Norm-Based Cutoffs as Predictors of Prolonged Recovery After Adolescent Sport-Related Concussion

Multidomain Predictors of Protracted Recovery following Concussion among 5- to 9-Year-Old Patients: A Preliminary Study

OBJECTIVE

To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion.

STUDY DESIGN

A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery.

RESULTS

The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001).

CONCLUSIONS

Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature

OBJECTIVE

The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion.

DATA SOURCES

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles.

STUDY SELECTION

Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool.

DATA EXTRACTION

After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies.

DATA SYNTHESIS

Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not.

CONCLUSIONS

Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review

OBJECTIVE

To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC.

DATA SOURCES

Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically.

STUDY ELIGIBILITY CRITERIA

Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery.

RESULTS

Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC.

CONCLUSION

No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

PROSPERO REGISTRATION NUMBER

CRD42022155121.

Median Time to Return to Sports After Concussion Is Within 21 Days in 80% of Published Studies

PURPOSE

To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol.

METHODS

A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment.

RESULTS

There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days.

CONCLUSIONS

Median time to return to sports after concussion is within 21 days in 80% of published studies.

LEVEL OF EVIDENCE

IV, systematic review of Level I to IV studies.

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.