Do post-concussion-like symptom responses change following exercise or sports participation in a non-concussed cohort?

Youth Preseason Performance on the Sport Concussion Assessment Tool 5 Across Multiple Sports

OBJECTIVE

To examine preseason Sport Concussion Assessment Tool 5 (SCAT5) performance of adolescent sport participants by environment (in-person/virtual), sex, age, concussion history, collision/noncollision sport participation, and self-reported medical diagnoses.

DESIGN

Cross-sectional.

SETTING

Canadian community and high-school sport settings.

PARTICIPANTS

Three thousand eight hundred five adolescent (2493 male, 1275 female, and 37 did not disclose; 11- to 19-year-old) sport participants.

ASSESSMENT OF RISK FACTORS

Sport Concussion Assessment Tool 5 administration method (in-person/virtual), sex (male/female/unreported), age (years), concussion history (0/1/2/3+), collision/noncollision sport participant, and self-reported medical diagnoses [attention deficit disorder or attention-deficit/hyperactivity disorder, headache/migraine, learning disability, and psychiatric disorder (ie, anxiety/depression/other)].

OUTCOME MEASURES

Preseason SCAT5 outcomes including total number of symptoms (TNS; /22), symptom severity score (SSS; /132), Standardized Assessment of Concussion (SAC; /50), and modified Balance Error Scoring System (mBESS; /30).

RESULTS

Multiple multilevel linear or Poisson regression complete case analyses adjusting for clustering and robust standard errors, with β-coefficients (95% CI) back-transformed to indicate an increase/decrease in SCAT5 subdomains when relevant for clinical interpretation. Virtual (V) performance was associated with fewer symptoms reported [TNS Difference V-IP = -1.53 (95% CI, -2.22 to -0.85)], lower SSS [-2.49 (95% CI, -4.41 to -0.58)], and fewer mBESS errors (IP) [-0.52 (95% CI, -0.77 to -0.27)] compared with in-person. For every one-year increase in age, more symptoms [TNS = 0.22 (95% CI, 0.01-0.44)], higher SSS [0.52 (95% CI, 0.01-1.06)], higher SAC [0.27 (95% CI, 0.15-0.38), and poorer balance [mBESS = -0.19 (-0.28 to -0.09)] were observed. Differences between males and females were also seen across all SCAT5 outcomes. Individuals reporting any medical diagnosis or 3+ concussion history also reported more symptoms (TNS) and higher SSS than those who did not.

CONCLUSIONS

Administration environment, sex, age, concussion history, and medical diagnoses were associated with SCAT5 subdomains and are important considerations when interpreting the SCAT5 results.

An At-Home, Virtually Administered Graded Exertion Protocol for Use in Concussion Management: Preliminary Evaluation of Safety and Feasibility for Determining Clearance to Return to High-Intensity Exercise in Healthy Youth and Children With Subacute Concussion

Graded exertion testing (GXT) is an important tool for concussion management, as it is used to personalize post-concussion exercise prescription and return athletes to sport. However, most GXT requires expensive equipment and in-person supervision. Our objective was to assess the safety and feasibility of the Montreal Virtual Exertion (MOVE) protocol, a no-equipment, virtually compatible GXT, in healthy children and children with subacute concussion. The MOVE protocol consists of seven stages of bodyweight and plyometric exercises performed for 60 sec each. Twenty healthy (i.e., non-concussed) children completed the MOVE protocol virtually over Zoom Enterprise. Next, 30 children with subacute concussion (median: 31.5 days post-injury) were randomized to the MOVE protocol or Buffalo Concussion Treadmill Test (BCTT), which increases the incline or speed of the treadmill every minute until maximum exertion. Out of an abundance of caution, all concussed participants completed the MOVE protocol in an in-person clinical space. However, the test evaluator was stationed in a different room within the clinic and administered the MOVE protocol using Zoom Enterprise software to mimic telehealth conditions. Safety and feasibility outcomes were recorded throughout GXT, including heart rate, rate of perceived exertion (RPE), and symptom outcomes. No adverse events were recorded, and all feasibility criteria were successfully met in healthy youth and youth with concussion. Among concussed youth, increases in heart rate (MOVE: 82.4 ± 17.9 bpm, BCTT: 72.1 ± 23.0 bpm; t(28) = 1.36, p = 0.18), RPE (MOVE: 5.87 ± 1.92, BCTT: 5.07 ± 2.34, t(28) = 1.02, p = 0.32), and overall symptom presentation were similar between the MOVE and BCTT protocols. The MOVE protocol is a safe and feasible GXT in healthy youth and youth with subacute concussion. Future studies should assess the fully virtual administration of the MOVE in children with concussion, MOVE protocol tolerability in children with acute concussion, and whether the MOVE protocol can be used to guide individualized exercise prescription.

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.

The effect of high-intensity physical exertion on measures of cervical spine, vestibular/ocular-motor screening, and vestibulo-ocular reflex function in university level collision and combative sport athletes

OBJECTIVES

To examine how high-intensity physical exertion affects clinical measures of cervical spine (CSp), vestibular/ocular motor screen (VOMS), and vestibulo-ocular reflex (VOR) function.

DESIGN

Case series.

SETTING

Sports Medicine Centre.

PARTICIPANTS

A total of 37 athletes consented to participate (22 rugby, 15 wrestling; 9 men, 28 women; median age = 19 years [range 17-23 years]).

MAIN OUTCOME MEASURES

Outcome measures included tests of CSp (cervical flexor endurance, head perturbation test, cervical flexion rotation test and anterolateral strength), VOR (head thrust test and dynamic visual acuity [DVA]), and a quantified version of the VOMS. These metrics were assessed prior to and after completing the 30-15 Intermittent Fitness Test. Bland-Altman plots and Wilcoxon signed-rank tests were utilized to analyze the data using an alpha of p < 0.004.

RESULTS

Cervical anterolateral strength (kg) was reduced post-exertion on the left (z = 3.87; p < 0.001), but not on the right between conditions (z = -1.49; p = 0.14). Athletes reported increased dizziness (z = -3.55; p = 0.004) and had reduced DVA following exertion (z = -2.78; p < 0.001). All other metrics were not significantly different following exertion (p > 0.011).

CONCLUSION

Reduced performance on DVA, decreased left-anterolateral strength, and increased dizziness occurred following high-intensity exertion in varsity collision and combative athletes, which has implications for sideline screening for sport-related concussion.

A cross-sectional cohort study of post-concussive symptoms and their relationships with depressive symptoms in youth with and without concussion

OBJECTIVES

To evaluate the frequency and severity of post-concussive symptoms in youth with a history of concussion relative to youth without concussion who had another medical diagnosis, as well as compare the correlations between post-concussive and depressive symptoms between groups. We hypothesized comparable symptom reporting and correlations in each group.

METHODS

A total of 564 youth ages 8-18 years were assessed regarding post-concussive symptoms. A subset of youth (n = 360) were compared on correlations between post-concussive and depressive symptoms. Non-parametric statistics were used for most analyses.

RESULTS

Youth with concussion reported a comparable number of post-concussive and depressive symptoms as youth with another medical condition without concussion. However, those with concussion reported greater post-concussive symptom severity (but small effect sizes). Relationships between post-concussive and depressive symptoms were comparable for both groups, but for those who sustained a concussion, the correlation was significantly stronger for females than males.

CONCLUSIONS

This study further demonstrates that post-concussive symptoms are nonspecific and provide little functional utility. Post-concussive and depressive symptoms are strongly correlated, particularly in females with concussion. Psychiatric comorbidities and other medical diagnoses should be assessed pre-injury because both affect interpretation of post-concussive symptom reports.

Changes in exertion-related symptoms in adults and youth who have sustained a sport-related concussion

OBJECTIVES

To identify the symptoms responsible for cessation of exercise testing and evaluate changes in post-concussion symptom scores on the Post-Concussion Symptom Scale (PCSS) from the Sport-Concussion Assessment Tool (SCAT5) immediately, 1-4h, and 6-12h following completion of the Buffalo Concussion Treadmill Test (BCTT) in youth and adults who have sustained a sport-related concussion.

DESIGN

Prospective case-series.

METHODS

Individuals who were diagnosed with a sport-related concussion and self-reported difficulties with exertion were referred to perform an exertional treadmill test. Individuals were recruited from a university sports medicine clinic. Change in PCSS symptom severity scores were operationally defined as a change ≥4 points.

RESULTS

Forty-five individuals aged 13-57 years consented to participate. A total of 14/24 (58.3%) female and 13/21 (61.9%) male participants reported an increase in symptom severity scores immediately following the BCTT. At 1-4h, 5/10 (50.0%) males and 5/14 (35.7%) females who completed the PCSS had elevated symptom severity scores compared to pre-exertion. Only 24.2% (3/17 males and 5/16 females) of participants completing the PCSS at 6-12h reported increased symptom severity scores.

CONCLUSION

Exertional testing is an important component of a multifaceted assessment following concussion; however, previous research evaluating symptom responses to exertion is limited. This study provides evidence to suggest individuals who experience an exacerbation of concussion-associated symptoms after exertion are likely to return to pre-exertion levels within the same day. Future research monitoring symptoms following exertion and throughout recovery should be performed in tandem with physiological measures to better understand the source of symptoms.

A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males

OBJECTIVE

To study the effect of early prescribed aerobic exercise versus relative rest on rate of recovery in male adolescents acutely after sport-related concussion (SRC).

DESIGN

Quasi-experimental design.

SETTING

University sports medicine centers.

PARTICIPANTS

Exercise group (EG, n = 24, 15.13 ± 1.4 years, 4.75 ± 2.5 days from injury) and rest group (RG, n = 30, 15.33 ± 1.4 years, 4.50 ± 2.1 days from injury).

INTERVENTIONS

Exercise group performed a progressive program of at least 20 minutes of daily subthreshold aerobic exercise. Rest group was prescribed relative rest (no structured exercise). Both groups completed daily online symptom reports (Postconcussion Symptom Scale) for 14 days.

MAIN OUTCOME MEASURES

Days to recovery after treatment prescription. Recovery was defined as return to baseline symptoms, exercise tolerant, and judged recovered by physician examination.

RESULTS

Recovery time from initial visit was significantly shorter in EG (8.29 ± 3.9 days vs 23.93 ± 41.7 days, P = 0.048). Mixed-effects linear models showed that all symptom clusters decreased with time and that there was no significant interaction between treatment group and time. No EG participants experienced delayed recovery (>30 days), whereas 13% (4/30) of RG participants experienced delayed recovery.

CONCLUSIONS

These preliminary data suggest that early subthreshold aerobic exercise prescribed to symptomatic adolescent males within 1 week of SRC hastens recovery and has the potential to prevent delayed recovery.

The use of an intensive physical exertion test as a final return to play measure in concussed athletes: a prospective cohort

OBJECTIVES

To examine the utility of a novel physical exertion test developed by the Chicago Blackhawks medical staff as a final return to play (RTP) clearance test in youth and young adult athletes, and to determine the relationship between participant and test variables on RTP within asymptomatic athletes diagnosed with concussion.

METHODS

Once asymptomatic and following completion of all RTP steps, concussed athletes underwent the Gapski-Goodman Test (GGT) or modified GGT (mGGT) at partnered Complete Concussion Management Inc. (CCMI) clinics as part of RTP decision-making. Prospective data was collected electronically by trained CCMI clinicians utilizing the CCMI Concussion Database System. A review was conducted to examine data collected between January 2016 and February 2017. Participant and test variables were analyzed to determine relationships with pass/fail rate of the GGT/mGGT.

RESULTS

A total of 759 athletes performed the GGT/mGGT in the study period. Although all asymptomatic, 14.6% of concussed athletes failed the GGT/mGGT while attempting to achieve RTP clearance. Statistically significant relationships were found between failure of the test and symptom severity score on initial presentation and self-reported history of pre-morbid anxiety. When taken together, sex, age, and pre-morbid anxiety significantly predicted the length of time between injury and RTP clearance.

CONCLUSION

The GGT may identify individuals who are not ready to RTP despite a self-reported asymptomatic status and completion of all RTP steps. These results illustrate that RTP clearance decisions based on self-reported asymptomatic status at rest may be inadequate. Instead, monitored, intensive, sport-specific, physical exertion testing should be utilized to inform clinical RTP decisions.