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

Early Targeted Heart Rate Aerobic Exercise Reduces Proportion of Subacute Musculoskeletal Injuries After Recovery From Sport-Related Concussion

OBJECTIVE

There is greater risk of musculoskeletal (MSK) injury after clinical recovery from sport-related concussion (SRC). We determined whether aerobic exercise treatment within 10 days of SRC reduced the proportion of MSK injury in recovered adolescent athletes at 4 months since injury.

DESIGN

Planned secondary analysis of a randomized trial of aerobic exercise versus stretching exercise in adolescents after SRC.

SETTING

Outpatient and hospital-based sports medicine centers.

PARTICIPANTS

Aerobic exercise (n = 38, 58% male, 15.6 years) and stretching exercise (n = 25, 64% male, 15.9 years) participants completed a questionnaire at 3.5 and 3.3 months since recovery, respectively.

INTERVENTIONS

Individualized subthreshold aerobic exercise versus placebo-like stretching.

MAIN OUTCOME MEASURES

Proportion of MSK injury, subsequent concussion, and return to exercise training, school, and sport determined 3 months after clinical recovery from SRC.

RESULTS

Overall, 24% of participants randomized to stretching experienced an MSK injury versus 5.3% of participants randomized to aerobic exercise. There was no difference in time to return to school, sport, or incidence of subsequent concussion. Stretching participants were 6.4 times (95% confidence interval 1.135-36.053) more likely to sustain MSK injury than aerobic exercise participants when controlling for the duration of exposure to sport and return to preinjury sport participation. All injuries were in male participants.

CONCLUSION

Adolescent male athletes prescribed aerobic exercise within 10 days of SRC had a significantly lower proportion of individuals injured in the 3 months following clinical recovery when compared with stretching. This may be due to a habituation/rehabilitation effect of aerobic activities to improve autonomic, vestibular, and/or oculomotor function after SRC.

Social Determinants of Health and Health Equity in the Treatment and Rehabilitation of Sport-Related Concussion: A Content Analysis of Intervention Research and Call-To-Action

This review was designed to (1) determine the extent to which the clinical science on sport-related concussion treatment and rehabilitation has considered social determinants of health (SDoH) or health equity and (2) offer recommendations to enhance the incorporation of SDoH and health equity in concussion treatment research and clinical care. The Concussion in Sport Group consensus statement (2023) was informed by two systematic reviews examining prescribed rest or exercise following concussion and targeted interventions to facilitate concussion recovery. We examined 31 studies, including 2,698 participants, from those two reviews. Race (k = 6; 19.4%) and ethnicity (k = 4; 12.9%) of the study samples were usually not reported. Four studies examined ethnicity (i.e., Hispanic), exclusively as a demographic category. Five studies (16.1%) examined race as a demographic category. Three studies (9.7%) examined socioeconomic status (SES; measured as household income) as a demographic category/sample descriptor and one study (3.2%) examined SES in-depth, by testing whether the treatment and control groups differed by SES. Five studies examined an SDoH domain in a descriptive manner and four studies in an inferential/intentional manner. No study mentioned SDoH, health equity, or disparities by name. Many studies (61.3%) excluded participants based on demographic, sociocultural, or health factors, primarily due to language proficiency. The new consensus statement includes recommendations for concussion treatment and rehabilitation that rely on an evidence base that has not included SDoH or studies addressing health equity. Researchers are encouraged to design treatment and rehabilitation studies that focus specifically on underrepresented groups to determine if they have specific and unique treatment and rehabilitation needs, whether certain practical modifications to treatment protocols might be necessary, and whether completion rates and treatment adherence and response are similar.

Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion

BACKGROUND

Aerobic exercise facilitates postconcussion symptom resolution at the group level, but patient-level characteristics may affect the likelihood of treatment efficacy.

PURPOSE

This study aimed to investigate demographic and clinical characteristics, which differentiate postconcussion aerobic exercise treatment efficacy from nonefficacy in the intervention arm of a randomized clinical trial.

METHODS

Adolescent and young adult participants initiated a standardized aerobic exercise intervention within 14 d of concussion, consisting of self-selected exercise for 100 min·wk -1 at an individualized heart rate (80% of heart rate induced symptom exacerbation during graded exercise testing). Treatment efficacy was defined as symptom resolution within 28-d postconcussion. Treatment efficacy and nonefficacy groups were compared on demographics, clinical characteristics, intervention adherence, and persistent symptom risk using the Predicting Persistent Postconcussive Problems in Pediatrics (5P) clinical risk score.

RESULTS

A total of 27 participants (16.1 ± 2.3 yr old; range, 11-21 yr; 52% female) began the intervention, with a mean of 9.5 ± 3.7 d after concussion; half ( n = 13; 48%) demonstrated treatment efficacy (symptom resolution within 28 d postconcussion). Those whose symptoms resolved within 28 d had significantly lower preintervention postconcussion symptom inventory scores (21.2 ± 13.2 vs 41.4 ± 22.2; P < 0.01), greater adherence to the intervention (77% vs 36%; P = 0.05), and longer average exercise duration (median [interquartile range], 49.7 [36.8-68.6] vs 30.4 [20.7-34.7] min; P < 0.01) than those whose symptoms lasted more than 28 d. Groups were similar in age, sex, timing of intervention, and preintervention 5P risk score.

CONCLUSIONS

A standardized aerobic exercise intervention initiated within 14 d of concussion demonstrated efficacy for approximately half of participants, according to our definition of treatment efficacy. This multisite aerobic exercise intervention suggests that lower symptom severity, higher intervention adherence, and greater exercise duration are factors that increase the likelihood of symptoms resolving within 28 d of concussion.

New Insights Into Accelerometer-Measured Habitual Physical Activity and Sedentary Time During Early Recovery in Pediatric Concussion

PURPOSE

Concussion management is shifting away from a rest-is-best approach, as data now suggest that exercise-is-medicine for this mild brain injury. Despite this, we have limited data on habitual physical activity following concussion. Therefore, our objective was to quantify accelerometer-measured physical activity and sedentary time in children with concussion (within the first month of injury) and healthy controls. We hypothesized that children with concussion would be less active than their healthy peers.

METHODS

We performed a secondary analysis of prospectively collected accelerometer data. Our sample included children with concussion (n = 60, 31 females) and historical controls (n = 60) matched for age, sex, and season of accelerometer wear.

RESULTS

Children with concussion were significantly more sedentary than controls (mean difference [MD], 38.3 min/d, P = .006), and spent less time performing light physical activity (MD, -19.5 min/d, P = .008), moderate physical activity (MD, -9.8 min/d, P < .001), and vigorous physical activity (MD, -12.0 min/d, P < .001); these differences were observed from 8:00 AM to 9:00 PM. Sex-specific analyses identified that girls with concussion were less active and more sedentary than both boys with concussion (P = .010) and healthy girls (P < .010).

CONCLUSION

There is an activity deficit observed within the first month of pediatric concussion. Physical activity guidelines should address this while considering sex effects.

Physical activity and recovery following concussion in collegiate athletes: a LIMBIC MATARS Consortium Investigation

OBJECTIVE

To investigate whether routine daily activities (RDA), non-prescribed exercise (Non-ERx), or prescribed exercise (ERx) were associated with recovery from sport-related concussion (SRC) in collegiate athletes.

MATERIALS AND METHODS

Data for this cross-sectional, retrospective chart review of collegiate athletes diagnosed with SRC (n = 285[39.6% female], age = 19.5 ± 1.4 years) were collected during the 2015-16 to 2019-20 athletic seasons. The independent variable was group (RDA, Non-ERx, ERx). Dependent variables included days from date of diagnosis to symptom resolution (Dx-SR) and SR to return to sport (SR-RTS).

RESULTS

Those in the Non-ERx group took nearly 1.3 times longer to achieve SR (IRR = 1.28, 95% CI: 1.11, 1.46) and, 1.8 times longer for RTS (IRR = 1.82, 95% CI: 1.11, 2.71) when compared to those in the RDA group. No other comparisons were significant.

CONCLUSION

Collegiate athletes in the Non-ERx group took approximately 1 week longer to achieve SR as compared to the RDA and ERx groups. Our findings suggest that if exercise is recommended following SRC, it must be clearly and specifically prescribed. If exercise parameters cannot be prescribed, or monitored, RDA appear to be similarly beneficial during recovery for collegiate athletes with concussion.

Brain changes: aerobic exercise for traumatic brain injury rehabilitation

Introduction

Traumatic Brain Injury (TBI) accounts for millions of hospitalizations and deaths worldwide. Aerobic exercise is an easily implementable, non-pharmacological intervention to treat TBI, however, there are no clear guidelines for how to best implement aerobic exercise treatment for TBI survivors across age and injury severity.

Methods

We conducted a PRISMA-ScR to examine research on exercise interventions following TBI in children, youth and adults, spanning mild to severe TBI. Three electronic databases (PubMed, PsycInfo, and Web of Science) were searched systematically by two authors, using keywords delineated from "Traumatic Brain Injury," "Aerobic Exercise," and "Intervention."

Results

Of the 415 papers originally identified from the search terms, 54 papers met the inclusion criteria and were included in this review. The papers were first grouped by participants' injury severity, and subdivided based on age at intervention, and time since injury where appropriate.

Discussion

Aerobic exercise is a promising intervention for adolescent and adult TBI survivors, regardless of injury severity. However, research examining the benefits of post-injury aerobic exercise for children and older adults is lacking.

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.

Early Exercise is Associated with Faster Concussion Recovery Among Collegiate Athletes: Findings from the NCAA-DoD CARE Consortium

BACKGROUND

Growing evidence indicates early exercise may improve symptoms and reduce clinical recovery time after concussion, but research examining collegiate student-athletes is scarce.

OBJECTIVE

The aim of this study was to compare symptom recovery time, clinical recovery time, and persisting post-concussion symptom (i.e., symptoms ≥ 28 days) prevalence by the timing of light exercise initiation before the graded return to play (RTP) protocol among concussed participants.

METHODS

Collegiate student-athletes (n = 1228; age 18.4 ± 0.9 years; 56.5% male, 76.3% division I; 33.7% ≥ 1 prior concussion) across 30 institutions enrolled in the CARE Consortium completed post-concussion assessments and were monitored over time. Symptom recovery (days from injury to symptom resolution) and clinical recovery (days from injury to return to play protocol completion) was determined by the student-athletes' clinicians. Student-athletes were categorized by timing of light exercise initiation. Early (< 2 days post-concussion; n = 161), typical (3-7 days post-concussion; n = 281), and late exercise (≥ 8 days post-concussion; n = 169) groups were compared with the no-exercise group (n = 617; i.e., did not exercise prior to beginning the RTP protocol) for all analyses. Multivariable Cox regression models with hazard ratios (HR) and survival curves and a multivariable binomial regression model with prevalence ratios (PR) compared recovery outcomes between exercise groups while accounting for covariates.

RESULTS

Compared to the no-exercise group, the early exercise group was 92% more probable to experience symptom recovery (HR 1.92; 95% CI 1.57-2.36), 88% more probable to reach clinical recovery (HR 1.88; 95% CI 1.55-2.28) and took a median of 2.4 and 3.2 days less to recover, respectively. The late exercise group relative to the no-exercise group was 57% less probable to reach symptom recovery (HR 0.43; 95% CI 0.35-0.53), 46% less probable to achieve clinical recovery (HR 0.54; 95% CI 0.45-0.66) and took 5.3 days and 5.7 days more to recover, respectively. The typical exercise group did not differ in hazard for symptom or clinical recovery (p ≥ 0.329) compared with the no-exercise group. The prevalence of persisting post-concussion symptoms in the combined sample was 6.6%. Early exercise had 4% lower prevalence (PR 0.96, 95% CI 0.94-0.99) and typical exercise had 3% lower prevalence (PR 0.97, 95% CI 0.94-0.99) of persisting post-concussion symptoms, while the late exercise group had an elevated prevalence (PR 1.11, 95% CI 1.04-1.18) compared with the no-exercise group.

CONCLUSION

Exercise < 2 days post-concussion was associated with more probable and faster symptom and clinical recovery, and lower persisting post-concussion symptom prevalence. When considering our findings and existing literature, qualified clinicians may implement early exercise into their clinical practice to provide therapeutic treatment and improve student-athlete recovery.

Exercise intensity and sex alter neurometabolic, transcriptional, and functional recovery following traumatic brain injury

Physical exercise represents a potentially inexpensive, accessible, and optimizable rehabilitation approach to traumatic brain injury (TBI) recovery. However, little is known about the impact of post-injury exercise on the neurometabolic, transcriptional, and cognitive outcomes following a TBI. In the current study, we examined TBI outcomes in adolescent male and female mice following a controlled cortical impact (CCI) injury. Mice underwent a 10-day regimen of sedentary, low-, moderate-, or high-intensity treadmill exercise and were assessed for cognitive function, histopathology, mitochondrial function, and oxidative stress. Among male mice, low-moderate exercise improved cognitive recovery, and reduced cortical lesion volume and oxidative stress, whereas high-intensity exercise impaired both cognitive recovery and mitochondrial function. On the other hand, among female mice, exercise had an intermediate effect on cognitive recovery but significantly improved brain mitochondrial function. Moreover, single nuclei RNA sequencing of perilesional brain tissue revealed neuronal plasticity-related differential gene expression that was largely limited to the low-intensity exercise injured males. Taken together, these data build on previous reports of the neuroprotective capacity of exercise in a TBI model, and reveal that this rehabilitation strategy impacts neurometabolic, functional, and transcriptional outcome measures in an intensity- and sex-dependent manner.

Are Sex Differences in Collegiate and High School Sports-Related Concussion Reflected in the Guidelines? A Scoping Review

Background: Sport-related concussion (SRC) is a common sport injury. Females are participating in sports at increasing rates, and there is growing awareness that female athletes may be more vulnerable to SRC. Objectives: We aimed to identify sex differences in epidemiology, clinical manifestation and assessment of SRC and examine how these relate to the 6th International Conference on Concussion in Sport (ICCS). Methods: We conducted a scoping review of the Medline database and identified 58 studies examining the effects of sex on SRC in collegiate and high school athletes that were written in English and published in a peer-reviewed journal between March 2012 and March 2022. Results: We found that female athletes suffer higher rates of concussion in sex-comparable sports, in particular soccer. Female athletes experience more somatic symptoms-headache/migraine/sleep disturbance-and may take longer to recover from concussion. Sex differences were also identified regarding some aspects of sideline concussion assessment with the Sport Concussion Assessment Tool. Conclusions: Females are at greater risk and experience SRC differently than males; this is mostly likely due to a combination of biomechanical factors, differences in neck musculature and hormonal and social factors. Sex differences are not widely addressed by the 6th ICSS, which informs many sports' concussion protocols.

Predicting Time to Evaluation After Pediatric Concussion: Factors Affecting Specialty Concussion Care

Background

The timing of clinical evaluation after pediatric concussion represents an important and potentially modifiable clinical milestone for diagnosis, selection of appropriate treatment pathways, and recovery prognosis. Patient demographics, socioeconomic status, or medical history may affect the time to the initial evaluation and subsequently influence recovery outcomes.

Purpose/Hypothesis

The purpose of this investigation was to evaluate the association of patient characteristics with the time to specialty evaluation after a concussion. It was hypothesized that patients with a history of concussion, a preexisting relationship with our specialty concussion program, or a higher ZIP code-based income estimate would present for care more quickly after a concussion than patients without these characteristics.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were patients with a concussion between 6 and 18 years old who were seen for care at a single sports medicine center between January 1 and December 31, 2019. Patient demographic, socioeconomic, injury, and clinical characteristics were collected through a retrospective review of the medical records. The primary outcome was the number of days between the date of the concussion and the patient's initial specialty evaluation.

Results

Overall, 220 patients (mean age, 14.4 ± 2.5 years; 46% female) were seen for care at a mean of 9.7 ± 5.6 days (range, 1-21 days) after concussion. A shorter time to specialty evaluation was associated with a history of concussion (β = -1.72 [95% CI, -3.24 to -0.20]; P = .03) and a prior clinical relationship with the treating clinical department (β = -1.85 [95% CI, -3.52 to -0.19]; P = .03). Referral by a primary care provider was associated with a longer time to evaluation (β = 3.86 [95% CI, 2.39-5.33]; P < .0001).

Conclusion

A history of concussion and having a preexisting clinical relationship with the deparment were associated with a shorter time to evaluation after concussion. Referral from a primary care physician was associated with a longer time to evaluation. Issues may exist in the propensity to access care after an injury, resulting in delays for initiating early treatment.

Putting the Mind to Rest: A Historical Foundation for Rest as a Treatment for Traumatic Brain Injury

Rest after traumatic brain injury (TBI) has been a part of clinical practice for more than a century but the use of rest as a treatment has ancient roots. In contemporary practice, rest recommendations have been significantly reduced but are still present. This advice to brain injured patients, on the face of it makes some logical sense but was not historically anchored in either theory or empirical data. The definition and parameters of rest have evolved over time but have encompassed recommendations including avoiding physical exercise, sensory stimulation, social contact, and even cognitive exertion. The goals and theoretical explanations for this approach have evolved and in modern conception include avoiding reinjury and reducing the metabolic demands on injured tissue. Moreover, as cellular and molecular understanding of the physiology of TBI developed, scientists and clinicians sometimes retroactively cited these new data in support of rest recommendations. Here, we trace the history of this approach and how it has been shaped by new understanding of the underlying pathology associated with brain injury.

The Additive Benefits of Aerobic Exercise and Cognitive Training Postconcussion: Current Clinical Concepts

Concussion induces the rapid onset of a short-lived neurophysiological disturbance that often results in autonomic nervous system dysfunction. This dysfunction affects both cardiovascular functioning and higher cognitive processing, inducing postconcussion clinical symptoms (somatic, cognitive, or emotional or a combination) and functional disturbances (impaired balance, cognition, and visual-vestibular performance). Current concussion rehabilitation paradigms using aerobic exercise may improve concussion symptoms. Additionally, cognitive training-focused rehabilitation interventions may enhance cognitive function postinjury. Though aerobic exercise and cognitive training-based concussion rehabilitation are successful independently, the multifaceted nature of concussion suggests the potential benefit of integrating both to improve concussion outcomes and clinician implementation. To support this clinical recommendation, we critiqued the existing research in which authors investigated aerobic exercise and cognitive training as postconcussion rehabilitation modalities, identified keys gaps in the literature, and proposed a practical clinical recommendation to integrate both modalities during concussion rehabilitation.

Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury - a study protocol with a nested feasibility study for a randomized controlled trial

BACKGROUND

Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI.

MAIN PURPOSE

The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation.

DESIGN

Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1.

METHODS

Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance-the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity.

DISCUSSION

This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT.

TRIAL REGISTRATION

Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021.

Active Rehabilitation Following Acute Mild Traumatic Brain Injury: A Systematic Review

Purpose:

Following mild traumatic brain injury (mTBI), patients are often advised to restrict physical activity until full symptom resolution followed by gradual return to activity. However, extended rest periods may prolong recovery and contribute to persistent symptoms. Emerging evidence suggests early active rehabilitation that increases heart rate without exacerbating symptoms may improve mTBI patient recovery. This review aims to: (1) appraise evidence on active rehabilitation intervention for mTBI recovery within one-month of injury (i.e., exercise type, duration, intensity, etc.); and (2) recommend evidence-based rehabilitation protocols.

Method:

Pubmed, CINAHL, PsychARTICLES, SportDISCUS, and AMED databases were searched using key terms “mild Traumatic Brain Injury”, “Rehabilitation”, “Acute”, and their synonyms. Evidence was appraised using Cochrane RoB-2 and ROBINS-I.

Results:

434 citations were initially identified with seven papers systematically reviewed. Within the reviewed articles, only three were randomized controlled trials with low risk of bias, and four were non-randomized trials with low to moderate risk of bias. Findings highlighted that a range of active rehabilitation protocols were used with different exercise modalities (primarily treadmills and static cycling), durations (9–20 min, or until symptomatic, for 30–50 days or symptoms resolved), and intensities (low, moderate or high). Active rehabilitation did not cause any serious adverse events (i.e., death, hospitalisation etc.), and six studies reported that it did not exacerbate mTBI symptoms in any participants (with one participant having symptom worsening in one study). Overall, the majority of reviewed studies ( n = 4) showed that active rehabilitation decreased time to mTBI symptom resolution compared to controls (strict rest/stretching exercises).

Conclusions:

Individualized active rehabilitation prescribed within one-month post-mTBI appears to be safe and effective at decreasing recovery time to symptom resolution in mTBI. However, there is a lack of consensus regarding specific intervention protocols that needs to be addressed before adoption within clinical practice.

Efficacy of aerobic exercise following concussion: a narrative review

Concussion is a type of mild traumatic brain injury which results in symptoms within the physical, cognitive, emotional, and sleep domains. Historically, guidelines established by expert opinion have recommended rest during the initial stages of recovery following a concussion until symptom resolution. However, recent recommendations have shifted to advise an initial period of 24-48 h of rest immediately following concussion with the gradual introduction of light-to-moderate intensity aerobic exercise thereafter. Given the relatively recent transition in recommendations, the aim of this review is to provide an overview of the current literature on the efficacy of aerobic exercise following concussion. The current literature is limited to studies assessing the impact of standardized aerobic exercise following concussion. Upon review, literature suggests participating in aerobic exercise below the point of symptom exacerbation is safe in both the acute and chronic post-concussion symptom stages of recovery and does not delay time to medical clearance. Future large-scale randomized controlled trials assessing the impact of aerobic exercise and differences between males and females would help support the current evidence suggesting aerobic exercise could improve time to recovery following concussion and identify any sex differences in response. As well, future studies with the purpose of identifying optimal aerobic exercise volume and intensity in the treatment of concussion could improve the specificity of the current guidelines.

History of Brain Injury Alters Cerebral Haemodynamic Oscillations with Cardiac Influence

(1) Background: Cerebral autoregulation is altered during acute mild traumatic brain injury, or concussion. However, it is unknown how a history of concussion can impact cerebral haemodynamic activity during a task that elicits an autoregulatory response. (2) Methods: We assessed cerebral haemodynamic activity in those with a history of three or more concussions. The study included 44 retired athletes with concussion history and 25 control participants. We recorded participants' relative changes in right and left pre-frontal cortex oxygenation collected by near-infrared spectroscopy and continuous beat-to-beat blood pressure measured by finger photoplethysmography. Participants completed a 5-min seated rest followed by a 5-min repeated squat (10-s) stand (10-s) maneuver (0.05 Hz) to elicit a cerebral autoregulatory response. Wavelet transformation was applied to the collected signals, allowing separation into cardiac interval I (0.6 to 2 Hz), respiratory interval II (0.145 to 0.6 Hz), and smooth muscle cell interval III (0.052 to 0.145 Hz). (3) Results: Significant increases at cardiac interval I were found for the wavelet amplitude of oxy-haemoglobin and haemoglobin difference at the right pre-frontal cortex. No significant difference was found at the left pre-frontal cortex or the blood pressure wavelet amplitudes. (4) Conclusions: Contributions from cardiac activity to the pre-frontal cortex oxygenation are elevated when eliciting dynamic cerebral autoregulation in those with a history of three or more concussions.

Heart Rate Variability as a Reliable Biomarker Following Concussion: A Critically Appraised Topic

CLINICAL SCENARIO

Recent systematic reviews show conflicting information regarding the effect of concussion on cardiac autonomic function. Controlled aerobic exercise is the most popular intervention for those recovering from a concussion. There is a gap in the literature supporting the utility of objective metrics during exertional return to play protocols and rehabilitation.

CLINICAL QUESTION

Can heart rate variability (HRV) during physical exertion be a reliable biomarker over time for those who suffered a sport-related concussion?

SUMMARY OF KEY FINDINGS

A literature search produced 3 studies relevant to the clinical question. One, a prospective-matched control group cohort study, reported disturbances in HRV during physical exertion in those with a history of concussion, and identified persistent HRV dysfunction after resolution of subjective complaints, return to play, and with multiple concussive events. Second, a cross-sectional cohort study found an HRV difference in those with and without a history of concussion and in HRV related to age and sex. Finally, the prospective longitudinal case-control cohort study did not find sex or age differences in HRV and concluded that, although postconcussion HRV improved as time passed, resting HRV was not as clinically meaningful as HRV during exertional activities.

CLINICAL BOTTOM LINE

There is emerging evidence to support the use of HRV as an observable biomarker, over time, of autonomic function during physical exertion following a sport-related concussion. However, the meaningfulness of HRV data is not fully understood and the utility seems individualized to the level of athlete, age, and sex and, therefore, cannot be generalizable. In order to be more clinically meaningful and to assist with current clinical decision making regarding RTP, a preinjury baseline assessment would be beneficial as an individualized reference for baseline comparison.

STRENGTH OF RECOMMENDATION

Although HRV is not fully understood, currently, there is grade B evidence to support the use of individualized baseline exertional HRV data as comparative objective metric to assess the autonomic nervous system function, over time, following a concussive event.

The Effect of Physical Exertional Testing on Postconcussion Symptom Scale Scores in Male and Female High School Students

PURPOSE

Symptom scores commonly measured following concussion were compared between male and female adolescents with (Hx+) and without (Hx-) a history of concussion, pre and post physical exertion testing.

METHODS

Eighty (males [n = 60; Hx+ = 19], female [n = 20; Hx+ = 5]) high school students (ages 15-17 y) completed the Buffalo Concussion Treadmill Test once and the modified shuttle run test twice. Symptom scores were collected using the 22-point Symptom Evaluation Scale on the Sport Concussion Assessment Tool (version 5) immediately pre and post physical exertion testing.

RESULTS

The symptoms most reported during preexertional testing were fatigue/low energy, feeling slowed down, and nervous/anxious, whereas feeling slowed down, fatigue/low energy, "pressure in head" (males only), and headache (females only) were most frequently reported during postexertion testing.

CONCLUSION

An understanding of the common exertion-related symptoms at baseline in a laboratory or field-based setting in adolescents may be advantageous for clinicians as they manage individual recovery postconcussion. This is particularly important during an adolescent's recovery and return to play when exertional testing may be implemented, especially since symptoms were reported pre and post exertional testing in both males and females regardless of concussion history.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Postconcussion Dizziness Severity Predicts Daily Step Count during Recovery among Adolescent Athletes

PURPOSE

Physical activity (PA) after concussion is an important aspect of appropriate clinical management. However, symptoms or functional deficits may reduce patient propensity toward PA, thereby negatively affecting recovery. Our purpose was to examine whether postconcussion dizziness, total symptom severity, or postural stability predicts PA level in the 2 wk after initial evaluation.

METHODS

We evaluated adolescent athletes within 14 d of concussion on assessments of symptoms, dizziness, and postural stability. Athletes were provided an activity monitor to track PA for 2 wk after the evaluation. Our primary outcome was step count (mean steps per day). Potential predictor variables included sex, Post-Concussion Symptom Inventory (PCSI) total symptom severity, individual PCSI ratings of dizziness and balance impairment, and postural stability assessments (single- and dual-task tandem gait, modified Balance Error Scoring System). To examine predictors of PA, we calculated correlation coefficients between steps per day and each potential predictor and included significantly correlated variables in a multivariable regression model.

RESULTS

Participants were ages 12-18 yr (n = 35, 15.2 ± 1.7 yr, 49% female) and initially evaluated 7.3 ± 3.0 d after concussion. Upon univariable evaluation, PCSI dizziness rating (Pearson R = -0.49, P = 0.003) and sex (mean difference, 2449 steps per day; P = 0.05) were associated with steps per day. Within the multivariable regression analysis, PCSI dizziness rating (β = -1035; 95% confidence interval, -191 to -1880; P = 0.018), but not sex, predicted average steps per day in the 2 wk after initial evaluation.

CONCLUSIONS

Self-reported dizziness, but not overall symptom severity or postural stability, assessed within 14 d of concussion predicted daily step count in the subsequent 2 wk. Given the importance of PA for concussion recovery, treating acute postconcussion dizziness can potentially reduce a barrier to PA and improve recovery trajectories.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Physical Activity Following Sport-Related Concussion in Adolescents: A Systematic Review

OBJECTIVE

To evaluate the evidence related to how physical activity (PA) affects recovery following a sport-related concussion (SRC) in adolescents.

DESIGN

Systematic review Data Source: PUBMED, MEDLINE, and SPORTDiscus Eligibility criteria for selecting study:(1) original research article (e.g., randomized controlled trials (RCT), quasi-experimental designs, cohort, case-control studies), (2) 66% or greater of the sample has to have a SRC diagnosed by a clinician, (4) human research, (5) evaluate the effect of a SRC on PA in adolescents only (<18 years). Participants were seen within 1-2 weeks post-SRC for acute studies and 4 weeks post-SRC for studies focused on prolonged recoveries.

RESULTS

Twenty-two studies met the inclusion criteria (i.e., 8 regarding PA (PA-daily aerobic activity including light-moderate intensities), 8 evaluating active rehabilitation/exercise programs (20 minutes of daily aerobic exercise below symptom threshold), 6 examining a single bout of exertion). The methodological quality of the literature was assessed using the Downs and Black risk of bias (ROB) checklist. The ROB scores ranged from 7-24, with only two RCTs included. Studies demonstrated single bouts of exertion testing were safe and feasible. Daily PA or active rehabilitation/exercise programs led to a reduction in symptoms present and a decrease in number of days to medical clearance.

CONCLUSION

Following a brief period of rest (24-48 hours), individuals can gradually and safely return to PA below their physical symptom exacerbation thresholds. Further research is warranted to delineate how to optimize the timing, intensity, duration, and modality of PA impacts symptom resolution and physiological recovery following SRC.

The acute, systemic effects of aerobic exercise in recently concussed adolescent student-athletes: preliminary findings

OBJECTIVES

Examine the acute effects (pre-, during, post-intervention) of two different intensities of aerobic exercise or rest on autonomic, oculomotor, and vestibular function and symptom burden in patients with a recent sport-related concussion (SRC) and compare their responses to sex-matched, age-stratified, non-concussed (HEALTHY) student-athletes.

METHODS

Student-athletes between the ages of 13 and 18 that presented to the sports medicine clinic within Day 3-7 post-SRC and from local schools were recruited for a randomized controlled trial (RCT). The participants were administered the Vestibular/Ocular Motor Screening (VOMS), King-Devick (K-D), and Post-Concussion Symptom Scale (PCSS) before and after the intervention. Heart rate variability (HRV) and mean arterial pressure (MAP) were collected before, during, and after the intervention. The intervention was either a single, 20-min session of treadmill walking at 40% (40HR) or 60% of age-predicted max heart rate (60HR), or seated, rest (NOEX).

RESULTS

30 participants completed the intervention with the SRC group treated 4.5 ± 1.3 days post-injury. Pre-exercise HRV and MAP were significantly different (p's < 0.001) during treatment but returned to pre-exercise values within 5 min of recovery in both the SRC and HEALTHY groups. Both the SRC and HEALTHY groups exhibited similar reductions pre- to post-intervention for symptom severity and count (p's < 0.05), three VOMS items (p's < 0.05) but not K-D time.

CONCLUSIONS

To date, this is the first adolescent RCT to report the acute, systemic effects of aerobic exercise on recently concussed adolescent athletes. The interventions appeared safe in SRC participants, were well-tolerated, and provided brief therapeutic benefit.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03575455.

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.

Acute Physical and Mental Activity Influence on Concussion Recovery

INTRODUCTION

Physical activity (PA) and mental activity (MA) postconcussion has received renewed attention to improve concussion management; however, most protocols start after several days and do not assess the acute window. Therefore, the purpose of this study was to assess PA and MA in the first 48 h postconcussion on the time to symptom-free status and return to play.

METHODS

We recruited 78 NCAA Division I athletes (male, 51.3%; age, 19.6 ± 1.4 yr; height, 173.7 ± 11.5 cm; weight, 80.1 ± 23.2 kg) who were diagnosed with a sports-related concussion. Participants completed a 0-5 PA and MA scale daily until fully cleared for return to participation (mean, 15.1 ± 6.9 d). A quadratic model regression assessed PA and MA over the first 2 d (acute) postconcussion on to time to symptom-free status and return to play.

RESULTS

The overall model was significant for both time to symptom free (r2 = 0.27, P = 0.004) and return to play (r2 = 0.23, P = 0.019). Reported PA was the only significant predictor for time to symptom-free (P = 0.002) and return-to-participation (P = 0.006) day. Reported MA was not associated either outcome.

CONCLUSIONS

The primary finding of this study was that mild to moderate PA acutely postconcussion was associated with reduced time to symptom free and return to participation as opposed to either lower or higher levels of PA. Conversely, acute MA was not associated with recovery outcomes. These results further elucidate the role of postconcussion PA.

The benefits of exercise for outcome improvement following traumatic brain injury: Evidence, pitfalls and future perspectives

Traumatic brain injury (TBI), also known as a silent epidemic, is currently a substantial public health problem worldwide. Given the increased energy demands following brain injury, relevant guidelines tend to recommend absolute physical and cognitive rest for patients post-TBI. Nevertheless, recent evidence suggests that strict rest does not provide additional benefits to patients' recovery. By contrast, as a cost-effective non-pharmacological therapy, exercise has shown promise for enhancing functional outcomes after injury. This article summarizes the most recent evidence supporting the beneficial effects of exercise on TBI outcomes, focusing on the efficacy of exercise for cognitive recovery after injury and its potential mechanisms. Available evidence demonstrates the potential of exercise in improving cognitive impairment, mood disorders, and post-concussion syndrome following TBI. However, the clinical application for exercise rehabilitation in TBI remains challenging, particularly due to the inadequacy of the existing clinical evaluation system. Also, a better understanding of the underlying mechanisms whereby exercise promotes its most beneficial effects post-TBI will aid in the development of new clinical strategies to best benefit of these patients.

Autonomic cardiovascular response during and after a graded exercise test in concussed athletes and healthy controls

Objective

Dysfunction of the autonomic cardiovascular system after a concussion is known to cause exercise intolerance due to symptoms exacerbation. The aim of this study was to compare athletes with symptoms of a sport-related concussion and healthy controls with regard to their heart rate during a graded exercise test and their heart rate recovery during the 5 min cool-down after the graded exercise test.

Methods

Sport-related concussion patients ( N = 61; 31% female) and controls ( N = 16; 50% female) participated in a graded exercise test on a cycle ergometer followed by 5 min active cool-down. Based on the results of graded exercise tests they were divided into four groups: (1) patients who reached the symptom threshold and had to stop the graded exercise test (symptom threshold; N = 39; 33.3% female), (2) patients with symptoms who finished the graded exercise test (S; N = 16; 25% female), (3) patients without symptoms (NS; N = 6; 33.3% female), (4) controls ( N = 16; 50% female).

Main outcome measures

Heart rate, severity of headache and dizziness during graded exercise test, heart rate recovery (median (heart rate recoveries/maximal heart rate) ± median absolute deviation (MAD)) 30, 60 and 300 s after the start of cool-down.

Results

Heart rate recovery at 30 s was significantly slower in symptom (0.95 ± 0.01) compared to all other groups ( p < 0.002; symptom threshold: 0.92 ± 0.02, NS: 0.91 ± 0.02, controls: 0.93 ± 0.02). Heart rate recovery at 60 s was significantly slower in symptom (0.90 ± 0.02) compared to the symptom threshold and controls ( p < 0.041; 0.86 ± 0.03, 0.85 ± 0.04). Heart rate recovery at 300 s was significantly slower in symptom threshold (0.72 ± 0.05) compared to controls ( p = 0.003; 0.66 ± 0.02).

Conclusions

Heart rate measurements in athletes with symptoms of sport-related concussion should be continued during cool-down after the graded exercise test, as dysfunction of the autonomic cardiovascular system might manifest also during cool-down.

Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial

OBJECTIVE

Investigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic.

METHODS

Real-life conditions, multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10-<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis.

RESULTS

456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=-1.3 (95% CI:-3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=-4.3 (95% CI:-8.4 to -0.2)).

CONCLUSION

Symptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks.

LEVEL OF EVIDENCE

1b.

TRIAL REGISTRATION NUMBER

NCT02893969.

REGISTRY NAME

Pediatric Concussion Assessment of Rest and Exertion (PedCARE).

Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial

BACKGROUND

Sport-related concussion is a public health problem, particularly in adolescents. Quality of life is reduced in adolescents with persistent post-concussive symptoms (symptoms >28 days). We replicated a previous randomised controlled trial to validate the safety, efficacy, and generalisability of, and objective adherence to, prescribed early targeted heart rate subsymptom threshold aerobic exercise compared with placebo-like stretching exercise for adolescent recovery from sport-related concussion and for reducing the risk of persistent post-concussive symptoms.

METHODS

This randomised controlled trial was done at three community and hospital-affiliated sports medicine concussion centres in the USA. Male and female adolescent athletes (aged 13-18 years) presenting within 10 days of sport-related concussion were randomly assigned to individualised subsymptom threshold aerobic or stretching exercise at least 20 min daily, for up to 4 weeks after injury. Exercise adherence and intensity were measured by heart rate monitors. The primary outcome was clinical recovery (ie, return to baseline symptoms, normal exercise tolerance, and a normal physical examination) within the 4-week intervention period, and development of persistent post-concussive symptoms beyond 28 days after injury. This study is registered with ClinicalTrials.gov, NCT02959216.

FINDINGS

Between Aug 1, 2018, and March 31, 2020, 118 adolescents were recruited (61 were randomly assigned to the aerobic exercise group and 57 to the stretching exercise group) and included in the intention-to-treat analysis. On survival analysis, controlling for sex, site, and mean daily exercise time, patients assigned to aerobic exercise were more likely to recover within 4 weeks after injury compared with those assigned to stretching exercise, with a 48% reduced risk of persistent post-concussive symptoms (hazard ratio for stretching vs aerobic exercise of 0·52 [95% CI 0·28-0·97], p=0·039). No adverse events were reported.

INTERPRETATION

This multicentre study found that early treatment with subsymptom threshold aerobic exercise safely speeds recovery from sport-related concussion and reduces the risk for persistent post-concussive symptoms, an important result given the impact of delayed recovery on adolescent quality of life. Adherence was good and there were no adverse events from this non-pharmacological treatment. These results suggest that physicians should not only permit, but consider prescribing, early subsymptom threshold physical activity to adolescents as treatment for sport-related concussion and to reduce the risk of persistent post-concussive symptoms.

FUNDING

American Medical Society for Sports Medicine.

Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms

OBJECTIVE

The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days).

METHODS

This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived.

RESULTS

Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation.

CONCLUSION

The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.

The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to conduct a systematic review and meta-analysis of active rehabilitation on concussion management. We also examined moderator variables that may contribute to differences across studies: symptom scale, physical activity type, time of injury to recruitment, and mechanism of injury.

METHODS

The standardized effect size of physical activity on concussion management was computed for 23 studies (29 effect sizes). Effect sizes were coded as positive when studies reported an improvement in symptom scores, which was represented by a decrease in postconcussive symptom scores.

RESULTS

The overall effect size of physical activity on concussion recovery was large and positive (g = 1.03). Subthreshold aerobic activity provided the largest effect size (g = 1.71), whereas multimodal interventions had a moderate effect size (g = 0.70). All other moderator variables produced positive effect sizes ranging from g = 0.59 to g = 1.46.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that current evidence supports the notion that physical activity is beneficial in decreasing postconcussive symptoms in both the acute and chronic phases after concussion. The results indicate that unimodal subthreshold aerobic activity may be the best course of action compared with multimodal interventions. Despite this growing body of evidence, additional research is needed to determine the optimal intensity, duration, and time to initiation of aerobic exercise after concussion.

Neuromuscular training after concussion to improve motor and psychosocial outcomes: A feasibility trial

OBJECTIVE

To determine the feasibility of an 8-week neuromuscular training program initiated upon return-to-play clearance following concussion.

DESIGN

Feasibility trial.

SETTING

A single sports medicine center.

PARTICIPANTS

We approached n = 54 patients; n = 32 agreed to participate (59%). N = 27 participants returned for their second visit at return-to-play clearance (84%) and were randomized to neuromuscular training (n = 13) or standard-of-care (n = 14).

MAIN OUTCOME MEASURES

Participants completed three assessments: within 14 days post-concussion, immediately after return-to-play clearance, and 8-weeks following return-to-play clearance. The intervention aimed to achieve positive neuromuscular adaptations and occurred 2x/week for 8 weeks under supervision.

RESULTS

N = 2 participants randomized to the intervention elected not to participate, both due to schedule conflicts (e.g., time required to meet with the study team). Participants began the intervention an average of 11 days after return-to-play clearance, the majority (91%) completed >75% of training sessions, and training sessions lasted an average of 18.2 ± 4.8 min. One participant stopped the intervention after 7 training sessions due to time availability.

CONCLUSION

It is feasible to initiate a neuromuscular training program for most athletes shortly after returning to play following concussion. Clinicians and researchers may consider this approach to mitigate the increased musculoskeletal injury risk for concussion patients returning to sports.

RELATIONSHIP BETWEEN PHYSICAL ACTIVITY PARTICIPATION AND RECOVERY OUTCOMES IN COLLEGE-AGED ADULTS WITH A CONCUSSION

CONTEXT

Previously, the most common treatment for a concussion was prolonged physical and cognitive rest. Recent research suggests that earlier physical activity (PA) may be better at promoting recovery. Research has not evaluated the relationship between free-living PA (e.g., walking) and symptom reporting or recovery duration.

OBJECTIVE

To assess the relationship between free-living physical activity (PA) participation and two recovery outcomes in college-aged adults with a concussion.

DESIGN

Prospective Cohort Setting: Division 1 & 3 Universities Participants: Thirty-two college-aged adults (68.8% female, age: 19.8±1.4) with a concussion.

MAIN OUTCOME MEASURES

Participants completed a post-concussion symptom evaluation at visits 1 (<72 hours from concussion) and 2 (8 days later). Between visits, participants' PA was monitored using an Actigraph GT9X Link PA monitor and expressed as total PA (counts per minute) and percent time of PA spent in moderate-to-vigorous intensity (%MVPA). Recovery time was the number of days from injury occurrence to medical clearance. Separate hierarchical multiple regressions evaluated the relationship between total PA and each recovery variable (visit 2 symptom severity, recovery time). Additionally, separate exploratory hierarchical multiple regressions evaluated the relationship between %MVPA and each recovery variable. Statistical significance was set a priori at p ≤ .05.

RESULTS

Participants averaged 2446±441 counts per minute and spent 12.1±4.2% of their PA performing MVPA. Participants yielded median symptom severities of 28[24] and 2[8] for visit 1 and 2, respectively. Average recovery time was 14.7±7.5 days. Total PA did not significantly contribute to the model for visit 2 symptom severity (p=.122) or recovery time (p=.301). Similarly, %MVPA had little contribution to the model for visit 2 symptom severity (p=.358) or recovery time (p=.276).

CONCLUSION

Results suggest that free-living PA may not be enough to reduce symptoms or shorten recovery. Thus, clinicians may need to provide patients with more structured PA protocols mimicking previous research.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis

ABSTRACT

The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

Early injury evaluation following concussion is associated with improved recovery time in children and adolescents

OBJECTIVES

Delayed treatment for paediatric concussion may impact recovery trajectory. This study aims to determine the relationship between time to evaluation and concussion recovery in children and adolescents.

DESIGN

Retrospective cross-sectional study.

METHODS

Records from 341 children and adolescents, aged 7-18 years, from a tertiary referral concussion clinic were analysed. All participants were assessed using a standardised concussion test battery by a specialist concussion physician and graded exercise testing. Evaluation time was defined as the number of days from injury occurrence to first presentation at the concussion clinic. Three distinct time to evaluation periods were categorised as: early evaluation (<14 days), mid evaluation (14-28 days), and late evaluation (>28 days). The main outcome measure was recovery time (days).

RESULTS

A total of 341 participants (mean age 13.0 ± 2.3, 74% male) were included in the study. Of these, 89 received evaluation during the early phase (mean age 12.2 ± 2.5, 65% male), 124 during the mid phase (mean age 13.1 ± 2.2, 81% male) and 128 during the late phase (mean age 13.5 ± 2.1, 75% male) following injury. Participants receiving late evaluation took three times longer to recover (mean 148.0 days, 95% CI: 121.1-173.9) compared to early (mean 38.7 days, 95% CI: 30.7-46.7) and mid (mean 51.5 days, 95% CI: 39.7-63.4) evaluation. There was a strong positive correlation between recovery time and evaluation time (r = 0.66, p < 0.001).

CONCLUSIONS

Delaying time to evaluation following a concussion can significantly prolong recovery from injury in children and adolescents.

Influence of Aerobic Exercise Volume on Postconcussion Symptoms

BACKGROUND

Aerobic exercise has emerged as a useful treatment to improve outcomes among individuals who experience a concussion. However, compliance with exercise recommendations and the effect of exercise volume on symptom recovery require further investigation.

PURPOSE

To examine (1) if an 8-week aerobic exercise prescription, provided within 2 weeks of concussion, affects symptom severity or exercise volume; (2) whether prescription adherence, rather than randomized group assignment, reflects the actual effect of aerobic exercise in postconcussion recovery; and (3) the optimal volume of exercise associated with symptom resolution after 1 month of study.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Individuals randomized to an exercise intervention (n = 17; mean age, 17.2 ± 2.0 years; 41% female; initially tested a mean of 11.3 ± 2.8 days after injury) or standard of care (n = 20; mean age, 16.8 ± 2.2 years; 50% female; initially tested a mean of 10.7 ± 3.2 days after injury) completed an aerobic exercise test within 14 days of injury. They returned for assessments 1 month and 2 months after the initial visit. The aerobic exercise group was instructed to exercise 5 d/wk, 20 min/d (100 min/wk), at a target heart rate based on an exercise test at the initial visit. Participants reported their exercise volume each week over the 8-week study period and reported symptoms at each study visit (initial, 1 month, 2 months). Because of low compliance in both groups, there was no difference in the volume of exercise between the 2 groups.

RESULTS

There were no significant symptom severity differences between the intervention and standard-of-care groups at the initial (median Post-Concussion Symptom Inventory, 15 [interquartile range = 10, 42] vs 20 [11, 35.5]; P = .26), 1-month (4 [0, 28] vs 5.5 [0.5, 21.5]; P = .96), or 2-month (6.5 [0, 27.5] vs 0 [0, 4]; P = .11) study visits. Exercise volume was similar between groups (median, 115 [54, 225] vs 88 [28, 230] min/wk for exercise intervention vs standard of care; P = .52). Regardless of group, those who exercised <100 min/wk reported significantly higher symptom severity at the 1-month evaluation compared with those who exercised ≥100 min/wk (median, 1.5 [0, 7.5] vs 12 [4, 28]; P = .03). Exercising ≥160 min/wk successfully discriminated between those with and those without symptoms 1 month after study commencement (classification accuracy, 81%; sensitivity, 90%; specificity, 78%).

CONCLUSION

Greater exercise volume was associated with lower symptom burden after 1 month of study, and an exercise volume >160 min/wk in the first month of the study was the threshold associated with symptom resolution after the first month of the study. Because our observation on the association between exercise volume and symptom level is a retrospective and secondary outcome, it is possible that participants who were feeling better were more likely to exercise more, rather than the exercise itself driving the reduction in symptom severity.

Effects of CranioSacral therapy upon symptoms of post-acute concussion and Post-Concussion Syndrome: A pilot study

OBJECTIVE

The purpose of this study was to investigate the utilization of CranioSacral Therapy (CST) in patients with Post-Concussion Syndrome (PCS) and capture patient-reported perceptions of clinical outcomes of lived treatment experiences.

DESIGN

Two-part, longitudinal study conducted through a chart review of target group, followed by a Patient-reported Treatment Outcome Survey (PTOS).

PARTICIPANTS

A convenience sample of 212 patients with a historical incidence of head trauma not requiring hospitalization was obtained through medical records department dating back ten years. Inclusion criteria for further chart review (n = 67) was determined by identifying patients with a confirmed concussion directly correlated with presenting symptoms and for which CST was specifically sought as a treatment option. Demographics and patient-determined treatment duration data were analyzed by comparison groups extensively suggested in existing literature: Recovery time since injury as either Post-acute concussion (<6 months) or Post-Concussion Syndrome (PCS) (≥6 months); Athletes (A) or Non-athletes (NA); and traditional gender. Final PTOS group criteria was determined by eliminating confounding issues reporting (n = 47): (A, n = 24 and NA, n = 23).

RESULTS

Quantitative data was analyzed via Numerical Analysis, and qualitative data was analyzed via Inductive Content Analysis. Symptoms reported in all charts as well as in the PTOS were consistent with identified PCS subtypes. Utilization of CST revealed that most patients determined the treatment effect upon concussion symptoms within 1-3 sessions. Nearly twice as many sessions were attended in the PCS than post-acute groups. Referral sources, studied for a perspective on local concussion after-care discharge planning, ranged from professional to personal recommendation or self-discovery. A majority of patients met goals of reducing post-acute or PCS as reasons cited by self-determined change-in-status or discharge from service. Patients were asked to indicate on the PTOS which pre- and post-treatment symptoms were helped or not helped by this particular intervention.

CONCLUSIONS

Patient-reported changes of PCS symptoms is critical when evaluating treatment options. CST is an experiential treatment that addresses subjective levels of dysfunction, thus it is the patient deciding the value of an intervention. A sizable portion of patients in all groups reported a positive effect upon their symptoms by CST. Patients indicated personal meaning to CST through their utilization of multiple sessions. A high percentage indicated the likelihood of referring others with PCS for CST. Of the 212 patient charts first studied, the 145 not meeting inclusion criteria suggest some chronic conditions may present as long-term effects of older head injuries. CST is a low-risk, conservative treatment option for PCS sub-types worthy of further clinical study.

Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion?

Introduction: Research indicates Sports-Related Concussion (SRC) impairs Vestibular-Ocular-Motor (VOM) function. The aim was to explore if VOM impairment correlates with longer Return To Play (RTP), symptom burden, neurocognitive performance and academic capability.Participants: 40 (61.4% male) Loughborough University, UK, rugby union student-athletes who sustained 42 SRCs.Methods: Student-athletes completed an assessment battery during pre-season (baseline), 2, 4, 8 and 14 days post-SRC and prior to RTP and were managed according to the rugby Football Union' community pathway.Outcome measures: Vestibular Ocular-Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Test, Post-Concussion Symptom Scale, Perceived Academic Impairment Tool questionnaire and percentage of academic activities specifically missed due to SRC.Results: VOMS scores were significantly (p < 0.005) greater than baseline at all time points except RTP. Presence of VOM dysfunction at 14 days post-SRC significantly correlated with a longer RTP, greater symptom burden and increased odds ratio at 2, 4 and 8 days and academic time loss at 2, 4 and 8 days post-SRC.Conclusion: VOM impairment is associated with an increased symptom burden and impaired academic capability, and a longer time to RTP when present at 14 days post-SRC.

The Influence of Timing of Reporting and Clinic Presentation on Concussion Recovery Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis.

OBJECTIVE

To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher.

RESULTS

12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI - 10.14, - 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later.

CONCLUSIONS

Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion.

Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms

CONTEXT

Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS.

EVIDENCE ACQUISITION

PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value.

CONCLUSION

Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes.

STRENGTH OF RECOMMENDATION TAXONOMY

2.

Association of Self-Paced Physical and Cognitive Activities Across the First Week Postconcussion With Symptom Resolution in Youth

OBJECTIVE

To examine the association of objectively measured, self-paced physical and cognitive activities across the first week postconcussion with symptom resolution in youth.

SETTING

Emergency department or concussion clinics.

PARTICIPANTS

Youth aged 11 to 17 years with physician-confirmed concussion.

DESIGN

Prospective cohort with repeated measures.

MAIN MEASURES

Days from injury to symptom resolution, based on daily ratings by youth on the Post-Concussive Symptom Scale. Physical and cognitive activities were assessed using an ActiGraph and a Narrative Clip, respectively.

RESULTS

A total of 83 youth participants were included (n = 54 [65%] males; mean age = 14.2 years, SD = 1.9). While self-paced daily physical and cognitive activities increased across the first week postinjury, daily postconcussion symptoms decreased. Increased daily step count was associated with an increased likelihood of early symptom resolution (hazard ratio [HR] = 1.17; 95% confidence interval [CI], 1.02-1.34). However, this association was not statistically significant after adjusting for acute postconcussion symptoms and other covariates. Greater school attendance time was associated with earlier symptom resolution (adjusted HR = 1.14; 95% CI, 1.02-1.27).

CONCLUSION

Self-paced physical and cognitive activities across the first week postinjury alone neither hastened nor prolonged concussion recovery. Youth with concussion may have some latitude to determine their activity levels.

First-time sports-related concussion recovery revisited: management changes and impact on recovery

Context

Concussion is among the most common injuries in athletes. Over the past 10 years, concussion knowledge has expanded, and guidelines for management have changed. Recent changes include recommendations against strict mental and physical rest after sustaining a concussion, a better recognition of preexisting conditions predisposing protracted concussion recovery, and the addition of preliminary patient counseling and education about the expected course of concussion recovery.

Objective

To assess the impact of changes in concussion management on the duration of symptoms in middle school and high school athletes after sustaining a first-time, sports-related concussion.

Methods

A retrospective review was performed of medical records of athletes who sustained a concussion between 2016 and 2018 and were treated by the same primary care physician (J.M.N) using the revised approach to concussion management described. Patients were included if they were 11 to 18 years old and had a diagnosis of first-time concussion sustained while playing organized sports. Athletes who sustained a concomitant injury or sustained a concussion outside of organized sports were excluded from the study; athletes lost to follow-up or with incomplete forms were also excluded. Each athlete's length of symptomatic time from his or her concussion was calculated. This data was then compared with a previously-published data set of athletes who sustained a concussion between 2011 and 2013, with the same inclusion criteria but a different approach to concussion management.

Results

A total of 110 male and 72 female athletes (N=182) met the study's eligibility criteria. Collectively, athletes of both sexes from the 2016-2018 data set reported a higher incidence of preexisting conditions associated with prolonged concussion recovery compared with the data set of 2011-2013 athletes. However, both sexes from the 2016-2018 data set also reported a shorter median duration of concussion symptoms compared with the 2011-2013 athletes (median duration 5 vs. 11 days for male athletes and 7 vs. 28 days for female athletes, respectively; p<0.001).

Conclusion

Recent changes in concussion management have led to decreased duration of symptoms among 11- to 18-year-old athletes with first-time, sports-related concussions. These management changes include advocating for early activity, recognizing preexisting conditions, and educating athletes about the realities of concussion recovery.

Perceptual Cognitive Training Does Not Improve Clinical Outcomes at 4 and 12 Weeks Following Concussion in Children and Adolescents: A Randomized Controlled Trial

OBJECTIVE

To determine whether a perceptual-cognitive training program using 3D-multiple object tracking (3D-MOT) can improve symptoms following acute pediatric concussion.

SETTING

Research laboratory within a pediatric trauma center.

PARTICIPANTS

Children and adolescents (n = 62, age= 13.27 ± 2.50) with diagnosed concussion.

DESIGN

Randomized controlled trial. Children were randomized into either 3D-MOT, 2048 game, or standard care-only groups. Participants and parents completed the Post-Concussion Symptom Inventory (PCSI) at baseline, 4, 8, and 12 weeks postinjury. Intervention participants completed either the 3D-MOT protocol or the 2048 game at 6 sessions between the baseline and 4-week assessment.

MAIN MEASURES

A 3 (group) × 10 (time) mixed-model analysis of variance evaluated PCSI total scores. The rate of persistent postconcussive symptom (PPCS) was evaluated at 4 weeks using χ2 analysis.

RESULTS

Symptoms decreased throughout the study using both child-reported (F(9,374) = 22.03, P < .001) and parent-reported scores (F(9,370) = 28.06, P < .001). Twenty-four (44.4%) children met the study definition for PPCS using the child-reported PCSI, while 20 (37.7%) children had PPCS using parent reports. The intervention did not significantly affect symptom resolution or PPCS rates.

CONCLUSION

There is no benefit to prescribing 3D-MOT training for acute rehabilitation in pediatric patients with concussion and clinicians should instead focus on more effective programs.

Female Athlete and Sports-Related Concussions

Female athletes are participating in collision sports in greater numbers than previously. The overall incidence of concussion is known to be higher in female athletes than in male athletes participating in similar sports. Evidence suggests anatomic, biomechanical, and biochemical etiologies behind this sex disparity. Future research on female athletes is needed for further guidance on prevention and management of concussion in girls and women.

Concussions in Dancers and Other Performing Artists

Dancers and other performing artists are subject to head impacts that result in concussion-like symptoms. In spite of this, performing arts do not have access to the continual, focused emphasis on the diagnosis, management, and prevention of concussions that is commonplace in sports. Performing arts present a unique environment in which concussions occur and must be managed. This article outlines what is known about performing arts concussions, describes mechanisms of head impacts sustained by participants in dance and the related artforms of theater, circus, and film and television stunts, and offers concussion management guidelines for these artistic fields.

College Athletic Trainers' Perceptions of Rest and Physical Activity When Managing Athletes With a Sport-Related Concussion

CONTEXT

Cognitive and physical rest are commonly utilized when managing a sport-related concussion (SRC); however, emerging research now suggests that excessive rest may negatively impact recovery. Despite current research recommendations, athletic trainers (ATs) may be behind in implementing this emerging research into clinical practice.

OBJECTIVE

To assess college ATs' perceptions and implementation of an emerging SRC management approach (cognitive and physical rest and activity).

DESIGN

Cross-sectional study.

SETTING

Survey.

PARTICIPANTS

A total of 122 (11.8%) ATs (53.3% female; 10.8 [9.8] y experience; 8.7 [6.9] SRCs managed annually) responded to the survey, which was randomly distributed to 1000 members of the National Athletic Trainers' Association, as well as 31 additional ATs from varying universities.

MAIN OUTCOME MEASURES

A 5-point Likert scale assessed the ATs' perceptions and clinical practices as they relate to specific athlete behaviors (ie, texting, sleeping). The ATs were asked about their willingness to incorporate physical activity into clinical practice.

RESULTS

Playing video games (95.9%) and practicing (93.4%) were the activities most perceived to extend SRC recovery. However, sleeping more than usual (7.4%) and increased time in a dark environment (11.5%) were viewed as less likely to extend recovery. ATs restricted practicing (98.4%) and working out (91.8%) for athletes with SRC, while sleeping more than usual (6.6%) and increased time in a dark environment (13.1%) were less restricted. About 71% of the ATs would implement light physical activity for athletes with a symptom score of 1 to 5, 31% with scores of 6 to 10, and 15% with scores of 11 to 20. About 43%, 74%, and 97% believe that light, moderate, and vigorous physical activity, while symptomatic, will extend recovery, respectively.

CONCLUSIONS

The ATs were receptive to including light physical activity into their SRC management, although only in certain situations. However, most ATs' beliefs and clinical practices did not completely align with emerging research recommendations for the management of SRCs.

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

INTRODUCTION

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

OBJECTIVE

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

DESIGN

Retrospective cohort.

SETTING

A concussion sub-specialty clinic at an academic institution.

PATIENTS

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

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Postconcussion Exertion Evolution: Clinical and Behavioral Considerations

The philosophy and practices concerning concussion management have evolved from passive to active strategies that incorporate immediate, guided rest followed by early integration of physical and cognitive activity as tolerated by symptoms. Recent research and clinical evidence support guidance that symptom tolerable and clinically guided activity is beneficial postconcussion both acutely and in the longer term. Furthermore, recent studies illustrate benefits of targeted deficit-based therapies (vestibular, cervicogenic, visual, psychological, etc.) postconcussion subacutely and in those with persistent symptoms. The dissemination of this new information occurs at a fast pace and is often difficult to rapidly integrate into clinical practice due to necessary policy and behavior changes. This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes.