Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time

Active Rehabilitation of Concussion and Post-concussion Syndrome

Concussion is a physiological brain injury with physical, cognitive, and emotional sequelae. The macrophysiological insult to the brain affects the autonomic nervous system and its control of cerebral blood flow. Most patients recover within 2 weeks, but some do not. Persistence of symptoms beyond the generally accepted time frame for recovery is called post-concussion syndrome (PCS). PCS is not a single entity; it is a group of disorders that requires specific forms of therapy. Rest has been the mainstay of the treatment for concussion and PCS. This article discusses the rationale for the active treatment of concussion and PCS.

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.

Exertional Tolerance Assessments After Mild Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To review the literature to identify and summarize strategies for evaluating responses to physical exertion after mild traumatic brain injury (mTBI) for clinical and research purposes.

DATA SOURCES

PubMed and EBSCOhost through December 31, 2016.

STUDY SELECTION

Two independent reviewers selected studies based on the following criteria: (1) inclusion of participants with mTBI/concussion, (2) use of a measurement of physiological or psychosomatic response to exertion, (3) a repeatable description of the exertion protocol was provided, (4) a sample of at least 10 participants with a mean age between 8 and 65 years, and (5) the article was in English. The search process yielded 2685 articles, of which 14 studies met the eligibility requirements.

DATA EXTRACTION

A quality assessment using a checklist was conducted for each study by 2 independent study team members and verified by a third team member. Data were extracted by one team member and verified by a second team member.

DATA SYNTHESIS

A qualitative synthesis of the studies revealed that most protocols used a treadmill or cycle ergometer as the exercise modality. Protocol methods varied across studies including differences in initial intensity determination, progression parameters, and exertion duration. Common outcome measures were self-reported symptoms, heart rate, and blood pressure.

CONCLUSIONS

The strongest evidence indicates that exertional assessments can provide important insight about mTBI recovery and should be administered using symptoms as a guide. Additional studies are needed to verify optimal modes and protocols for post-mTBI exertional assessments.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Use of the stepwise progression return-to-play protocol following concussion among practicing athletic trainers

PURPOSE

The purpose of this study was to determine whether practicing athletic trainers (ATs) were using the stepwise progression to make return-to-play (RTP) decisions after concussion and to determine what factors influenced their decision to use the stepwise progression.

METHODS

A total of 166 ATs (response rate = 16.6%) completed a 21-item questionnaire that evaluated participant demographics, methods of concussion management, and RTP decision-making using the stepwise progression. Descriptive statistics and a logistic regression were completed to analyze data.

RESULTS

Factors such as education level (p = 0.05) and number of concussions treated (p = 0.05) predicted use of the stepwise progression, whereas sex (p = 0.17), employment setting (p = 0.17), state law (p = 0.86), and years practicing (p = 0.17) did not predict whether ATs were following the stepwise progression.

CONCLUSION

The majority of the ATs from this study are employing the stepwise progression to safely return athletes to play after sustaining a concussion. This demonstrates that ATs are providing a standard of care for concussed athletes across various athletic training settings; however, having a graduate degree and treating more concussions per year are predictors of whether an AT follows all steps of the stepwise progression.

Psychiatric Sequelae of Concussions

PURPOSE OF REVIEW

The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations.

RECENT FINDINGS

Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.

Return to learn after concussion in children

Question Despite recent interest in the pathophysiology and management of concussion in children, as well as the ongoing concern about return to activity, advice regarding the type and length of cognitive rest has been inconsistent. What should I recommend to the children and adolescents in my clinic regarding cognitive rest following mild concussion? Answer Strict cognitive rest is not needed in those with mild concussion. Evidence suggests a decrease in usual activity to a level that allows children to remain asymptomatic, followed by a gradual return to learning, is appropriate. It is clear that either too little or too much activity is disadvantageous to recovery and can worsen outcomes.

Pediatric Mild Traumatic Brain Injury in the Acute Setting

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

A Collaborative Model for Return to Academics After Concussion: Athletic Training and Speech-Language Pathology

PURPOSE

In this article, we describe an academic concussion management protocol designed for grades Pre-K to 12, called Cognitive Return to Exertion (CoRTEx). Collaboration between the speech-language pathologist (SLP) and athletic trainer (AT) is highlighted.

METHOD

A description of CoRTEx is provided, and the need for collaboration is emphasized. A case study illustrates an example of how CoRTEx can be implemented at the individual student level.

RESULTS

A total of 165 students went through CoRTEx from the pilot in April 2014 through December 2016. Referrals to CoRTEx were highest for football, blows to the head, and soccer. Anecdotal evidence suggests that CoRTEx provided necessary support for students and their families, although research is needed to provide objective data.

CONCLUSIONS

CoRTEx and other similar protocols can be used as models for SLPs to create their own academic concussion management protocols. For cases in which the injured student is an athlete, the SLP-AT collaboration is critical to carefully coordinate return to academics and return to play so that students are successful in school, as well as ready to safely return to sport. Suggestions are made for designing research studies that can provide empirical evidence for the efficacy of such academic concussion management protocols.

Comparison of Psychological Response between Concussion and Musculoskeletal Injury in Collegiate Athletes

The psychological response to musculoskeletal injuries has been well documented, however, research on the psychological response to concussion is limited. The Profile of Mood States (POMS) and the State-Trait Anxiety Inventory (STAI) have recently been used to assess the psychological recovery of concussions. Although some studies indicate that psychological response is different for musculoskeletal injuries and concussion, there is currently not enough information to indicate this difference occurs at specific clinical milestones. The purpose of this study was to compare the psychological responses of student-athletes who have been diagnosed with a concussion to those of athletes diagnosed with musculoskeletal injuries with similar recovery duration. Fifteen collegiate athletes who sustained a musculoskeletal injury were recruited and matched with 15 previously collected concussion participants. The main outcome measures were the scores of POMS constructs: tension-anxiety, anger-hostility, fatigue-inertia, depression-dejection, vigor-activity, confusion-bewilderment, and total mood disturbance and STAI (state anxiety only). Two-way MANOVAs was run to determine the effects of group and time on POMS and STAI constructs. There were no significant interactions identified, but follow-up ANOVAs identified a main effect for time for most POMS subscales, with POMS scores improving over time in both groups. Analyses also revealed that tension-anxiety, vigor-activity and the STAI were not affected by time or group. The findings of this study, that both groups' psychological response to injury improves over time and at similar clinical milestones suggests reduction in sports and team related activities may play a substantial role in the psychological response to either concussion or musculoskeletal injury.

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.

Concussion Management Plan Compliance: A Study of NCAA Power 5 Conference Schools

Background:

In response to concerns over concussions and repeated head impacts that occur during sports, the National Collegiate Athletic Association (NCAA) mandated that all member institutions enact a concussion management plan (CMP). Although institutional and health care provider self-reports have been investigated, compliance with NCAA protocol recommendations has not been examined.

Purpose:

To examine the CMPs from the 65 institutions within the NCAA Power 5 conferences for compliance with the NCAA 2015 concussion guidelines.

Study Design:

Descriptive epidemiology study.

Methods:

Each institution’s publicly available CMP was obtained in 2015, reviewed, and coded for compliance with each of the required 47 components. Overall compliance rate, item-level, category-level, and institution-level compliance was assessed. Independent predictors of compliance, including each institution’s athletic training staff size, academic performance, and athletic performance, were examined with quasi-binomial regression.

Results:

CMPs varied substantially in length and level of detail. The overall compliance rate for all components across all institutions was 94.3% (2880/3055). Twelve components achieved 100% (65/65) compliance, and the lowest levels of compliance were clustered in “return to learn.” There were 22 institutions that achieved a 100% compliance rate; the lowest institutional compliance was 59.6%. There were no significant associations between the independent predictors and institutional compliance.

Conclusion:

Overall compliance with NCAA concussion management requirements was high, but there remains room for improvement. The lowest level of compliance was clustered in the return-to-learn section. There were limited details provided in the reducing head trauma component. Items with lower compliance (reducing head trauma, return to learn) tended to be outside the core competencies of the medical staff, indicating an area for improvement. Encouragingly, many institutions and specific components demonstrated full compliance.

Neuropsychiatric aspects of concussion

Over the past decade, concussion has become the most widely discussed injury in contact sports. However, concussions also occur in several other settings, such as non-contact sports, elderly individuals, young children, military personnel, and victims of domestic violence. Concussion is frequently undiagnosed as a cause of psychiatric morbidity, especially when the patient has no history of loss of consciousness or direct head trauma. Almost all of the extant literature focuses on traumatic brain injury and assumes that concussion is merely a mild form of traumatic brain injury, which has resulted in a lack of understanding about what concussion is, and how to diagnose, monitor, and treat its varied neuropsychiatric symptoms. In this Review, we address key issues so that the psychiatric clinician can better understand and treat patients with a clinical phenotype that might be the direct result of, or be exacerbated by, concussion. Future research needs to focus on prospective clinical trials in all affected patient populations (ie, those affected by concussion and those affected by various degrees of traumatic brain injury), the identification of reliable biomarkers that can be used to assist with diagnosis and treatment response, and the development of effective treatment interventions. Clearly differentiating concussion from traumatic brain injury is essential to achieve reliable and clinically relevant outcomes.

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.