Examining prescribed rest as treatment for adolescents who are slow to recover from concussion

The Unconsidered Pathway: Suggestions for Physical Therapists to Facilitate Student Reintegration to Physical Education after a Concussion

Background/Objectives: "Return-to-play" and "return-to-learn" after a concussion are familiar concepts due to guidelines proposed by the Concussion in Sport Group and Heads-Up Initiative. The purpose of this commentary is to expand upon the current consensus guidelines for treatment of concussed children and adolescents, as well as provide guidelines for returning to physical education (RT-PE) classes. Proposal: The authors propose one general and four subtype-specific guidelines post-concussion injury. This framework highlights the role of physical therapists in the management of children with prolonged recovery. The final RT-PE determination should occur with documented medical clearance from a licensed healthcare provider trained in the evaluation and management of a concussion. Conclusions: Despite significant gains regarding the management of concussed children and adolescents, confusion remains regarding RT-PE post-concussion. To eliminate ambiguity and promote adherence to a gradual return to activity protocols, the authors developed guidelines based on current evidence and recommendations.

Evidence-Based Medical Management and Physiotherapy Rehabilitation in Pediatric Traumatic Brain Injury: A Narrative Review

Children between the ages of one and 18 are at a heightened risk of death and impairment due to traumatic brain injury (TBI). TBI can be deadly and is usually categorized as mild, moderate, or severe according to the Glasgow Coma Scale (GCS). For individuals with a TBI and an abnormal GCS, the preferred modality is non-contrast CT of the head. This review focuses on the medical treatment and rehabilitation of children with TBI and their outcomes. This was searched in databases such as PubMed, Google Scholar, and EMBASE. The literature search criteria included "traumatic brain injury AND physiotherapy rehabilitation OR medical treatment," with additional filters applied, including full text, both male and female, ages below 18 years, and publications from 2012 to 2024. This study conducted research on the treatment and rehabilitation of children with TBI. Ten randomized clinical trials, non-randomized trials, and longitudinal cohort study randomized trials met the inclusion criteria, which include hyperbaric oxygen therapy, melatonin, nabiximols, psycho-educational intervention, online therapy, the virtual reality rehabilitation program, and conventional occupational therapy. The results show significant improvement in forearm supination, performance in daily living, quality of life, reduced anger, improved school functioning, improvement in TBI conditions, reduced hospital stay, activity facilitating recovery, and reduced prolonged symptoms. This review has addressed the effectiveness of various medical management and rehabilitation strategies, which are important in TBI and aim to mitigate post-traumatic/concussion impact and improve quality of life. Articles regarding children's TBI rehabilitation are comparatively few. One possible solution to this issue would be to encourage further rehabilitation intervention trials.

Knowledge, Attitude, Beliefs, and Practice Related to Concussion Injury Among Sports Physical Therapists in Riyadh, Saudi Arabia. A Cross-sectional Analysis

Background and Objective

Sport-related concussions (SRC) are estimated to affect more than 55 million individuals annually. Physical therapists ought to have fundamental knowledge regarding the evaluation and treatment of SRC. Thus, this study aims to evaluate the knowledge, attitude, and practice of the physical therapists regarding SRC management in Riyadh, Saudi Arabia.

Materials and Methods

The cross-sectional study enrolled 83 sports physical therapist who had atleast undergraduate degree and above in physical therapy from Riyadh region. The participants who worked outside the Riyadh region were excluded. A validated adopted questionnaire was used to evaluate the outcome measures.

Results

The study showed that sport physical therapists have a good understanding and knowledge about concussions having 3.91 ± 0.98 scores on the five-point Likert scale. In addition, participants were able to recognize concussion signs and symptoms correctly; however, they felt that they lacked confidence to make a decision regarding return to play.

Conclusion

Our study revealed important knowledge gaps regarding the utilization of concussion severity scales, management of youth concussion, and/or the use of neurological imaging modalities for diagnosing concussion cases.

Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury

BACKGROUND

Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions.

OBJECTIVE

To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice.

LITERATURE SURVEY

A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process.

METHODOLOGY

A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed.

SYNTHESIS

There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity.

CONCLUSIONS

The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.

Does time since injury and duration matter in the benefits of physical therapy treatment for concussion?

Objective

To determine if there are differences in post-concussion symptom levels depending on 1) when physical therapy treatment is begun after the concussion and 2) the length of treatment.

Method

Retrospective chart review yielded 202 patients who sustained concussions and were referred for physical therapy. Participants/patients were assigned to independent groups based on time elapsed between concussion and physical therapy (0–14, 15–30, 31–60, 61–120, 121–365 days), and on months spent in treatment (1–4). Pre- and post- treatment scores were documented for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p < .005.

Results

All patients demonstrated improvements with treatment, with no significant differences in outcomes for time elapsed since injury (SCAT Symptom Score ( p = .80), SCAT Symptom Severity Score ( p = .97), CISS ( p = .61), DHI ( p = .65), mCTSIB ( p = .13)); or for months in treatment (SCAT Symptom Score ( p = .23), SCAT Symptom Severity Score ( p = .04), CISS ( p = .41), DHI ( p = .37), mCTSIB ( p = .50)).

Conclusions

Improvements were similar for all patients receiving post-concussive physical therapy, regardless of time between injury and treatment onset, and regardless of time spent in treatment. These results may have implications for clinical decision-making and for third party payors’ coverage of post-concussion treatment. Longer periods of treatment may not necessarily be of greater benefit and application of treatment if delayed may also be beneficial. Limitations to the study, such as its retrospective nature, lack of randomization, and convenience sample size are discussed.

The care of the concussed pediatric patient prior to presentation to primary care pediatrician versus concussion specialists: Implications for management

Objective

Absent adequate randomized control trials to inform appropriate treatment for concussion in pediatric patients, guidelines have been developed based on expert opinion and observational data that may not apply to all groups. This study examines differences in the previous clinical care between concussed patients who present in pediatric practice and specialty clinics. Differences found might influence treatment recommendations for each setting.

Study design

Prospective data collected from a pediatric practice in 2011 to 2013 were compared to chart review data from two specialty clinics between 2015 and 2017. In all three groups patients 11–19 years of age with an ICD9 billing code for concussion were included if they met the 4th International Consensus definition of concussion. Patients were excluded if hospitalized or had abnormal CNS imaging.

Results

The time between injury and presentation was substantially longer in specialty clinic patients versus those seen in the primary pediatric care office. (median 10 vs. 2 days-p < 0.001) Primary care patients presenting had higher rates of immediate rest after injury, 61.4% vs 27.9% (p < 0.001). More specialty clinic patients had been seen in the emergency departments prior to presentation (47.5% vs. 18.8% p < 0.001) regardless of rest status at presentation to the office.

Conclusion

Several differences in previous clinical care between the groups were found. These included the time of presentation from injury, rates of cognitive rest both immediate and non-immediate, and emergency department visits. These differences may have implications for management recommendations. Accordingly, the appropriate treatment for patients seen by the primary pediatric care physicians may be different from those referred to specialty care. Given these findings randomized controlled trails should be conducted independently in both groups of patients.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

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.

Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents

OBJECTIVE

To compare a sample of adolescents with sport-related concussion (SRC) who were prescribed rest with 2 arms of a randomized controlled trial comparing aerobic exercise with placebo-like stretching. We also compared sex differences across the 3 approaches to treatment.

DESIGN

Quasi-experimental trial.

SETTING

University concussion management clinics.

PARTICIPANTS

Adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG], n=48, 15.4±1y, 25% female). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG], n=52, 15.3±2y, 46% female) or placebo-like stretching (placebo group [PG], n=51, 15.4±2y, 47% female) (N=151).

MAIN OUTCOME MEASURES

The primary outcome was median days from injury to recovery. The secondary outcome was proportion classified as normal recovery (<30d) or delayed recovery (≥30d).

RESULTS

The RG recovered in 16 days (interquartile range, 9.25-23.25d), which was significantly delayed (P=.020) compared with EG (13d; interquartile range, 10-18.5d). The PG recovered in 17 days (interquartile range, 13-23d). Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery (P=.190). There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups (P=.013).

CONCLUSION

Relative rest and a placebo-like stretching program were very similar in days to recovery and symptom improvement pattern after SRC. Both conditions were less effective than subsymptom threshold aerobic exercise. Female adolescents appear to be susceptible to symptom increase when prescribed rest.

Methodology and Implementation of a Randomized Controlled Trial (RCT) for Early Post-concussion Rehabilitation: The Active Rehab Study

Background: Sports-related concussion (SRC) is a complex injury with heterogeneous presentation and management. There are few studies that provide guidance on the most effective and feasible strategies for recovery and return to sports participation. Furthermore, there have been no randomized studies of the feasibility, safety, and efficacy of early rehabilitation strategies across multiple sports and age groups. This international cluster-randomized pragmatic trial evaluates the effectiveness of early multi-dimensional rehabilitation integrated with the current return to sport strategy vs. the current return to sport strategy alone.

Methods: The study is a cluster-randomized pragmatic trial enrolling male and female athletes from 28 sites. The sites span three countries, and include multiple sports, levels of play (high school, college, and professional), and levels of contact. The two study arms are Enhanced Graded Exertion (EGE) and Multidimensional Rehabilitation (MDR). The EGE arm follows the current return to sport strategy and the MDR arm integrates early, MDR strategies in the context of the current return to sport strategy. Each arm employs a post-injury protocol that applies to all athletes from that site in the event they sustain a concussion during their study enrollment. Participants are enrolled at pre-season baseline. Assessment timepoints include pre-season baseline, time of injury (concussion), 24–48 h post-injury, asymptomatic, and 1-month post-injury. Symptoms and activity levels are tracked post injury through the return to play process and beyond. Injury and recovery characteristics are obtained for all participants. Primary endpoints include time to medical clearance for full return to sport and time to become asymptomatic. Secondary endpoints include symptom, neurocognitive, mental status, balance, convergence insufficiency, psychological distress, and quality of life trajectories post-injury.

Discussion: Outputs from the trial are expected to inform both research and clinical practice in post-concussion rehabilitation across all levels of sport and extend beyond civilian medicine to care for military personnel.

Ethics and Dissemination: The study is approved by the data coordinating center Institutional Review Board and registered at clinicaltrials.gov. Dissemination will include peer-reviewed publications, presentation to patients and public groups, as well as dissemination in other healthcare and public venues of interest.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02988596

Trial Funding: National Football League.

Sports Medicine Update: Concussion

A systematic approach is required for patients with a suspected concussion. Although standardized tools can aid in assessment, the diagnosis of concussion remains a clinical one. At the time of diagnosis, patients should be given both verbal and written review of the common symptoms of concussion, expected course of recovery, as well as strategies to manage symptoms. Most patients benefit from a brief period of rest, followed by a gradual reintroduction of activities, and a graduated return-to-sport protocol. Patients with prolonged recovery from a concussion may benefit from exercise, vestibular, and cognitive rehabilitation programs.

The Association Between Moderate and Vigorous Physical Activity and Time to Medical Clearance to Return to Play Following Sport-Related Concussion in Youth Ice Hockey Players

Design: Prospective cohort study.

Background: The recommendations regarding the optimal amount and type of rest for promoting recovery following concussion are based on expert opinion rather than evidence-based guidelines due to current a lack of high-level studies. There is an evident need for more research into the parameters of rest and activity and its effects on recovery from concussion.

Objective: To evaluate the association between the amount of moderate and vigorous physical activity (MVPA) during the first 3 days following concussion diagnosis and time to medical clearance (days) to return to play in youth ice hockey players.

Methods: Thirty youth ice hockey players (12–17 years) that were diagnosed with a concussion sustained during ice hockey were recruited to participate. The exposure was the cumulative amount of MVPA (minutes), measured using a waist-worn Actigraph accelerometer. Participants were dichotomized into high (≥148.5) and low (<148.5) activity groups based on the median of cumulative time spent in MVPA over the first 3 days following injury diagnosis.

Results: Participants in both the low and high activity group reported to the clinic at a median time of 4 days post-injury (low activity IQR: 3–5 days; high activity IQR: 3–7 days). The low activity group completed a median time of 110.7 min (IQR: 76.2–131.0 min) in MVPA, whereas the high activity had a median of 217.2 min (IQR 184.2–265.2 min) in MVPA. Kaplan Meier survival curves with Log-rank tests of hypothesis revealed the high activity group took significantly more time to be medically cleared to return to play (p = 0.041) compared to the low activity group.

Conclusion: The results from this study suggest that more time in MVPA early in the recovery period may result in a greater time to medical clearance to return to full participation in ice hockey. Future research, using valid measures of activity, are required to better understand the relationship between early activity and recovery following concussion in youth.

Non-pharmacological rehabilitation interventions for concussion in children: a scoping review

PURPOSE

To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children.

METHODS

An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down's and Black criteria was conducted.

RESULTS

Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good.

CONCLUSIONS

The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy. Implications for rehabilitation Few studies have examined rehabilitation interventions for youth following concussion. Research ranging from rest to exercise highlights the uncertainty of the field. Low quality research limits the generalizability of results. The use of physical activity appears to be an emerging area of interest. Individualised, aerobic exercise should be used as part of clinical management.

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

Importance

Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.

Objective

To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Evidence Review

The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.

Findings

The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.

Conclusions and Relevance

This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

A systematic review of criteria used to define recovery from sport-related concussion in youth athletes

OBJECTIVE

The Concussion in Sport Group guidelines recommend a multifaceted approach to help clinicians make return to sport decisions. The purpose of this study was to identify the most common multifaceted measures used to define clinical recovery from sport-related concussion in young athletes (high school and/or college level) and to summarise existing knowledge of criteria used to make return to sport decisions.

DESIGN

Systematic review.

DATA SOURCES

The PubMed (MEDLINE), SPORTDiscus and Embase electronic databases were searched from 1 January 2000 to 1 March 2017 by three independent reviewers.

ELIGIBILITY CRITERIA

Inclusion criteria: elementary, high school and college age groups, and a specific definition of clinical recovery that required two or more measures.

EXCLUSION CRITERIA

review articles, articles using the same sample population, case studies, non-English language and those that used one measure only or did not specify the recovery measures used.

STUDY QUALITY

Study quality was assessed using the Downs and Black Criteria.

RESULTS

Of 2023 publications, 43 met inclusion criteria. Included articles reported the following measures of recovery: somatic symptom resolution or return to baseline (100%), cognitive recovery or return to baseline (86%), no exacerbation of symptoms on physical exertion (49%), normalisation of balance (30%), normal special physical examination (12%), successful return to school (5%), no exacerbation of symptoms with cognitive exertion (2%) and normalisation of cerebral blood flow (2%). Follow-up to validate the return to sport decision was reported in eight (19%) articles. Most studies were case-control or cohort (level of evidence 4) and had significant risk of bias.

CONCLUSION

All studies of sport-related concussion use symptom reports to define recovery. A minority of studies used multiple measures of outcome or had clearly defined recovery criteria, the most common being a combination of a self-reported symptom checklist and a computerised neurocognitive test. Future studies ideally should define recovery a priori using objective physiological measures in addition to symptom reports.

The role of family and personal psychiatric history in postconcussion syndrome following sport-related concussion: a story of compounding risk

OBJECTIVE Sport-related concussion (SRC) has become a major public health concern. Prolonged recovery after SRC, named postconcussion syndrome (PCS), has been associated with several biopsychosocial factors, yet the role of both family and personal psychiatric histories requires investigation. In a cohort of concussed high school athletes, the authors examined the role(s) of family and personal psychiatric histories in the risk of developing PCS. METHODS A retrospective cohort study of 154 high school athletes with complete documentation of postconcussion symptom resolution or persistence at 6 weeks was conducted. PCS was defined as 3 or more symptoms present 6 weeks after SRC. Three groups were defined: 1) positive family psychiatric history and personal psychiatric history (FPH/PPH), 2) positive FPH only, and 3) negative family and personal psychiatric histories (controls). Three bivariate regression analyses were conducted: FPH/PPH to controls, FPH only to controls, and FPH/PPH to FPH. Post hoc bivariate regression analyses examined specific FPH pathologies and PCS. RESULTS Athletes with FPH/PPH compared with controls had an increased risk of PCS (χ² = 8.90, p = 0.018; OR 5.06, 95% CI 1.71-14.99). Athletes with FPH only compared with controls also had an increased risk of PCS (χ² = 6.04, p = 0.03; OR 2.52, 95% CI 1.20-5.30). Comparing athletes with FPH/PPH to athletes with FPH only, no added PCS risk was noted (χ² = 1.64, p = 0.247; OR 2.01, 95% CI 0.68-5.94). Among various FPH diagnoses, anxiety (χ² = 7.48, p = 0.021; OR 2.99, 95% CI 1.36-6.49) and bipolar disorder (χ² = 5.13, p = 0.036; OR 2.74, 95% CI 1.14-6.67) were significantly associated with the presence of PCS. CONCLUSIONS Concussed high school athletes with FPH/PPH were greater than 5 times more likely to develop PCS than controls. Athletes with only FPH were over 2.5 times more likely to develop PCS than controls. Those with an FPH of anxiety or bipolar disorder are specifically at increased risk of PCS. These results suggest that not only are athletes with FPH/PPH at risk for slower recovery after SRC, but those with an FPH only-especially anxiety or bipolar disorder-may also be at risk. Overall, this study supports taking a detailed FPH and PPH in the management of SRC.

School Nurses' Management and Collaborative Practices for Student-Athletes Following Sport-Related Concussion

The purpose of this study was to examine school nurses' management and collaboration with health-care providers (HCPs) for student-athletes following a concussion. Secondary school nurses accessed an online survey titled the Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussions (access rate = 15.6%; n = 1,246/8,000). Approximately 40% of schools where nurses were employed administered baseline and postinjury concussion assessments. No significant differences were found between employment model (single vs. multiple sites) in regard to conducting baseline (p = .908) administration at their site; however, those employed at a single school more frequently offered postinjury assessments at their site than those at multiple sites (p = .019). School nurses most frequently reported relationships with an athletic trainer (38.8%, n = 483/1,246) compared to other HCPs. A concussion management team, including school nurses, and other recommended members should develop comprehensive concussion management plans. Plans should comprise of multiple concussion assessments to aid in the return-to-learn/play processes.

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.

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion

OBJECTIVE

To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only.

STUDY DESIGN

Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?² with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury.

RESULTS

A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?²?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?<?.05) for the symptoms group. Rest was beneficial for patients in the signs group on verbal memory performance (t?=??2.28, P?=?.029), but not for the symptoms group.

CONCLUSION

Compared with patients with signs of injury, patients with predominantly symptoms were more likely to remain symptomatic after injury if prescribed rest, whereas patients with signs of injury benefited from rest after a concussion. Individualized treatment planning after concussion should start in the emergency department.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01101724.

A Physiological Approach to Prolonged Recovery From Sport-Related Concussion

Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.

Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature

OBJECTIVE

To systematically review the literature regarding rest and return to activity after sport-related concussion.

DATA SOURCES

The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity.

STUDY SELECTION

Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression.

DATA EXTRACTION

The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article.

DATA SYNTHESIS

Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables.

CONCLUSIONS

Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.

What is the difference in concussion management in children as compared with adults? A systematic review

AIM

To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC.

RESULTS

A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5-12 years.

SUMMARY/CONCLUSIONS

This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039184.

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.

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.

Cognitive Rest

Cognitive rest has been suggested as a treatment for school athletes who have sustained a concussion, but the concept has rarely been defined. The purpose of this article is to provide a comprehensive definition of cognitive rest, based on an integrative literature review. The method of synthesis was guided by Avant and Walker’s concept analysis format. The importance of rest is discussed as a nursing intervention, and model cases are presented to clarify the concept. Three defining attributes of cognitive rest are established: freedom from physical or mental discomfort, abstinence from mental exertion, and mental and emotional balance. Empirical referents are given as well as a suggested protocol to enable school nurses to form cognitive rest and return-to-classroom protocols that can be adapted to individual school settings.

Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes?

The current treatment of concussion or mild traumatic brain injury (mTBI) is primarily based on expert consensus. Most clinical practice guidelines advise cognitive and physical rest after injury including withdrawal from normal life activities such as school attendance, sports participation, and technology use until symptoms resolve. Some individuals who sustain an mTBI experience persistent physical, cognitive, and mental health problems. Activity restriction itself may contribute to protracted recovery and other complications. Williamson's Activity Restriction Model of Depression, formulated more than 20 years ago, is central to this hypothesis. We review research evidence for potential harms of prolonged activity restriction and report an mTBI case as an example of how an "activity restriction cascade" can unfold. According to this model, psychological consequences of removal from validating life activities, combined with physical deconditioning, contribute to the development and persistence of postconcussive symptoms after mTBI in some youth. A modification to mTBI guidelines that emphasizes prompt reengagement in life activities as tolerated is encouraged.

Physical Activity Level and Symptom Duration Are Not Associated After Concussion

BACKGROUND

Physical rest after a concussion has been described as a key component in the management of the injury. Evidence supporting this recommendation, however, is limited.

PURPOSE

To examine the association between physical activity and symptom duration in a cohort of patients after a concussion.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This study included 364 patients who were diagnosed with a concussion, were seen by a physician within 3 weeks of injury, and completed a questionnaire at the initial clinic visit. The questionnaire assessed the postconcussion symptom scale (PCSS) score, previous number of concussions, presence of the loss of consciousness or amnesia at the time of injury, and prior treatment for headaches. During each follow-up clinic visit, physical activity level was self-reported. A Cox proportional hazard model was constructed to determine the association between symptom duration, initial clinic visit responses, and self-reported physical activity level after the injury.

RESULTS

Study participants ranged in age from 8 to 27 years (mean age, 15.0 years) and had sustained a mean of 0.8 prior concussions; 222 patients (61%) were male. On initial examination, the mean PCSS score was 34.7. The mean symptom duration was 48.9 days after the injury. Among the variables included in the model, initial PCSS score and female sex were independently associated with symptom duration, while physical activity level after the injury was not. For participants aged between 13 and 18 years, however, higher levels of physical activity after the injury were associated with a shorter symptom duration.

CONCLUSION

Results from this study indicate that physical activity after the injury may not be universally detrimental to the recovery of concussion symptoms.

Repetitive concussions in adolescent athletes - translating clinical and experimental research into perspectives on rehabilitation strategies

Sports-related concussions are particularly common during adolescence, a time when even mild brain injuries may disrupt ongoing brain maturation and result in long-term complications. A recent focus on the consequences of repetitive concussions among professional athletes has prompted the development of several new experimental models in rodents, as well as the revision of guidelines for best management of sports concussions. Here, we consider the utility of rodent models to understand the functional consequences and pathobiology of concussions in the developing brain, identifying the unique behavioral and pathological signatures of concussive brain injuries. The impact of repetitive concussions on behavioral consequences and injury progression is also addressed. In particular, we focus on the epidemiological, clinical, and experimental evidence underlying current recommendations for physical and cognitive rest after concussion, and highlight key areas in which further research is needed. Lastly, we consider how best to promote recovery after injury, recognizing that optimally timed, activity-based rehabilitative strategies may hold promise for the adolescent athlete who has sustained single or repetitive concussions. The purpose of this review is to inform the clinical research community as it strives to develop and optimize evidence-based guidelines for the concussed adolescent, in terms of both acute and long-term management.