Returning to School Following Sport-Related Concussion

Variables associated with days of school missed following concussion: results from the Sport Concussion Outcomes in PEdiatrics (SCOPE) study

OBJECTIVE

To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion.

STUDY DESIGN

We performed a prospective cohort study of children and adolescents (8-18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss.

RESULTS

167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03-0.08, p < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28-2.45, p = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p < 0.001; Cohen's d = 0.87).

CONCLUSIONS

Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Prospective evaluation of 24-hour movement behaviors among adolescents recovering from a sport-related concussion

This study aimed to describe the 24-hour composition of movement behaviors, including sleep, sedentary behavior, and physical activity (PA), among pediatric sports-related concussion (SRC) patients over their recovery period, assess the association between movement compositions and recovery time, and understand feasibility of 24-hour accelerometry in the study population. A cohort of 50 pediatric SRC patients were asked to wear a wrist-worn accelerometer continuously for the duration of their recovery. Among all enrolled participants, the sample was primarily 14 or 15 years of age (65%), female (55%), and recovered in under 28 days (88%). Accelerometer compliance was moderate; 35 participants (70%) were compliant with the protocol. Compositional analysis was used to address time-use objectives in 33 participants who provided adequate data for inclusion. Overall, participants spent an average of 50% of their 24-hour day sedentary, 33% sleeping, 11% in light intensity PA, and 6% in moderate or vigorous intensity PA. The 24-hour composition of movement behaviors was not associated with recovery time (p = .09-.99). However, the limited sample size may have contributed to null findings. Given recent evidence supporting the effects of sedentary behavior and PA on concussion recovery, future studies should aim to further validate these findings in a larger sample.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in Adolescents

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in adolescent student athletes. We hypothesized that there would be an association between the severity of acute symptoms experienced in the first 72 hours and functional recovery such that adolescents with the lowest burden of acute symptoms would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 375 adolescent student athletes aged 14-19 years who sustained a sport-related concussion between 2014 and 2020. Athletic trainers documented time to return to school and to sports. A greater proportion of adolescents with the highest acute symptoms remained out of school at 3 (odds ratio [OR] = 2.5, 95% confidence interval [CI] 1.5-4.4), 5 (OR = 2.4, 95% CI 1.4-4.0), 7 (OR = 2.6, 95% CI 1.5-4.3), and 10 days (OR = 2.3, 95% CI 1.3-3.9) compared to those with the lowest acute symptoms. Similarly, a greater proportion of athletes with the highest acute symptoms remained out of sports at 7 (OR = 3.5, 95% CI 1.5-8.1), 10 (OR = 3.1, 95% CI 1.8-5.6), 14 (OR = 1.8, 95% CI 1.1-3.0), and 21 days (OR = 1.9, 95% CI 1.0-3.6) compared to those with the lowest acute symptoms. This study underscores the adverse effect of high acute symptom burden following concussion on return to school and to sports among adolescent student athletes. Conversely, student athletes with a low burden of acute symptoms have a faster return to school and to sports.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report

Aim:

To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility.

Materials & methods:

A total of 40 families of concussed children, aged 8–18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined.

Results:

All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains.

Conclusion:

The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Return to Learn: Preferences of College Educators When Receiving Concussion Medical Notes

The aim of this work is to uncover the preferences and perspectives of college educators as they interpret medical documentation outlining medically requested return-to-learn (RTL) instructions. Participants were recruited from five colleges across campus at a large Midwest public university. They each engaged in a private, one-on-one, audio-recorded interview. All recordings were transcribed and inductively analyzed using a grounded theory approach and two-coder system. All codes and themes were finalized once agreement was reached by both coders. Resultant themes from axial coding had to represent the voices of at least 80% of participants. Three characteristics emerged as being desired by college educators: brevity, clarity, and direction. Educators also expressed considerably less utility with medical documentation designed for pediatric students with concussion. College educators desire medical notes that are brief, clear, and provide straightforward direction, in addition to documentation that is tailored for the college setting.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in NCAA Division III Collegiate Athletes

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in National Collegiate Athletic Association (NCAA) Division III collegiate athletes. We hypothesized that students with the lowest burden of acute symptoms, measured in the first 72 h, would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 808 athletes from 11 NCAA Division III colleges who sustained a concussion between 2014 and 2019. Athletic trainers documented time to return to school and to sports. Kruskal-Wallis tests with post-hoc planned comparison Mann-Whitney U tests were used to assess whether athletes took longer to return based on their acute symptom burden (Low, Medium, or High). Survival analysis (Kaplan Meier with log rank tests) was used to compare the recovery times based on acute symptom burden (censored at 28 days). Chi-square tests compared the proportion of those who had not yet returned to school or sports at various recovery benchmarks (i.e., 1 week, 10 days, 2 weeks, 3 weeks, 4 weeks) based on acute symptom burden. Women (median = 5 days) took slightly longer than men (median = 4 days) to return to school (p = 0.001; r = −0.11, small effect). Women and men did not differ on time to return to sports (p = 0.32, r = −0.04). A greater proportion with high acute symptoms remained out of school at 5 (odds ratio, OR = 4.53), 7 (OR = 4.98), and 10 (OR = 4.80) days compared to those with low acute symptoms. A greater proportion with high acute symptoms remained out of sports at 10 (OR = 4.11), 14 (OR = 3.46), and 21 (OR = 3.01) days compared to those with low acute symptoms. This study shows a strong association between having a high burden of acute post-concussion symptoms and having a slower return to school and sports in Division III collegiate athletes. Moreover, it also illustrates the converse: that those athletes with a low burden of acute symptoms have a faster return to school and sports.

Evaluating Adherence to Return to School and Activity Protocols in Children After Concussion

OBJECTIVE

The need to have a pediatric-specific concussion management protocol on Return to School (RTS) and Return to Activity (RTA) after concussion has been recognized internationally. The first step to evaluate the protocol effectiveness is to establish whether children and youth are adhering to these recommendations. The objective of this study was to explore the prevalence and predictors of adherence to RTS and RTA concussion management protocols for children/youth.

DESIGN

A prospective cohort of children/youth with concussion.

SETTING

Childhood Disability Research Centre.

PARTICIPANTS

One hundred thirty-nine children/youth aged 5 to 18 years, diagnosed with concussion and symptomatic upon enrollment, were followed for up to 6 months. Primary recruitment occurred from a Children's Hospital Emergency Department.

INTERVENTION

Provision of RTS/RTA guidelines.

MAIN OUTCOME MEASURES

Measurement of adherence came from multiple sources, including the child's and parent's knowledge of protocols, research personnel evaluations, and self-reported stages of RTS/RTA and Post-Concussion Symptom Scale (PCSS) scores.

RESULTS

Spearman correlations and logistic regression were used, investigating the relationship between PCSS and progression of protocols and determining predictors of adherence. Significant negative associations between total PCSS score and stage of RTS/RTA protocols were found. Fifty-three percent and 56% of the participants adhered to the RTS and RTA protocols, respectively.

CONCLUSIONS

Children's knowledge of protocols and total PCSS scores significantly predicted adherence to RTS/RTA and may be the most important factors in predicting adherence during recovery from concussion.

Concussion Characteristics and Early Postinjury Outcomes Between College Students and Intercollegiate Athletes

OBJECTIVE

To describe concussion characteristics among general college students and compare postinjury outcomes to intercollegiate student athletes.

DESIGN

Retrospective cohort.

SETTING

Large university in the Southeast region of the United States.

PARTICIPANTS

A total of 179 (N=179) college students' (female=120; 67.0%; 23.9±3.9 years) and 49 athletes' (female=28, 57.1%;19.3±1.3 years) medical records were examined. Participants self-reported injury mechanism, health history information, and completed clinical assessments acutely (<7 days postinjury).

MAIN OUTCOME MEASURES

Descriptive statistics were calculated for each group. Concussion outcomes between students with and without certain health history diagnoses were assessed using separate t tests. We conducted univariate regression analyses to determine if sex, age, and time from concussion to first clinical assessment were significant predictors of clinical outcomes. Statistically significant variables were included as covariates in a series of 1-way analyses of covariance to identify differences in balance, symptom severity, total symptom presence, and neurocognitive domain performance between students and athletes. Fisher exact tests were used to compare health history information between groups (α<0.05).

RESULTS

Among students, 24% reported sustaining a concussion while participating in recreational sports, and 27% of impacts occurred to the back of the head. Students had higher proportions of headache, migraine, anxiety, and depression (P<.05). Students reported greater total symptom presence (P=.006) and performed worse on the computerized neurocognitive test domain score for complex attention (P=.015) relative to athletes.

CONCLUSIONS

These findings highlight the need for better access to medical care for non- National Collegiate Athletic Association sanctioned athletes because of a large proportion of concussions in the student sample being sustained during sports participation. Identifying common injury mechanisms can provide clinicians with powerful information to improve evaluation and treatment models.

Critical Elements of Return to Learn for Students With Concussion: A Scoping Review

OBJECTIVE

To identify critical elements of return to learn (RTL) for students with concussion and examine the state of the peer-reviewed published literature through a scoping review.

METHODS

Three electronic databases were systematically searched, and reference lists screened for articles addressing components of RTL protocols and accommodations for students with concussion. In total, 100 articles met inclusion criteria, including 56 empirical studies and 44 expert articles.

RESULTS

Four key components to RTL protocols were identified: RTL teams, management approaches, outcome measurement, and accommodations. Both bodies of literature agree on the importance of RTL teams, but evidence for specific monitoring tools and management approaches is less robust. Accommodations have been better addressed by experts than empirical evaluation. Empirical studies are largely cross-sectional, and many are survey based. Just 24 include student perspectives. Publication of expert literature has declined in frequency, as empirical studies have become more common.

CONCLUSION

This scoping review describes the current landscape of RTL and provides guidance toward expanding the empirical literature to systematically determine best practices to serve students with concussion.

Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study

INTRODUCTION

While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion.

METHODS AND ANALYSIS

In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group.

ETHICS AND DISSEMINATION

Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000418370; pre-results.

Management and Treatment of Concussions via Tele-Concussion in a Pediatric Setting: Methodological Approach and Descriptive Analysis

BACKGROUND

Approximately 2 million children in the United States sustain a concussion annually, resulting in an economic impact as high as US $20 billion. Patients who receive treatment at concussion specialty clinics, versus primary care, experience faster recovery, thereby reducing patient burden and subsequent medical-related costs. Accessibility to specialty clinics is typically limited by the availability of in-office visits. This is particularly relevant in light of the severe acute respiratory syndrome coronavirus 2 pandemic and subsequent guidance to eliminate all non-medically necessary in-clinic visits. Telehealth has been used to effectively deliver in-clinic care across several disciplines including psychiatry, psychology, and neuropsychology. However, a model of telehealth delivered concussion assessment, treatment, and management has not been established.

OBJECTIVE

The purposes of this paper are to describe a pediatric concussion specialty clinic's experiences in delivering telehealth concussion services and to provide preliminary descriptive data on a sample of pediatric telehealth patients with concussions.

METHODS

The specialty pediatric concussion clinic described here began providing telehealth services in 2019 and is part of the largest and fastest-growing telehealth hospital network in the United States. The clinical care process will be described, including accessing the telehealth platform, assessment during the initial appointment, injury management including communication with relevant patient stakeholders (eg, parent or guardians, athletic trainers), dissemination of rehabilitation exercises, and nature of follow-up visits. Descriptive data will include patient demographics, the radius of care, the time between the date of injury and initial visit, the average number of follow-up visits, and days until medically cleared for return-to-learn and return-to-play.

RESULTS

The analytic sample included 18 patients with concussions who were seen for all of their visits via telehealth between August 2019 and April 2020. The mean age of the sample was 14.5 (SD 2.5) years. The radius of care was a median of 17 (IQR 11.0-31.0) miles from the clinic with a median time between injury and the first visit of 21 (IQR 6.0-41.5) days. The mean number of visits was 2.2 (SD 0.8) with a median days between visits of 5.4 (IQR 3.0-9.3) to manage and treat the concussion. Of the 18 patients, 55.6% (n=10) were medically cleared for return-to-learn or -play in a median of 15.5 (IQR 11.0-29.0) days.

CONCLUSIONS

Limited access to health care is a well-understood barrier for receiving quality care. Subsequently, there are increasing demands for flexibility in delivering concussion services remotely and in-clinic. This is the first paper to provide a clinically relevant framework for the assessment, management, and treatment of acute concussion via telehealth in a pediatric population.

Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review

Objective

To determine the effects of following return to activity (RTA) and return to school (RTS) protocols on clinical outcomes for children with concussion. The 12 subquestions of this review focus on the effectiveness of protocols, guidelines and recommendations, and the evidence supporting content of the protocols including rest, exercise and school accommodations.

Design

Systematic review.

Data sources

PubMed, MEDLINE, EMBASE, CINAHL, ERIC and manual reference list check.

Eligibility criteria for selecting studies

Studies were included if they evaluated RTA or RTS protocols in children aged 5–18 years with a concussion or if they reported a rigorous study design that provided evidence for the recommendations. Included studies were original research or systematic reviews. Articles were excluded if they did not report on their methodology or included participants with significant neurological comorbidities.

Results

The literature search retrieved 198 non-duplicate articles and a total of 13 articles were included in this review. Despite the adoption of several RTS and RTA protocols in clinical practice there is little evidence to determine their efficacy in the paediatric population.

Summary

The current data support the recommendation that children in the acute stage postconcussion should undergo 1–2 days physical and cognitive rest as they initiate graduated RTA/RTS protocols. Prolonged rest may increase reported symptoms and time to recovery. Further interventional studies are needed to evaluate the effectiveness of RTA/RTS protocols in youth with concussion.

A commentary for neuropsychologists on CDC's guideline on the diagnosis and management of mild traumatic brain injury among children

Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline.Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline.Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices.Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

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.

Maximizing Recovery From Concussions for Youth Participating in Sports and Recreational Activities

Concussions have become a public health issue. This public health concern has drawn the attention of many states in which laws were created to address concussions safety, recognition of signs and symptoms, immediate removal, medical clearance, and return-to-play protocols. Most state legislation focused on student athletes participating in organized sports. However, the rise in concussion can be directly attributed to children, youth, and adolescents participating in nonsports-related events. Maximizing recovery from a concussion involves implementing education programs that focus on recognition of symptoms, treatment, and return-to-learn options. Treatment strategies used to address concussed youth include physical and cognitive rest and minimizing external stimuli that can increase symptoms. Because learning is a direct outcome for all youth, a return-to-learn protocol based on a collaborative school-based team approach is suggested.

Language Comprehension After Mild Traumatic Brain Injury: The Role of Speed

Purpose The aim of this study was to characterize language comprehension in mild traumatic brain injury (mTBI) by testing a speed-based hypothesis. We hypothesized that adults with mTBI would perform worse than a group of adults with orthopedic injuries (OIs) on an experimental language comprehension task. Method The study employed a prospective experimental design. Participants were 19 adults with mTBI and 19 adults with OI ages 18-55 years. Participants completed the Whatdunit task, a sentence agent selection task in speeded and unspeeded conditions. Results In the unspeeded condition, the mTBI group performed with a marginally significant higher accuracy than the OI group. In the speeded condition, the mTBI group performed with lower accuracy than the OI group; however, this difference did not reach statistical significance. There was a marginally significant interaction of Sentence Type × Group for reaction time in the speeded condition. Conclusions While our task might have been sensitive to cognitive processing abilities in both groups (as evidenced by the main effects of condition and sentence type), the task was not specific enough to capture mTBI-related deficits. The similarities in performance between both groups have clinical implications for the treatment of not just brain-related trauma but also trauma in general.

Assessing concussion knowledge and awareness in faculty and staff in a collegiate setting

Purpose

To examine faculty and academic support staff members’ awareness and knowledge regarding concussions.

Design

Cross-sectional, web-based questionnaire.

Setting

Division II collegiate setting.

Subjects

A total of 123 collegiate faculty, administrative and academic support staff participated in the study. Measure(s): Participants completed the Faculty and Staff Concussion Awareness and Knowledge Survey. Analysis: Descriptive statistics were compiled for demographic information within the survey. Analysis of variance was performed on concussion awareness and concussion knowledge survey questions.

Results

The majority of the sample had teaching responsibilities in the University (75%). There was a significant effect of college departments within the university on individuals’ level of awareness (F (5, 117) = 9.74, p < .001). The Athletics department scored the highest in awareness of concussion symptomology, while the Business department scored the lowest. Females demonstrated significantly more awareness of concussion symptoms than males (F (1, 121) = 10.488, p = .002). University department significantly impacted knowledge of concussion treatments (F (5, 117) = 3.67, p < .004). The Health Sciences department scored the highest in knowledge of concussion treatments, while the Business department scored the lowest. Past experience with academic accommodations was associated with respondents’ knowledge of concussion treatment (F (1, 121) = 4.046, p = .047).

Conclusions

Concussion management in a collegiate setting should include the faculty and academic support staff. Colleges and Universities should consider educational programming regarding etiology and recovery from concussions for effective management when student experience a concussion.

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.

Acute Post-Traumatic Sleep May Define Vulnerability to a Second Traumatic Brain Injury in Mice

Chronic neurological impairments can manifest from repetitive traumatic brain injury (rTBI), particularly when subsequent injuries occur before the initial injury completely heals. Herein, we apply post-traumatic sleep as a physiological biomarker of vulnerability, hypothesizing that a second TBI during post-traumatic sleep worsens neurological and histological outcomes compared to one TBI or a second TBI after post-traumatic sleep subsides. Mice received sham or diffuse TBI by midline fluid percussion injury; brain-injured mice received one TBI or rTBIs at 3- or 9-h intervals. Over 40 h post-injury, injured mice slept more than shams. Functional assessments indicated lower latencies on rotarod and increased Neurological Severity Scores for mice with rTBIs within 3 h. Anxiety-like behaviors in the open field task were increased for mice with rTBIs at 3 h. Based on pixel density of silver accumulation, neuropathology was greater at 28 days post-injury (DPI) in rTBI groups than sham and single TBI. Cortical microglia morphology was quantified and mice receiving rTBI were de-ramified at 14 DPI compared to shams and mice receiving a single TBI, suggesting robust microglial response in rTBI groups. Orexin-A-positive cells were sustained in the lateral hypothalamus with no loss detected, indicating that loss of wake-promoting neurons did not contribute to post-traumatic sleep. Thus, duration of post-traumatic sleep is a period of vulnerability that results in exacerbated injury from rTBI. Monitoring individual post-traumatic sleep is a potential clinical tool for personalized TBI management, where regular sleep patterns may inform rehabilitative strategies and return-to-activity guidelines.

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial

IMPORTANCE

Sport-related concussion (SRC) is a significant public health problem without an effective treatment.

OBJECTIVE

To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen.

INTERVENTIONS

After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website.

MAIN OUTCOMES AND MEASURES

Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery.

RESULTS

A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08).

CONCLUSIONS AND RELEVANCE

This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02710123.

Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children

INTRODUCTION

Rest until symptom-free, followed by a progressive stepwise return to activities, is often prescribed in the management of paediatric concussions. Recent evidence suggests prolonged rest may hinder recovery, and early resumption of physical activity may be associated with more rapid recovery postconcussion. The primary objective is to determine whether the early reintroduction of non-contact physical activity beginning 72 hours postinjury reduces postconcussive symptoms at 2 weeks in children following an acute concussion as compared with a rest until asymptomatic protocol.

METHODS AND ANALYSIS

This study is a randomised clinical trial across three Canadian academic paediatric emergency departments. A total of 350 participants, aged 10-17.99 years, who present within 48 hours of an acute concussion, will be recruited and randomly assigned to either the study intervention protocol (resumption of physical activity 72 hours postconcussion even if experiencing symptoms) or physical rest until fully asymptomatic. Participants will document their daily physical and cognitive activities. Follow-up questionnaires will be completed at 1, 2 and 4 weeks postinjury. Compliance with the intervention will be measured using an accelerometer (24 hours/day for 14 days). Symptoms will be measured using the validated Health and Behaviour Inventory. A linear multivariable model, adjusting for site and prognostically important covariates, will be tested to determine differences between groups. The proposed protocol adheres to the RCT-CONSORT guidelines.

DISCUSSION

This trial will determine if early resumption of non-contact physical activity following concussion reduces the burden of concussion and will provide healthcare professionals with the evidence by which to recommend the best timing of reintroducing physical activities.

TRIAL REGISTRATION NUMBER

Trial identifier (Clinicaltrials.gov) NCT02893969.

The Mild Traumatic Brain Injury Rest and Activity Questionnaire (MTBI-RAQ): A Pilot Study

Objective: To develop a tool for assessing intentions to continue or change activities for recovery following mild traumatic brain injury (mTBI) and determine if they are dependent on injury context or activity type. Method: Adult volunteers with no (or no recent) history of mTBI were randomly allocated to one of two vignette conditions, each with a different injury context. The vignette described an mTBI due to a motor vehicle accident (MVA, n = 76) or sport (SPORT, n = 89). Volunteers reported their rest or activity plans for 39 behaviours comprising three behaviour types (cognitive, physical, and restful). Results: Compared to a cut-score representing no change, on average there was a significant (p <= .001) planned decrease in physical and cognitive behaviours (MVAphysicalt(53) = 7.373; SPORTphysicalt(41) = 9.281; MVAcognitivet(41) = 9.367; SPORTcognitivet(51) = −3.521) and a significant planned increase in restful behaviours, such as sleep (MVArestfult(72) = 10.006; SPORTrestfult(86) = 9.566). An overall within-group effect for behaviour-type was not identified and there was no effect of condition (MVA vs. SPORT). Conclusion: The acute rest and activity plans for a simulated mTBI are behaviour specific and not dependent on context. An expectation for blanket-rest was not was observed but rest was planned for specific behaviours. This tool could be used to guide discussions with mTBI patients about their recovery so that their plans align with advice, and it could aid further research into the relation between intended and actual rest and activity and the effect on eventual outcomes.

What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review

Objective

To evaluate the evidence regarding (1) factors affecting return to school (RTS) and (2) strategies/accommodations for RTS following a sport-related concussion (SRC) in children and adolescents.

Design

A systematic review of original studies specifically addressing RTS following concussion in the paediatric and sporting context.

Data sources

MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid) electronic databases and the grey literature OpenGrey, ClinicalTrials.gov and Google Advanced.

Eligibility criteria

Studies were included if they were original research on RTS following SRC in children aged 5–18 years published in English between 1985 and 2017.

Results

A total of 180 articles were identified; 17 articles met inclusion criteria. Several factors should be considered for RTS after concussion, including: symptomatology; rest following injury; age/grade; and course load. On RTS after concussion, 17%–73% of students were provided academic accommodations or experienced difficulty with RTS. Students were more likely to obtain academic accommodations in schools with a concussion policy if they had a medical RTS letter and had regular medical follow-up after concussion.

Conclusions

Schools should have a concussion policy and offer individualised academic accommodations to students recovering from SRC on RTS; a medical letter should be provided to facilitate provision/receipt of academic accommodations; students should have early, regular medical follow-up following SRC to help with RTS and monitor recovery; students may require temporary absence from school after SRC; clinicians should assess risk factors/modifiers that may prolong recovery and require more intensive academic accommodations.

PROSPERO registration number

CRD42016039184.

School nurses' perceptions and experiences with an interprofessional concussion management team in the secondary school setting

Following a concussion, both cognitive and physical rest are imperative aspects of injury management. The inclusion of academic adjustments and the formation of an interprofessional concussion management team (ICMT) provide a mechanism to manage academic issues following a concussion. As one of the sole healthcare providers presents during school hours, the school nurse may offer unique insight regarding the infrastructure of an ICMT in the secondary school setting. The purpose of this study was to explore school nurses' perceptions of and experiences with an ICMT for adolescents following a concussion in the secondary school setting. The consensual qualitative research approach was used to guide this study. Semi-structured individual telephone interviews were conducted with 15 school nurses employed in the secondary school setting across the United States. During data analysis, themes and categories were established based on a consensus process by the research team. Study findings indicated that school nurses identified several stakeholders regarding the concussion management team that are essential to include in the concussion management process. In addition to the school nurse, participants perceived an ICMT should include a physician, athletic trainer, school counsellor, teachers, and other stakeholders such as the patient and their parents. Additionally, participants discussed their perceptions of their own role as a member of an ICMT in the secondary school setting. The inclusion of an ICMT to aid the recovery following a concussion is vital to ensure proper care for the adolescent patient. Furthermore, the school nurse and athletic trainer must effectively collaborate, when possible, to ensure that concussed adolescents are allowed sufficient cognitive rest via the incorporation of academic adjustments during the recovery process.

Using Acute Performance on a Comprehensive Neurocognitive, Vestibular, and Ocular Motor Assessment Battery to Predict Recovery Duration After Sport-Related Concussions

BACKGROUND

A sport-related concussion (SRC) is a heterogeneous injury that requires a multifaceted and comprehensive approach for diagnosis and management, including symptom reports, vestibular/ocular motor assessments, and neurocognitive testing.

PURPOSE

To determine which acute (eg, within 7 days) vestibular, ocular motor, neurocognitive, and symptom impairments predict the duration of recovery after an SRC.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Sixty-nine patients with a mean age of 15.3 ± 1.9 years completed a neurocognitive, vestibular/ocular motor, and symptom assessment within 7 days of a diagnosed concussion. Patients were grouped by recovery time: ≤14 days (n = 27, 39.1%), 15-29 days (n = 25, 36.2%), and 30-90 days (n = 17, 24.6%). Multinomial regression was used to identify the best subset of predictors associated with prolonged recovery relative to ≤14 days.

RESULTS

Acute visual motor speed and cognitive-migraine-fatigue symptoms were associated with an increased likelihood of recovery times of 30-90 days and 15-29 days relative to a recovery time of ≤14 days. A model with visual motor speed and cognitive-migraine-fatigue symptoms within the first 7 days of an SRC was 87% accurate at identifying patients with a recovery time of 30-90 days.

CONCLUSION

The current study identified cognitive-migraine-fatigue symptoms and visual motor speed as the most robust predictors of protracted recovery after an SRC according to the Post-concussion Symptom Scale, Immediate Post-concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening (VOMS). While VOMS components were sensitive in identifying a concussion, they were not robust predictors for recovery. Clinicians may consider particular patterns of performance on clinical measures when providing treatment recommendations and discussing anticipated recovery with patients.

The use of ibuprofen and acetaminophen for acute headache in the postconcussive youth: A pilot study

Objective

Acute postconcussive headaches are problematic for children after mild traumatic brain injury. There are no evidence-based guidelines for their management. This pilot study aims to assess the feasibility and efficacy of routine analgesia administration.

Methods

A four-arm open-label randomized controlled trial pilot/feasibility study was conducted: (i) acetaminophen, (ii) ibuprofen, (iii) alternating acetaminophen and ibuprofen and (iv) a control group. Children and youth 8 to 18 years of age presenting to emergency department with headache within 48 hours of their first concussion were recruited consecutively and sequentially randomized. Children with abnormal neuroimaging, history of previous concussions and bleeding disorder were excluded. A headache survey was administered at recruitment. All participants were provided with standard concussion management education and were also instructed on how to use the headache diary for the 1-week study follow-up period. The diary captures (i) headache days, (ii) number of headaches, (iii) headache intensity and (iv) return-to-school information. Feasibility was assessed based on study recruitment and compliance.

Results

There were no feasibility concerns with the recruitment and no major compliance issues. Patients on acetaminophen, ibuprofen or both had significantly less headache days, episodes of headache and lower headache intensity than did the standard care group. Patients on both ibuprofen and acetaminophen (79.0%) and on ibuprofen alone (61.0%) were more likely to be back at school 1 week postinjury as compared with the acetaminophen group (33.3%) and the standard care group (21.1%).

Conclusion

Results showed routine analgesia administration was feasible and effective for postconcussive headache management. A larger full-scale randomized controlled trial is required to further assess the efficacy with longer follow-up, a wider variety of patients and more concussion related outcomes.

Dove and hawk profiles in youth concussion: Rethinking occupational performance

Background.

Youth concussion and its subsequent recovery have been described as heterogeneous; no one injury is the same, and each youth is different in how he or she recovers.

Purpose.

This paper proposes a theoretical perspective on the management of youth with persistent concussion symptoms.

Key Issues.

When managing concussion within youth, further consideration of person, occupation, and environment factors may provide insight on (a) the differential spectrum of profiles that exist among youth who have experienced a concussion and (b) how these profiles can support client-centred rehabilitation. Passive-dove and active-hawk stress profiles from evolutionary literature will be used to contextualize return to occupational performance. An innovative, novel model—the Dove-Hawk Model of Allostatic Load for Youth With Persistent Concussion Symptoms—is proposed to illustrate these concepts, and approaches to rehabilitation across the spectrum of profiles are offered.

Implications.

Viewing persistent youth concussion recovery in this way may elucidate different approaches to client-centred rehabilitation.