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Wingerson MJ, Hunt DL, Wilson JC, Mannix RC, Meehan WP, Howell DR. Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion. Med Sci Sports Exerc 2024; 56:783-789. [PMID: 38109187 PMCID: PMC11018463 DOI: 10.1249/mss.0000000000003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
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.
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Affiliation(s)
- Mathew J. Wingerson
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
| | - Danielle L. Hunt
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - Julie C. Wilson
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
| | - Rebekah C. Mannix
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - William P. Meehan
- Boston Children’s Hospital, Micheli Center for Sports Injury Prevention, Boston, MA
| | - David R. Howell
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO
- Children’s Hospital Colorado, Sports Medicine Center, Aurora, CO
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Jaganathan KS, Sullivan KA, Kinmond S, Berndt S, Street S, Haden C, Greenslade J, McMahon K, Mitchell G, Kerr G. Exercise Parameters for Postconcussion Symptom Rehabilitation: A Systematic Review. J Sport Rehabil 2023:1-10. [PMID: 36940683 DOI: 10.1123/jsr.2022-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 12/04/2022] [Accepted: 12/21/2022] [Indexed: 03/23/2023]
Abstract
CONTEXT Exercise rehabilitation for postconcussion symptoms (PCS) has shown some benefits in adolescent athletes; but a synthesis of evidence on exercise per se has been lacking. OBJECTIVE This systematic review aimed to determine if unimodal exercise interventions are useful to treat PCS and if so, to identify a set of clearly defined and effective exercise parameters for further research. EVIDENCE ACQUISITION Relevant health databases and clinical trial registries were searched from inception to June 2022. The searches used a combination of subject headings and keywords related to mild traumatic brain injury (mTBI), PCSs, and exercise. Two independent reviewers screened and appraised the literature. The Cochrane Collaboration's Risk of Bias-2 tool for randomized controlled trials was used to assess methodological quality of studies. EVIDENCE SYNTHESIS Seven studies were included in the review. Four studies were assessed to have a low overall risk of bias, 2 with low risk and 1 with some concerns. Participants in the studies comprised mostly adolescents with sports-related concussion. The review found exercise to be more beneficial than control conditions in 2 studies investigating acute PCS and 2 studies investigating persistent PCS. Within-group differences showing symptom improvement over time were observed in all 7 studies. In general, the review found support for programmatic exercise that commences after an initial period of rest for 24 to 48 hours. Recommendations for exercise parameters that can be explored in subsequent research include progressive aerobic exercise starting from 10 to 15 minutes at least 4 times a week, at a starting intensity of 50% HR of the subsymptom threshold, with length of program depending on recovery. CONCLUSION The evidence in support of exercise rehabilitation for PCSs is moderate based on the small pool of eligible studies. Further research can be guided by the exercise parameters identified in this review.
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Affiliation(s)
| | - Karen A Sullivan
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Sally Kinmond
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Sara Berndt
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Steve Street
- School of Psychology & Counseling, Queensland University of Technology, Brisbane, QLD,Australia
| | - Catherine Haden
- QUT Library, Academic Division, Queensland University of Technology, Brisbane, QLD,Australia
| | - Jaimi Greenslade
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD,Australia
- Emergency and Trauma Centre, RBWH Brisbane, QLD,Australia
| | - Katie McMahon
- School of Clinical Sciences, Center for Biomedical Technologies, Queensland University of Technology, Brisbane, QLD,Australia
| | - Gary Mitchell
- Emergency and Trauma Centre, RBWH Brisbane, QLD,Australia
| | - Graham Kerr
- School of Exercise & Nutrition Sciences, Queensland University of Technology, Brisbane, QLD,Australia
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3
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Shore J, Nalder E, Hutchison M, Reed N, Hunt A. Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development. JMIR Pediatr Parent 2022; 5:e34822. [PMID: 35377326 PMCID: PMC9016504 DOI: 10.2196/34822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Josh Shore
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Emily Nalder
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Michael Hutchison
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Nick Reed
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Anne Hunt
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
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4
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Pratile T, Marshall C, DeMatteo C. Examining how time from sport-related concussion to initial assessment predicts return-to-play clearance. PHYSICIAN SPORTSMED 2022; 50:132-140. [PMID: 33475440 DOI: 10.1080/00913847.2021.1879603] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE (i) To analyze data of adolescents who have sustained a sport-related concussion (SRC) through the use of Complete Concussion Management Inc. (CCMI) concussion database system; and (ii) to determine an optimal time to assess and manage an athlete with an SRC by prospectively analyzing data from CCMI concussion database system. METHOD A cohort of patients, ages 8-18 years, who sustained an SRC, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada were prospectively followed. The primary outcome measure was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski-Goodman test without symptom exacerbation. RESULTS 1213 athletes (482 female) were included for analysis. Days between injury and initial assessment (p = 0.00), male sex (p = 0.00), and previous concussion history (p = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (p = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5, 24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7, 40.5). Athletes who were assessed at 0 to 9 days from injury were two times more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, p = 0.00). CONCLUSION Time from SRC to initial assessment significantly predicted time to discharge, with those being evaluated earlier experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following an SRC in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.
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Affiliation(s)
- Taylor Pratile
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Cameron Marshall
- Department of research, Complete Concussion Management Inc, Oakville, Ontario, Canada
| | - Carol DeMatteo
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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5
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Carter KM, Pauhl AN, Christie AD. The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis. Med Sci Sports Exerc 2021; 53:1835-1845. [PMID: 33787531 DOI: 10.1249/mss.0000000000002663] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Kathryn M Carter
- Faculty of Health Sciences, School of Kinesiology, Western University, Ontario, CANADA
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6
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Alarie C, Gagnon I, Quilico E, Teel E, Swaine B. Physical Activity Interventions for Individuals With a Mild Traumatic Brain Injury:: A Scoping Review. J Head Trauma Rehabil 2021; 36:205-223. [PMID: 33528174 DOI: 10.1097/htr.0000000000000639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To document the characteristics, measured outcomes, and effectiveness of physical activity (PA) interventions designed to improve health-related outcomes in individuals with a mild traumatic brain injury (mTBI) to assist in rehabilitation quality improvement efforts of a TBI rehabilitation program. METHODS A scoping review following a 6-step iterative framework search across 5 databases (MEDLINE, CINAHL, PsycINFO, SPORTDiscuss, and EMBASE) and the gray literature (Google) was performed. Selected PA interventions were designed for individuals of all ages and any mechanism of injury (eg, sports-related and falls). Data were charted, collated, and summarized according to the Consensus on Exercise Reporting Template checklist and domains of the International Classification of Functioning, Disability and Health. Involvement of clinical experts ensured tailoring of the knowledge synthesis to meet clinical needs. RESULTS Thirty-five articles and 14 gray literature records were retained. Five types of PA interventions were identified with the majority being multimodal. Reporting of PA intervention characteristics was highly variable across studies; many details necessary for intervention replication are missing. Study outcomes focused primarily on improving body functions and symptoms of mTBI, and less frequently on activities, participation, and health-related quality of life. The methodological quality of studies varies. CONCLUSIONS Identified PA intervention types offer various management options for healthcare providers. PA interventions may improve a wide range of health-related outcomes supporting the inclusion of PA in the management of individuals of all ages with mTBI. Higher-quality research and better reporting about intervention characteristics is however needed.
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Affiliation(s)
- Christophe Alarie
- École de Réadaptation, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada (Mr Alarie and Dr Swaine); Institut Universitaire sur la Réadaptation Physique de Montréal (IURDPM)-Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Montréal, Québec, Canada (Messrs Alarie and Quilico and Dr Swaine); School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montréal, Québec, Canada (Drs Gagnon and Teel); Trauma Center and Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center, Montréal, Québec, Canada (Dr Gagnon); and Rehabilitation Science Institute, University of Toronto, Toronto, Canada (Mr Quilico)
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7
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Anderson V, Rausa VC, Anderson N, Parkin G, Clarke C, Davies K, McKinlay A, Crichton A, Davis GA, Dalziel K, Dunne K, Barnett P, Hearps SJ, Takagi M, Babl FE. Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study. BMJ Open 2021; 11:e041458. [PMID: 33574145 PMCID: PMC7880104 DOI: 10.1136/bmjopen-2020-041458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion. METHODS AND ANALYSIS In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group. ETHICS AND DISSEMINATION Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12617000418370; pre-results.
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Affiliation(s)
- Vicki Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
- Psychology Service, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Vanessa C Rausa
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nicholas Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Georgia Parkin
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Cathriona Clarke
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Katie Davies
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Audrey McKinlay
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Psychology, University of Canterbury, Ilam, Christchurch, New Zealand
| | - Ali Crichton
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Gavin A Davis
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Neurosurgery, Austin and Cabrini Hospitals, Melbourne, Victoria, Australia
| | - Kim Dalziel
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Kevin Dunne
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Rehabilitation Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Peter Barnett
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stephen Jc Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Michael Takagi
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
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8
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Fino PC, Weightman MM, Dibble LE, Lester ME, Hoppes CW, Parrington L, Arango J, Souvignier A, Roberts H, King LA. Objective Dual-Task Turning Measures for Return-to-Duty Assessment After Mild Traumatic Brain Injury: The ReTURN Study Protocol. Front Neurol 2021; 11:544812. [PMID: 33519659 PMCID: PMC7844093 DOI: 10.3389/fneur.2020.544812] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 12/07/2020] [Indexed: 02/05/2023] Open
Abstract
Determining readiness for duty after mild traumatic brain injury (mTBI) is essential for the safety of service members and their unit. Currently, these decisions are primarily based on self-reported symptoms, objective measures that assess a single system, or standardized physical or cognitive tests that may be insensitive or lack ecological validity for warrior tasks. While significant technological advancements have been made in a variety of assessments of these individual systems, assessments of isolated tasks are neither diagnostically accurate nor representative of the demands imposed by daily life and military activities. Emerging evidence suggests that complex tasks, such as dual-task paradigms or turning, have utility in probing functional deficits after mTBI. Objective measures from turning tasks in single- or dual-task conditions, therefore, may be highly valuable for clinical assessments and return-to-duty decisions after mTBI. The goals of this study are to assess the diagnostic accuracy, predictive capacity, and responsiveness to rehabilitation of objective, dual-task turning measures within an mTBI population. These goals will be accomplished over two phases. Phase 1 will enroll civilians at three sites and active-duty service members at one site to examine the diagnostic accuracy and predictive capacity of dual-task turning outcomes. Phase 1 participants will complete a series of turning tasks while wearing inertial sensors and a battery of clinical questionnaires, neurocognitive testing, and standard clinical assessments of function. Phase 2 will enroll active-duty service members referred for rehabilitation from two military medical treatment facilities to investigate the responsiveness to rehabilitation of objective dual-task turning measures. Phase 2 participants will complete two assessments of turning while wearing inertial sensors: a baseline assessment prior to the first rehabilitation session and a post-rehabilitation assessment after the physical therapist determines the participant has completed his/her rehabilitation course. A variable selection procedure will then be implemented to determine the best task and outcome measure for return-to-duty decisions based on diagnostic accuracy, predictive capacity, and responsiveness to rehabilitation. Overall, the results of this study will provide guidance and potential new tools for clinical decisions in individuals with mTBI. Clinical Trial Registration: clinicaltrials.gov, Identifier NCT03892291.
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Affiliation(s)
- Peter C Fino
- Department of Health and Kinesiology, University of Utah, Salt Lake City, UT, United States
| | | | - Leland E Dibble
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Mark E Lester
- Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX, United States.,Department of Physical Therapy, Texas State University, Round Rock, TX, United States
| | - Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX, United States
| | - Lucy Parrington
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | - Jorge Arango
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO, United States
| | | | - Holly Roberts
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA, United States
| | - Laurie A King
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
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9
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Dobney DM, Gagnon I. Concussion Management Practices for Youth Who Are Slow to Recover: A Survey of Canadian Rehabilitation Clinicians. Physiother Can 2021; 73:90-99. [PMID: 35110827 PMCID: PMC8774951 DOI: 10.3138/ptc-2019-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Purpose: The objective of this study was to estimate the scope of concussion management practices for youth used by Canadian rehabilitation clinicians. A secondary objective was to determine the use of aerobic exercise as a management strategy. Method: Members of the Canadian Association of Occupational Therapists, Canadian Athletic Therapists Association, and Canadian Physiotherapy Association were invited to participate in an online cross-sectional survey. Two clinical vignettes were provided with a brief history. The respondents were asked about the type of treatments they would provide (e.g., manual therapy, education, aerobic exercise, return-to-learn or return-to-play protocol, goal setting). Results: The survey was completed by 555 clinicians. The top five treatment options were education, sleep recommendations, goal setting, energy management, and manual therapy. Just more than one-third of the clinicians prescribed aerobic exercise. Having a high caseload of patients with concussion (75%-100%) was a significant predictor of prescribing aerobic exercise. Conclusions: A wide variety of treatment options were selected, although the most common were education, sleep recommendations, energy management, and goal setting. Few clinicians used aerobic exercise as part of their concussion management strategy.
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Affiliation(s)
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy
- Department of Pediatric Emergency Medicine, Faculty of Medicine, McGill University
- Trauma Centre, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Que
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10
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Hunt AW, Agnihotri S, Sack L, Tint A, Greenspoon D, Gauvin-Lepage J, Gagnon I, Reed N, Scratch S. Mood-related changes in children and adolescents with persistent concussion symptoms following a six-week active rehabilitation program. Brain Inj 2020; 34:1068-1073. [PMID: 32529851 DOI: 10.1080/02699052.2020.1776396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PRIMARY OBJECTIVE The purpose of this study is to explore changes in mood in youth with persistent post-concussion symptoms following participation in a six-week active rehabilitation program. RESEARCH DESIGN A pre-post test design was used. METHODS AND PROCEDURES Participants (N = 40 children and adolescents with concussion symptoms >2 weeks post-injury) were recruited from the concussion services at an urban children's rehabilitation hospital and the community. The program consisted of individualized low-intensity aerobic exercise, sport-specific drills, relaxation exercises and comprehensive education and support. The 6 week program was completed by participants in their home or local community with weekly check-ins with the research team. Data were analyzed using descriptive statistics and linear regressions. MAIN OUTCOMES AND RESULTS Outcome measures included the Beck Youth Inventories (youth), and the Child Behavior Checklist (parents). Results indicated significant improvements in anger and anxiety post-intervention with anger reduction being more pronounced in girls. CONCLUSIONS Active rehabilitation interventions may have positive effects on mood in youth recovering from concussion. Clinicians may wish to consider addressing anxiety and anger management strategies as part of comprehensive concussion management in youth.
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Affiliation(s)
- Anne W Hunt
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, University of Toronto , Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto, ON, Canada
| | - Sabrina Agnihotri
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto, ON, Canada
| | - Leah Sack
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada
| | - Ami Tint
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada.,Centre for Addiction and Mental Health , Toronto, ON, Canada.,Faculty of Medicine, University of Toronto , Toronto, ON, Canada
| | - Dayna Greenspoon
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada
| | - Jerome Gauvin-Lepage
- Faculty of Nursing, Université De Montréal , Montreal, QC, Canada.,Research Center of the Sainte-Justine University Hospital , Montreal, QC, Canada
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University , Montreal, QC, Canada.,Division of Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center , Montreal, QC, Canada
| | - Nick Reed
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, University of Toronto , Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto, ON, Canada
| | - Shannon Scratch
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital , Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto, ON, Canada
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11
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Coslick AM, Chin KE, Kalb LG, Slomine BS, Suskauer SJ. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery. PM R 2020; 12:1195-1204. [PMID: 32578944 DOI: 10.1002/pmrj.12443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Alexis M Coslick
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kaitlyn E Chin
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Luther G Kalb
- Kennedy Krieger Institute, Biddeford, ME, USA.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Beth S Slomine
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Kennedy Krieger Institute, Biddeford, ME, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stacy J Suskauer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Kennedy Krieger Institute, Biddeford, ME, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.
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Early Controlled Exercise and Timing of Treatment Following Concussion: A Critically Appraised Topic. J Sport Rehabil 2020; 29:360-366. [PMID: 31628271 DOI: 10.1123/jsr.2019-0187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/19/2019] [Indexed: 11/18/2022]
Abstract
Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.
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The Role of Subsymptom Threshold Aerobic Exercise for Persistent Concussion Symptoms in Patients With Postconcussion Syndrome. Am J Phys Med Rehabil 2019; 99:257-264. [DOI: 10.1097/phm.0000000000001340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mucha A, DeWitt J, Greenspan AI. The CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children: What Physical Therapists Need to Know. Phys Ther 2019; 99:1278-1280. [PMID: 31197370 DOI: 10.1093/ptj/pzz085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/24/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Anne Mucha
- Centers for Rehab Services, University of Pittsburgh Medical Center, 3200 South Water St, Pittsburgh, PA 15203 (USA)
| | - John DeWitt
- Physical Therapy Department, The Ohio State University, Columbus, Ohio
| | - Arlene I Greenspan
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents. J Neurol Phys Ther 2019; 42:123-131. [PMID: 29846269 DOI: 10.1097/npt.0000000000000227] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Physical therapy (PT) is a management strategy increasingly recognized to facilitate recovery after concussion. The purpose of this study was to investigate the safety and outcomes of multimodal impairment-based PT at varying time points after injury in youth diagnosed with concussion. METHODS Data were extracted retrospectively from medical records for patients who received PT for concussion-related impairments. Patient records were categorized into 3 cohorts on the basis of the timing of PT implementation: 0-20 days following injury (early intervention), 21 to 41 days following injury (middle intervention), and 42 or more days following injury (late intervention). The primary outcome measure was Post-Concussion Symptom Inventory score from the beginning to the end of the PT episode of care. Additional outcome measures included number of PT sessions, duration of PT episode of care (days), and occurrence of unplanned visits to a health care provider. RESULTS A total of 120 patient records (mean age of 14.77 years) were analyzed. Thirty-three, 39, and 48 individuals were categorized into the early, middle, and late intervention cohorts, respectively. There were no significant differences between intervention cohorts with regard to symptom change on the Post-Concussion Symptom Inventory from the beginning to the end of the PT episode of care, unplanned health care visits, number of PT sessions, or duration of PT episode of care. DISCUSSION AND CONCLUSIONS Early initiation of PT may be safe and tolerable. Future prospective studies are needed to explore the efficacy of PT services administered early following injury to help characterize an optimal care plan for youth following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A210).
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Active Rehabilitation After Childhood and Adolescent Mild Traumatic Brain Injury: a Narrative Review and Clinical Practice Implications. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-0207-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dobney DM, Miller MB, Tufts E. Non-pharmacological rehabilitation interventions for concussion in children: a scoping review. Disabil Rehabil 2017; 41:727-739. [PMID: 29157025 DOI: 10.1080/09638288.2017.1400595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children. METHODS An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down's and Black criteria was conducted. RESULTS Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good. CONCLUSIONS The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy. Implications for rehabilitation Few studies have examined rehabilitation interventions for youth following concussion. Research ranging from rest to exercise highlights the uncertainty of the field. Low quality research limits the generalizability of results. The use of physical activity appears to be an emerging area of interest. Individualised, aerobic exercise should be used as part of clinical management.
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Affiliation(s)
- Danielle M Dobney
- a School of Physical and Occupational Therapy, Faculty of Medicine , McGill University , Montreal , Canada
| | - Matthew B Miller
- b Department of Exercise Science, Faculty of Arts and Science , Concordia University , Montreal , Canada
| | - Emily Tufts
- c Centennial College Libraries , Toronto , Canada
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