molecular changes with shifts in circulating neurotrophins; impaired neural metabolism; changes in cerebrovascular autoregulation, vasoreactivity, and neurovascular coupling; and alterations in functional brain connectivity. In animal models of TBI, aerobic exercise reduces neuronal injury, promotes neuronal survival, and enhances the production of neuroprotective trophic factors. However, the timing of exercise initiation is an important consideration as early exercise in the acute postinjury period may impede recovery mechanisms, although evidence for this in humans is lacking. Though human clinical studies are limited, aerobic exercise post-TBI engages cerebrovascular mechanisms and may impart neurophysiologic benefits to mitigate post-TBI pathophysiologic changes. Additionally, subsymptom threshold exercise in humans has been demonstrated to be safe, feasible, and effective in decreasing symptom burden in individuals with mild TBI, and to counteract the detrimental effects of prolonged inactivity, subsequent physical deconditioning, and its negative emotional sequelae. This chapter will explore the potential role of aerobic exercise in neurorecovery after TBI.

Office-based concussion evaluation, diagnosis, and management: pediatric

More children and adolescents are participating in competitive sports than ever before, causing an overall increase in sport-related injuries. Concussion is a common injury in the pediatric population and its prevalence has increased with increased visibility and awareness. This chapter will discuss the clinical presentation, evaluation, and management of concussions sustained by pediatric athletes, while addressing the distinctive factors that pertain to this population. Management of concussion should be tailored to patients' symptoms and should focus on an early and gradual return to both cognitive and noncontact low-risk physical activity. A multidisciplinary approach is often helpful in addressing more specific symptoms, which fall into the somatic, cognitive, vestibular, emotional, and sleep domains. A prolonged recovery is defined by symptoms lasting more than 4 weeks. Individualized return-to-play decisions should focus on the safety of the young athlete.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

Concussion knowledge among rehabilitation staff

A concussion knowledge survey was completed by 561 rehabilitation professionals across a wide range of disciplines in a nationwide rehabilitation hospital system. Item questions were structured to reflect key areas of concussion knowledge targeted in a prior consensus statement. The vast majority of staff provided responses consistent with the current concussion literature regarding concussion diagnosis and symptom presentation immediately after concussion. Greater variability was seen for items assessing beliefs about the typical recovery from concussion, best care practices, and long-term effects from concussion. Factors such as profession, years of experience, and work with concussion or traumatic brain injury were not consistently related to better performance on the survey. Prior concussion-focused education/training was related to better survey performance. This survey highlights the pressing need to educate frontline health providers regarding concussion recovery and best care practices.