Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes?

When in doubt, sit it out! Pediatric concussion-an update

Concussion is a major public health issue that has received much publicity in recent years. Reported concussions are increasing across all ages, including the highest rates in pediatric age ranges. Due to the age-related physiological responses and differential recovery of symptoms after concussion, special consideration must be given to youth concussions. Concussion can affect each child differently and likely affects children differently than adults. Until the past decade, there has been a scarcity of scientifically rigorous studies examining concussions in children. This increasing amount of research and consensus has begun to influence the definition, evaluation, management, return to school and play recommendations, prevention, and education relating to pediatric concussion. The purpose of this article is a review of relevant research published in the last few years (2015-2017) with highlights of these updates summarized for clinical use.

Pediatric Mild Traumatic Brain Injury in the Acute Setting

Pediatric mild traumatic brain injuries, most of which are concussions, are an increasingly common reason for presentation to emergency departments. The diagnosis of concussion has increased dramatically over the past decade, necessitating the acute care provider to have up-to-date knowledge of the definition, pathophysiology, signs and symptoms, physical examination findings, and acute management of pediatric concussion. This article also addresses populations most vulnerable to prolonged recovery from pediatric concussion and referral recommendations.

The Role of Active Recovery and "Rest" After Concussion

For several years both cognitive and physical rest remained at the forefront in pediatric postconcussion management. However, the concept of "rest" has not been well defined and there remains significant variability both in terms of rest recommendations provided as well as adherence to such recommendations. More recently, there has been growing evidence to suggest that an earlier return to light or moderate activity is not detrimental and may, in fact, facilitate symptomatic improvement, thereby highlighting a new role for active rehabilitation in recovery from concussion. In this article, we compare historic recommendations for rest with emerging strategies focused on active rehabilitation. [Pediatr Ann. 2017;46(4):e139-e144.].

Rest and treatment/rehabilitation following sport-related concussion: a systematic review

AIM OR OBJECTIVE

The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded.

RESULTS

Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care.

SUMMARY/CONCLUSIONS

A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039570.

Same Care, Different Populations

The authors conducted a cross-sectional survey of Massachusetts school nurses examining return-to-learn practices for children recovering from concussion in prekindergarten through high school. Regardless of school setting, all students received academic accommodations to support learning during recovery. School nurses perceived less benefit to prolonged cognitive rest (>4 days) for high school students relative to students in elementary school, but provided academic accommodations to them for comparatively longer periods of time (10-14 days vs 6-10 days). In all settings, respondents indicated a need for improved communication among treating physicians, parents, and school personnel, as well as improved education and standardized management tools for younger children and those who sustain non-sport-related injuries. Despite serving children at different developmental stages, school return-to-learn practices are essentially the same in primary and secondary schools, highlighting the need for standardized, developmentally appropriate return-to-learn plans and additional education for the providers and school personnel who implement them.

Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial

The purpose of this study was to (a) assess the feasibility of recruitment/retention of participants, protocol/resource management, and participant safety, and (b) estimate the size of the effect between the experimental and control groups. This was a feasibility study conducted as a prospective pilot double-blind randomized clinical trial. Subjects aged 10-23 years old with acute concussion and dizziness were enrolled from sports medicine centers. Forty-one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post-concussion. Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions. Subjects in the control received prescriptive sham to minimally progressive interventions. The two primary outcomes were medical clearance for return-to-play and symptomatic recovery. The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26. The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control. According to Cox proportional hazards regression for time to medical release for return-to-play, the experimental group demonstrated a hazard ratio of 2.91 (95% CI: 1.01, 8.43) compared to the control. For time-to-symptomatic recovery, those in the experimental group demonstrated a hazard ratio of 1.99 (95% CI: 0.95, 4.15) compared to the control. The results indicate that it is feasible and safe to complete this type of intervention study. The results provide strong support for the allocation of resources to conduct well-powered randomized clinical trials of this intervention.

Concussion in Sports: What Do Orthopaedic Surgeons Need to Know?

A concussion is a relatively common sports-related injury that affects athletes of all ages. Although orthopaedic surgeons are not expected to replace sports medicine physicians and neurologists with regard to the management of concussions, orthopaedic surgeons, particularly those who are fellowship-trained in sports medicine, must have a current knowledge base of what a concussion is, how a concussion is diagnosed, and how a concussion should be managed. Orthopaedic surgeons should understand the pathophysiology, assessment, and management of concussion so that they have a basic comprehension of this injury, which is at the forefront of the academic literature and North American media. This understanding will prepare orthopaedic surgeons to work in concert with and assist sports medicine physicians, athletic trainers, and physical therapists in providing comprehensive care for athletes with a concussion.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment.

OBJECTIVE

To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion.

METHODS

On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device.

RESULTS

A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%.

CONCLUSION

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

ABBREVIATIONS

ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project

Introduction

Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic.

Methods

Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the "return to drive" project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record.

Results

At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations.

Conclusions

The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.

Use of a multi-level mixed methods approach to study the effectiveness of a primary care progressive return to activity protocol after acute mild traumatic brain injury/concussion in the military

The large number of U.S. service members diagnosed with concussion/mild traumatic brain injury each year underscores the necessity for clear and effective clinical guidance for managing concussion. Relevant research continues to emerge supporting a gradual return to pre-injury activity levels without aggravating symptoms; however, available guidance does not provide detailed standards for this return to activity process. To fill this gap, the Defense and Veterans Brain Injury Center released a recommendation for primary care providers detailing a step-wise return to unrestricted activity during the acute phase of concussion. This guidance was developed in collaboration with an interdisciplinary group of clinical, military, and academic subject matter experts using an evidence-based approach. Systematic evaluation of the guidance is critical to ensure positive patient outcomes, to discover barriers to implementation by providers, and to identify ways to improve the recommendation. Here we describe a multi-level, mixed-methods approach to evaluate the recommendation incorporating outcomes from both patients and providers. Procedures were developed to implement the study within complex but ecologically-valid settings at multiple military treatment facilities and operational medical units. Special consideration was given to anticipated challenges such as the frequent movement of military personnel, selection of appropriate design and measures, study implementation at multiple sites, and involvement of multiple service branches (Army, Navy, and Marine Corps). We conclude by emphasizing the need to consider contemporary approaches for evaluating the effectiveness of clinical guidance.

Physical Activity and Intermittent Postconcussion Symptoms After a Period of Symptom-Limited Physical and Cognitive Rest

Reference: Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.

CLINICAL QUESTION

After concussion and a period of symptom-limited physical and cognitive rest, do athletes who experience intermittent symptoms return to asymptomatic condition more quickly with physical activity than with prolonged physical rest?

DATA SOURCES

One investigator performed an individual search for each research question using the following databases: CINAHL, Cochrane Controlled Trials Registers, EMBASE, HealthSTAR, ProQuest, PsychInfo, PubMed, SPORTDiscus, and Web of Science. Search terms for rest were brain concussion, cognitive rest, mild traumatic brain injury, physical exertion, postconcussive syndrome, rehabilitation, sport-related concussion, therapy, treatment, and treatment outcome. Search terms for treatment were the same terms as for rest, as well as brain training, cervical spine, cognitive therapy, dizziness, exercise, headache, neck, pharmacotherapy, postural balance, and vertigo. The authors included peer-reviewed, published articles and abstracts and performed a citation search.

STUDY SELECTION

Studies were included based on the following criteria as determined before searching: classified as original research, symptoms resulted after sport-related concussion, and investigation of the effects of either rest or treatment on symptoms. Abstracts that were excluded failed to evaluate rest, omitted sport-related concussion as the cause of symptoms, failed to evaluate a treatment's effect on sport-related concussion, or did not present original research.

DATA EXTRACTION

The following data were extracted from each study that fit the selection criteria: study design; sample size; participants' demographic information (age and sex); type, duration, and intensity of treatment; key findings including effect sizes and means with 95% confidence intervals (calculated when possible using the data provided in the original study, even if not presented in the original study); and relevant comments.

MAIN RESULTS

The search revealed 749 articles evaluating the effects of rest and 1175 articles evaluating the effects of treatment. Of the 749 articles evaluating the effects of rest, only 2 met all the inclusion criteria. Of the 1175 articles evaluating the effects of treatment, only 10 met all the inclusion criteria. Ultimately, the authors were able to identify additional treatment articles that met the inclusion criteria, for a total of 12. The nature of the treatments and the participants differed enough that meta-analysis was not possible.  One of the 2 articles that evaluated rest was a retrospective analysis of athletes that showed those who were prescribed a period of cognitive rest had a longer duration of symptoms. The other study followed athletes postconcussion who were retrospectively assigned to groups based on self-reported activity level after injury. Those who reported moderate levels of cognitive and physical exertion over the first month postinjury appeared to demonstrate improved outcomes compared with those who pursued small or large amounts of activity.  Twelve studies evaluated the effects of treatment on symptoms after sport-related concussion. Various interventions were reviewed, including pharmacotherapy, light aerobic activity, graded exercise treadmill test, hyperbaric oxygen therapy, vestibular physiotherapy, and cervical spine manual therapy. Unfortunately, the authors did not report effect sizes for specific interventions, and due to the varied nature of each study and its respective treatment approach, no pooled data could be analyzed. However, a group of adolescents treated with submaximal aerobic and coordination exercises, visualization, and imagery returned to full normal physical activity at a mean duration of 4.4 weeks (95% confidence interval = 3.1, 5.7 weeks). Furthermore, a randomized controlled trial of patients experiencing persistent neck pain, dizziness, and headaches who underwent manual and physical therapy showed they were more likely to return to sport after 8 weeks of treatment. Despite the inability to pool data, the authors concluded that each treatment appeared to positively influence specific aspects of certain patients' symptoms.

CONCLUSIONS

Little high-quality evidence has addressed the effects of rest and treatment after sport-related concussion. Current evidence suggests that an initial period of rest appears to be beneficial. Further research is needed to evaluate the long-term outcomes of rest (including the quality and quantity of the rest). Low levels of exercise may benefit the athlete postinjury, but additional study is required to determine the optimal timing for initiation of treatment postinjury. Patients with cervical spine or vestibular dysfunction may benefit from rehabilitation techniques targeted at their individual symptom profile to facilitate recovery. Overall, we need high-quality studies evaluating resting period, pharmacologic interventions, rehabilitative techniques, and exercise and their effects on patients slow to recover from concussion symptoms.

Impact of a State Law on Physician Practice in Sports-Related Concussions

OBJECTIVE

To determine physician-reported adherence to and support of the 2010 Massachusetts youth concussion law, as well as barriers to care and clinical practice in the context of legislation.

STUDY DESIGN

Primary care physicians (n = 272) in a large pediatric network were eligible for a cross-sectional survey in 2014. Survey questions addressed key policy and practice provisions: concussion knowledge, state regulations and training, practice patterns, referrals, patient characteristics, and barriers to care. Analyses explored relationships between practice and policy, adjusting for physician demographic and practice characteristics.

RESULTS

The survey response rate was 64% among all responders (173 of 272). A total of 146 respondents who had evaluated, treated, or referred patients with a suspected sports-related concussion in the previous year were eligible for analysis. The vast majority (90%) of providers agreed that the current Massachusetts laws regarding sports concussions are necessary and support the major provisions. Three-quarters (74%) had taken a required clinician training course on concussions. Those who took training courses were significantly more likely to develop individualized treatment plans (OR, 3.6; 95% CI, 1.1-11.0). Physician training did not improve screening of youth with concussion for depression or substance use. Most physicians (77%) advised patients to refrain from computer, telephone, or television for various time periods. Physicians reported limited communication with schools.

CONCLUSIONS

Primary care physicians report being comfortable with the diagnosis and management of concussions, and support statewide regulations; however, adherence to mandated training and specific legal requirements varied. Broader and more frequent training may be necessary to align current best evidence with clinical care and state-mandated practice.

Valsalva maneuver unveils central baroreflex dysfunction with altered blood pressure control in persons with a history of mild traumatic brain injury

Background

Patients with a history of mild TBI (post-mTBI-patients) have an unexplained increase in long-term mortality which might be related to central autonomic dysregulation (CAD). We investigated whether standardized baroreflex-loading, induced by a Valsalva maneuver (VM), unveils CAD in otherwise healthy post-mTBI-patients.

Methods

In 29 healthy persons (31.3 ± 12.2 years; 9 women) and 25 post-mTBI-patients (35.0 ± 13.2 years, 7 women, 4–98 months post-injury), we monitored respiration (RESP), RR-intervals (RRI) and systolic blood pressure (BP) at rest and during three VMs. At rest, we calculated parameters of total autonomic modulation [RRI-coefficient-of-variation (CV), RRI-standard-deviation (RRI-SD), RRI-total-powers], of sympathetic [RRI-low-frequency-powers (LF), BP-LF-powers] and parasympathetic modulation [square-root-of-mean-squared-differences-of-successive-RRIs (RMSSD), RRI-high-frequency-powers (HF)], the index of sympatho-vagal balance (RRI LF/HF-ratios), and baroreflex sensitivity (BRS). We calculated Valsalva-ratios (VR) and times from lowest to highest RRIs after strain (VR-time) as indices of parasympathetic activation, intervals from highest systolic BP-values after strain-release to the time when systolic BP had fallen by 90 % of the differences between peak-phase-IV-BP and baseline-BP (90 %-BP-normalization-times), and velocities of BP-normalization (90 %-BP-normalization-velocities) as indices of sympathetic withdrawal.

We compared patient- and control-parameters before and during VM (Mann-Whitney-U-tests or t-tests; significance: P < 0.05).

Results

At rest, RRI-CVs, RRI-SDs, RRI-total-powers, RRI-LF-powers, BP-LF-powers, RRI-RMSSDs, RRI-HF-powers, and BRS were lower in patients than controls. During VMs, 90 %-BP-normalization-times were longer, and 90 %-BP-normalization-velocities were lower in patients than controls (P < 0.05).

Conclusions

Reduced autonomic modulation at rest and delayed BP-decrease after VM-induced baroreflex-loading indicate subtle CAD with altered baroreflex adjustment to challenge. More severe autonomic challenge might trigger more prominent cardiovascular dysregulation and thus contribute to increased mortality risk in post-mTBI-patients.

Factors Associated With Concussion-like Symptom Reporting in High School Athletes

IMPORTANCE

Every state in the United States has passed legislation for sport-related concussion, making this health issue important for physicians and other health care professionals. Safely returning athletes to sport after concussion relies on accurately determining when their symptoms resolve.

OBJECTIVE

To evaluate baseline concussion-like symptom reporting in uninjured adolescent student athletes.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional, observational study, we studied 31 958 high school athletes from Maine with no concussion in the past 6 months who completed a preseason baseline testing program between 2009 and 2013.

RESULTS

Symptom reporting was more common in girls than boys. Most students with preexisting conditions reported one or more symptoms (60%-82% of boys and 73%-97% of girls). Nineteen percent of boys and 28% of girls reported having a symptom burden resembling an International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). Students with preexisting conditions were even more likely to endorse a symptom burden that resembled PCS (21%-47% for boys and 33%-72% for girls). Prior treatment of a psychiatric condition was the strongest independent predictor for symptom reporting in boys, followed by a history of migraines. For girls, the strongest independent predictors were prior treatment of a psychiatric condition or substance abuse and attention-deficit/hyperactivity disorder. The weakest independent predictor of symptoms for both sexes was history of prior concussions.

CONCLUSIONS AND RELEVANCE

In the absence of a recent concussion, symptom reporting is related to sex and preexisting conditions. Consideration of sex and preexisting health conditions can help prevent misinterpretation of symptoms in student athletes who sustain a concussion.