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Yang J, Alshaikh E, Asa N, VonDeylen O, Desai N, Taylor HG, Pommering T, MacDonald JP, Cohen DM, Yeates KO. Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years. Br J Sports Med 2024; 58:328-333. [PMID: 38346776 DOI: 10.1136/bjsports-2023-107601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 03/16/2024]
Abstract
OBJECTIVE As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.
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Affiliation(s)
- Jingzhen Yang
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medcine, Columbus, Ohio, USA
| | - Enas Alshaikh
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nichole Asa
- University of Washington, Seattle, Washington, USA
| | - Olivia VonDeylen
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nikhil Desai
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Hudson Gerry Taylor
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medcine, Columbus, Ohio, USA
| | - Thomas Pommering
- Department of Pediatrics, The Ohio State University College of Medcine, Columbus, Ohio, USA
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - James P MacDonald
- Department of Pediatrics, The Ohio State University College of Medcine, Columbus, Ohio, USA
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Daniel M Cohen
- Department of Pediatrics, The Ohio State University College of Medcine, Columbus, Ohio, USA
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
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Pollard-McGrandy AM, Tracey AJ, Wallace J, Covassin T, Beidler E. Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes. Brain Inj 2023; 37:1362-1369. [PMID: 38111232 DOI: 10.1080/02699052.2023.2292998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/05/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions. METHODS This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions. RESULTS 24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96). CONCLUSIONS This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.
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Affiliation(s)
| | - Allie J Tracey
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Jessica Wallace
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Erica Beidler
- Department of Athletic Training, Duquesne University, Pittsburgh, Pennsylvania, USA
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3
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Kontos AP, Eagle SR, Braithwaite R, Preszler J, Manderino L, Turner RL, Jennings S, Trbovich A, Hickey RW, Collins MW, McCrea M, Nelson LD, Root J, Thomas DG. The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients. Am J Sports Med 2023; 51:3893-3903. [PMID: 36847271 DOI: 10.1177/03635465221150214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION CRD42021253060 (PROSPERO).
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rock Braithwaite
- Department of Kinesiology and Recreation Administration, Cal Poly Humboldt, Arcata, California, USA
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Lisa Manderino
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Rose L Turner
- Health Science Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alicia Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Children's Hospital of Pittsburgh Division of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeremy Root
- Pediatric Emergency Medicine, George Washington School of Medicine, Washington, DC, USA; Children's National Health System, Fairfax, Virginia, USA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Pediatric Emergency Medicine, Children's Wisconsin, Wauwatosa, Wisconsin, USA)
- Investigation performed at University of Pittsburgh Medical Center Sports Concussion Program and University of Pittsburgh Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, USA
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De Luigi AJ, Bell KR, Bramhall JP, Choe M, Dec K, Finnoff JT, Halstead M, Herring SA, Matuszak J, Raksin PB, Swanson J, Millett C. 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. PM R 2023; 15:1605-1642. [PMID: 37794736 DOI: 10.1002/pmrj.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 10/06/2023]
Abstract
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.
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Affiliation(s)
- Arthur J De Luigi
- Department Chair of Physical Medicine & Rehabiltation, Medical Director of Sports Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kathleen R Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Katherine Dec
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan T Finnoff
- United States Olympic and Paralympic Committee, Colorado Springs, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, Colorado, USA
| | - Mark Halstead
- Washington University Sports Medicine, St Louis, Missouri, USA
| | - Stanley A Herring
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jason Matuszak
- Sports Medicine, Excelsior Orthopaedics, Buffalo, New York, USA
| | - P B Raksin
- John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital), Rush University Medical Center, Chicago, Illinois, USA
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Neely LM, Smulligan KL, Wingerson MJ, Seehusen CN, Simon SL, Wilson JC, Howell DR. The association between sleep and physical activity with persisting postconcussion symptoms among adolescent athletes. PM R 2023; 15:1122-1129. [PMID: 36580488 PMCID: PMC10875599 DOI: 10.1002/pmrj.12939] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 11/09/2022] [Accepted: 12/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Both sleep duration and physical activity following concussion may influence subsequent recovery. Objective measurement of sleep and physical activity behavior via wearable technology may provide insights into their association with concussion recovery. OBJECTIVE To determine whether sleep behavior (eg, duration, timing) and/or physical activity (steps/day, or exercise frequency, duration, intensity) in the first month after adolescent sports-related concussion are associated with developing persisting postconcussion symptoms (PPCS). DESIGN Case-control. SETTING Outpatient sports medicine clinic. PARTICIPANTS The study prospectively enrolled adolescent athletes who sustained a concussion (N = 49, age = 14.8 ± 1.8 years; 51% female) who were evaluated within 14 days of concussion (mean = 6.7 ± 2.7 days) and followed uvia sleep/physical activity monitoring for the subsequent 2 weeks. MAIN OUTCOME MEASURES Participants wore a monitor to track sleep (sleep time, wake time, and time spent awake in bed at night) and physical activity (average steps/day, exercise frequency, exercise duration) behavior for 2 weeks after initial assessment. Participants were followed until symptom resolution, and the main outcome of interest was development of PPCS (symptom duration >28 days). A multivariable logistic regression model was used to examine associations between physical activity and sleep behavior with PPCS. RESULTS Of the 49 participants, 47% (n = 23, mean symptom resolution = 57 ± 23 days post injury) developed PPCS and 53% (n = 26, mean symptom resolution = 15 ± 7 days post injury) did not. Univariable analysis showed that the PPCS group took fewer steps/day (7526 ± 2975 vs. 9803 ± 3786 steps/day; p = .02), exercised less frequently (2.5 ± 2.2 vs. 4.4 ± 2.1 days/week; p = .005), and spent more time in bed awake (1.2 ± 0.3 vs. 0.8 ± 0.3 h/night; p = .03) than the no PPCS group. Multivariable results indicated the odds of developing PPCS significantly increased with fewer exercise session/week (adjusted odds ratio = 1.96, 95% confidence interval = 1.09, 3.51, p = .024). CONCLUSIONS More exercise sessions that were longer than 15 minutes during concussion recovery was associated with a lower risk of developing PPCS, whereas sleep and other physical activity measures were not. Further studies regarding exercise duration and intensity are needed. Clinicians may consider advising patients to optimize sleep and physical activity during concussion recovery.
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Affiliation(s)
- Linda M Neely
- Modern Human Anatomy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Katherine L Smulligan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital of Colorado, Aurora, CO, USA
| | - Mathew J Wingerson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital of Colorado, Aurora, CO, USA
| | - Corrine N Seehusen
- University of New England School of Osteopathic Medicine, Biddeford, ME, USA
| | - Stacey L Simon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Pediatric Sleep Center, Children’s Hospital of Colorado, Aurora, CO, USA
| | - Julie C Wilson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital of Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - David R Howell
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital of Colorado, Aurora, CO, USA
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Sports-Related Concussion Is a Personalized Issue—Evaluation of Medical Assessment and Subjective Feeling of the Athlete in a German Level 1 Trauma Center. J Pers Med 2022; 12:jpm12101596. [PMID: 36294735 PMCID: PMC9605563 DOI: 10.3390/jpm12101596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes.
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Cook NE, Gaudet Iii CE, Van Patten R, Kissinger-Knox AM, Iverson G. Clinical Outcome Following Sport-Related Concussion Among Children and Adolescents with a History of Prior Concussion: A Systematic Review. J Neurotrauma 2022; 39:1146-1158. [PMID: 35505613 DOI: 10.1089/neu.2022.0078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5,118 total records screened, 51 studies (46 cohort studies and 5 case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k=37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussions are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently, and more conservatively, because doing so, in some cases, might be counterproductive.
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Affiliation(s)
- Nathan E Cook
- Harvard Medical School, 1811, Physical Medicine and Rehabilitation, 79/96 Thirteenth Street, Center for Health and Rehabilitation, Department of Physical Medicine & Rehabilitation, Harvard Medical School, 79/96 Thirteenth Street, Charlestown, Massachusetts, United States, 02129.,Spaulding Rehabilitation Hospital, 24498, Charlestown, Massachusetts, United States.,MassGeneral Hospital for Children, Sport Concussion Program, Boston, Massachusetts, United States;
| | - Charles E Gaudet Iii
- Harvard Medical School, 1811, Physical Medicine and Rehabilitation, Charlestown, Massachusetts, United States;
| | - Ryan Van Patten
- Providence Veterans Administration Medical Center, Providence, Rhode Island, United States.,Warren Alpert Medical School of Brown University, 12321, Department of Psychiatry and Human Behavior, Providence, Rhode Island, United States;
| | - Alicia M Kissinger-Knox
- Harvard Medical School, 1811, Physical Medicine and Rehabilitation, Charlestown, Massachusetts, United States;
| | - Grant Iverson
- Harvard Medical School, 1811, Physical Medicine and Rehabilitation, Center for Health and Rehabilitation Research, 79/96 Thirteenth Street, Charlestown, Massachusetts, United States, 02129;
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Howell DR, Wingerson MJ, Kirkwood MW, Grubenhoff JA, Wilson JC. Early aerobic exercise among adolescents at moderate/high risk for persistent post-concussion symptoms: A pilot randomized clinical trial. Phys Ther Sport 2022; 55:196-204. [DOI: 10.1016/j.ptsp.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022]
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Miutz LN, Burma JS, Lapointe AP, Newel KT, Emery CA, Smirl JD. Physical Activity Following Sport-Related Concussion in Adolescents: A Systematic Review. J Appl Physiol (1985) 2022; 132:1250-1266. [PMID: 35323056 DOI: 10.1152/japplphysiol.00691.2021] [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: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Lauren N Miutz
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Joel S Burma
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Andrew P Lapointe
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kailey T Newel
- Faculty of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan David Smirl
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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10
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Buckley TA, Munkasy BA, Evans KM, Clouse B. Acute Physical and Mental Activity Influence on Concussion Recovery. Med Sci Sports Exerc 2022; 54:307-312. [PMID: 34559729 PMCID: PMC8760145 DOI: 10.1249/mss.0000000000002787] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, Interdisciplinary program in Biomechanics and Movement Science University of Delaware, Newark, DE
| | - Barry A. Munkasy
- School of Health and Kinesiology, Georgia Southern University, Statesboro, GA
| | | | - Brandy Clouse
- Department of Intercollegiate Athletics, Georgia Southern University, Statesboro, GA
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Cook NE, Teel E, Iverson GL, Friedman D, Grilli L, Gagnon I. Lifetime History of Concussion Among Youth With ADHD Presenting to a Specialty Concussion Clinic. Front Neurol 2022; 12:780278. [PMID: 35126288 PMCID: PMC8810649 DOI: 10.3389/fneur.2021.780278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/24/2021] [Indexed: 12/03/2022] Open
Abstract
Child and adolescent student athletes with attention-deficit/hyperactivity disorder (ADHD) report a greater lifetime history of concussion than those without ADHD. This case-control study compared youth with and without ADHD presenting for care at a specialty concussion clinic on their lifetime history of concussion. We hypothesized that a greater proportion of youth with ADHD would report a history of prior concussion. Archival clinical data from patients presenting to a specialty concussion clinic in Montreal, Québec, Canada between September 2015 and August 2019 were analyzed. The sample included 2,418 children and adolescents (age: M = 13.6, SD = 2.7, range 5–18 years; 50.9% girls), including 294 (12.2%) with ADHD and 2,124 (87.8%) without ADHD. The proportion with prior concussion among youth with ADHD (43.9%) was significantly greater than youth without ADHD [37.5%, χ2 = 4.41, p = 0.04, OR = 1.30, 95% confidence interval (CI): 1.02–1.67]. A significantly higher proportion of boys with ADHD had a prior concussion history (48.1%) than boys without ADHD [38.4%, χ2 = 5.33, p = 0.02, OR = 1.48 (95% CI: 1.06–2.09)], but this difference was not observed for girls (χ2 = 0.31, p = 0.58). Youth with ADHD did not differ with regard to their estimated longest duration of symptoms from a prior concussion (Z = 1.52, p = 0.13) and the proportion who reported taking longer than 28 days to recover from a prior concussion did not differ between those with ADHD (15.3%) and without ADHD (12.2%), χ2 = 2.20, p = 0.14. Among youth presenting to a specialty clinic, ADHD was associated with greater lifetime history of concussion but not a greater duration of symptoms from a prior injury.
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Affiliation(s)
- Nathan E. Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- MassGeneral Hospital for Children Sports Concussion Program, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
- *Correspondence: Nathan E. Cook
| | - Elizabeth Teel
- School of Physical and Occupational Therapy, McGill University, Montréal, QC, Canada
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- MassGeneral Hospital for Children Sports Concussion Program, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
- Spaulding Research Institute, Charlestown, MA, United States
| | - Debbie Friedman
- Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
- Department of Pediatrics and Pediatric Surgery, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada
- CHIRPP/Public Health Agency of Canada, Montréal, QC, Canada
| | - Lisa Grilli
- Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, McGill University, Montréal, QC, Canada
- Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
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12
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Ledoux AA, Barrowman N, Bijelić V, Borghese MM, Davis A, Reid S, Sangha G, Yeates KO, Tremblay MS, McGahern C, Belanger K, Barnes JD, Farion KJ, DeMatteo CA, Reed N, Zemek R. 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. Br J Sports Med 2021; 56:271-278. [PMID: 34836880 DOI: 10.1136/bjsports-2021-105030] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/24/2022]
Abstract
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).
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Affiliation(s)
- Andrée-Anne Ledoux
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada .,Cellular and Molecular Medicine- Neuroscience, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Vid Bijelić
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Michael M Borghese
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario, Canada
| | - Adrienne Davis
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Sarah Reid
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Division of Emergency Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Gurinder Sangha
- Division of Emergency Medicine, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Mark S Tremblay
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Candice McGahern
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Kevin Belanger
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Joel D Barnes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J Farion
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Division of Emergency Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Carol A DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Nick Reed
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Division of Emergency Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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13
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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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14
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More Physical Activity after Concussion Is Associated with Faster Return to Play among Adolescents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147373. [PMID: 34299824 PMCID: PMC8306405 DOI: 10.3390/ijerph18147373] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022]
Abstract
Concussion management has evolved to de-emphasize rest in favor of early introduction of post-injury physical activity. However, the optimal quantity, frequency and intensity of physical activity are unclear. Our objective was to examine the association between objective physical activity metrics and clinical recovery after concussion. We prospectively enrolled a cohort of 32 youth athletes with concussion, evaluated within 14 days of injury and after return-to-play (RTP) clearance. For two weeks after enrollment, we quantified steps/day and exercise frequency, duration, and intensity via wrist-worn actigraphy. We grouped participants by RTP clearance timing (<28 days vs. ≥28 days). Seventeen (53%) participants required ≥28 days post-concussion for RTP clearance. Groups were similar in age (14.9 ± 1.9 vs. 15.4 ± 1.5 years; p = 0.38), proportion of females (47% vs. 40%; p = 0.69), and concussion history (59% vs. 47%; p = 0.49). During the study period, the RTP ≥ 28 days group took fewer steps/day (8158 ± 651 vs. 11,147 ± 4013; p = 0.02), exercised fewer days/week (2.9 ± 2.4 vs. 5.0 ± 1.9 days/week; p = 0.01), and exercised fewer total minutes/week (117 ± 122 vs. 261 ± 219 min/week; p = 0.03). Furthermore, we observed ≥10,251 average steps/day, ≥4 exercise sessions/week, and exercising ≥134 total minutes/week were optimal cutpoints to distinguish between groups. These findings support the benefit of physical activity during concussion recovery.
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15
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Haider MN, Bezherano I, Wertheimer A, Siddiqui AH, Horn EC, Willer BS, Leddy JJ. Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms. Sports Health 2021; 13:154-160. [PMID: 33147117 PMCID: PMC8167349 DOI: 10.1177/1941738120946015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Mohammad Nadir Haider
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Itai Bezherano
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Alex Wertheimer
- Department of Emergency Medicine, State University of New York at Buffalo, Buffalo, New York
| | | | - Emily C Horn
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, New York
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
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16
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Orr R, Bogg T, Fyffe A, Lam LT, Browne GJ. Graded Exercise Testing Predicts Recovery Trajectory of Concussion in Children and Adolescents. Clin J Sport Med 2021; 31:23-30. [PMID: 30439726 DOI: 10.1097/jsm.0000000000000683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether graded exercise testing can predict recovery trajectory of concussion in children and adolescents. DESIGN Prospective study. SETTING Children's Hospital, Westmead, Australia. PARTICIPANTS One hundred thirty-nine children aged 12 to 16 years at 5 to 7 days after an acute concussive injury. INTERVENTION Graded exercise testing on a treadmill at the subacute phase to assess symptom provocation and determine clinical recovery indicating readiness to commence a return to activity (RTA) protocol. Exercise time to symptom exacerbation and clinical recovery were measured. MAIN OUTCOME MEASURES Standard concussion assessment and clinical testing (neurocognitive, vestibular/ocular, and balance) were conducted to determine major clinical drivers/indicators. RESULTS Participants (mean age 12.4 ± 2.8 years, 73% male) had a confirmed sport-related concussion. The main clinical drivers identified on exercise testing were headache, balance, and vestibular dysfunction. Participants fell into 1 of 2 groups, exercise-tolerant (54%) and exercise-intolerant (46%). Exercise-tolerant patients showed mild clinical indicators, no symptom exacerbation during 10.3 ± 3.3 minutes of exercise, were safely transitioned to a RTA protocol, and recovered within 10 days. Exercise-intolerant patients had high clinical indicators, significant symptom exacerbation at 4.2 ± 1.6 minutes of exercise, and prolonged recovery of 45.6 days. No adverse effects from exercise were reported in either group. Combined use of provocative exercise and clinical testing was 93% predictive of outcome. CONCLUSIONS Exercise testing during the subacute phase after a concussion can predict longer recovery. Exercise testing can identify a unique window where patients can be safely transitioned to activity, enabling clinicians to better inform patients and families, allocate resources and streamline care.
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Affiliation(s)
- Rhonda Orr
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, and Discipline of Emergency Medicine, The Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Tina Bogg
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
| | - Andrew Fyffe
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
| | - Lawrence T Lam
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, Australia ; and
| | - Gary J Browne
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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17
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van Ierssel J, Ledoux AA, Tang K, Correll R, Yeates KO, Gioia G, Freedman SB, Sangha G, Boutis K, Beer D, Craig W, Burns E, Mikrogianakis A, Dubrovsky AS, Gagnon I, Gravel J, McGahern C, Osmond MH, Zemek R. Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion. J Pediatr 2021; 228:190-198.e3. [PMID: 32858032 DOI: 10.1016/j.jpeds.2020.08.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion. STUDY DESIGN Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury. RESULTS Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009). CONCLUSIONS Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.
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Affiliation(s)
| | - Andrée-Anne Ledoux
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Ken Tang
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Rhonda Correll
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Canada; Alberta Children's Hospital Research Institute, Calgary, Canada
| | - Gerald Gioia
- Children's National Health System, George Washington University School of Medicine, Rockville, MD
| | - Stephen B Freedman
- Alberta Children's Hospital Research Institute, Calgary, Canada; Department of Paediatrics, Alberta Children's Hospital, Calgary, Canada
| | | | - Kathy Boutis
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Darcy Beer
- Department of Pediatrics, Winnipeg Children's Hospital, Winnipeg, Canada
| | - William Craig
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Canada
| | - Emma Burns
- Department of Pediatrics, IWK Health Sciences Centre, Halifax, Canada
| | - Angelo Mikrogianakis
- Department of Pediatrics, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster Children's Hospital & St Joseph's Healthcare, Hamilton, Canada
| | - Alexander S Dubrovsky
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Canada; Department of Pediatrics, McGill University, Montreal, Canada
| | - Isabelle Gagnon
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Canada; School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Jocelyn Gravel
- Department of Pediatrics, Hôpital Ste. Justine, Montreal, Canada
| | - Candice McGahern
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Martin H Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada
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18
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Root JM, Sady MD, Gai J, Vaughan CG, Madati PJ. Effect of Cognitive and Physical Rest on Persistent Postconcussive Symptoms following a Pediatric Head Injury. J Pediatr 2020; 227:184-190.e4. [PMID: 32702425 DOI: 10.1016/j.jpeds.2020.07.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the effect of cognitive and physical rest on persistent postconcussive symptoms in a pediatric population. STUDY DESIGN A prospective cohort study of 5- to 18-year-olds diagnosed with an acute concussion in a tertiary care pediatric emergency department was conducted from December 2016 to May 2019. Participants (n = 119) were followed over 1 month to track days off from school and sports and the development of persistent postconcussive symptoms (residual concussion symptoms beyond 1 month). Participants were dichotomized into minimal (≤2) and moderate (>2) rest, based on days off from school and sports after a concussion. Univariate and multivariable logistic regression analyses were completed to examine associations with persistent postconcussive symptoms. RESULTS Of the participants in our study, 24% had persistent postconcussive symptoms. Adolescent age, history of prolonged concussion recovery, and headache at presentation were associated with higher odds of persistent postconcussive symptoms in univariate analyses. In a multivariable logistic regression model, only adolescent age was associated with increased odds of persistent postconcussive symptoms. Compared with the minimal cognitive rest group, moderate cognitive rest did not decrease the odds of persistent postconcussive symptoms (aOR, 1.15; 95% CI, 0.44-2.99). Compared with the minimal physical rest group, moderate physical rest also did not decrease the odds of persistent postconcussive symptoms (aOR, 3.17; 95% CI, 0.35-28.78). CONCLUSIONS Emerging evidence supports early return to light activity for recovery of acute pediatric concussion. Our study adds to this management approach as we did not find that rest from school and sports resulted in a decreased odds of persistent postconcussive symptoms.
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Affiliation(s)
- Jeremy M Root
- Division of Emergency Medicine, Children's National Health System, Washington, DC.
| | - Maegan D Sady
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC
| | - Jiaxiang Gai
- Biostatistics and Study Methodology Division, Clinical and Translational Science Institute at Children's National (CTSI-CN), Washington, DC
| | - Christopher G Vaughan
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC
| | - Ponda J Madati
- Division of Emergency Medicine, Children's National Health System, Washington, DC
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19
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Zimmerman SD, Vernau BT, Meehan WP, Master CL. Sports-Related Concussions and the Pediatric Patient. Clin Sports Med 2020; 40:147-158. [PMID: 33187605 DOI: 10.1016/j.csm.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pediatric patients with concussions have different needs than adults throughout the recovery process. Adolescents, in particular, may take longer to recover from concussion than adults. Initially, relative rest from academic and physical activities is recommended for 24 to 48 hours to allow symptoms to abate. After this time period, physicians should guide the return to activity and return to school process in a staged fashion using published guidelines. Further concussion research in pediatric patients, particularly those younger than high-school age, is needed to advance the management of this special population.
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Affiliation(s)
- Stessie Dort Zimmerman
- Urgent Care, Seattle Children's Hospital, 4800 Sand Point Way Northeast, M/S MB.7.520, Seattle, WA 98105, USA
| | - Brian T Vernau
- Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopedics, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - William P Meehan
- Division of Sports Medicine, The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Harvard Medical School, 9 Hope Avenue-Suite 100, Waltham, MA 02453, USA
| | - Christina L Master
- Minds Matter Concussion Program, Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopedics, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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20
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Shen X, Gao B, Wang Z, Yang Y, Chen Z, Yu L, Wang Z. Therapeutic Effect of Aerobic Exercise for Adolescents After Mild Traumatic Brain Injury and Sport-Related Concussion: A Meta-Analysis from Randomized Controlled Trials. World Neurosurg 2020; 146:e22-e29. [PMID: 33010508 DOI: 10.1016/j.wneu.2020.09.143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials from January 1980 to April 2018 for adolescents with mild traumatic brain injury (mTBI) to explore the value of aerobic exercise in sport-related concussion (SRC) and mTBI treatment. METHODS A meta-analysis for the postconcussion symptom scale (PCSS) score and time to recovery was performed with STATA software. RESULTS We found that aerobic exercise versus usual treatment significantly decreased the PCSS score (weighted mean difference = 6.51, 95% confidence interval: 0.29, 12.72; P = 0.040), as well as the time to recovery (weighted mean difference = -3.87; 95% confidence interval: -6.50, -1.23; P = 0.004). However, aerobic exercise showed no significant improvement in immediate postconcussion assessment and cognitive testing (P = 0.471/0.129/0.648/0.800, respectively, in verbal memory, visual memory, visual motor speed, and reaction time). CONCLUSIONS Compared with usual treatment, aerobic exercise promoted mTBI adolescents' recovery, assessed by PCSS and time to recovery. However, aerobic exercise may not help with neurocognitive function recovery.
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Affiliation(s)
- Xiaotian Shen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China; Shanghai Medical College, Fudan University, Shanghai, China
| | - Bixi Gao
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yanbo Yang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Lelin Yu
- Radiology, Suzhou Kowloon Hospital Shanghai Jiao Tong University School of Medicine, Suzhou, Jiangsu Province, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
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Yao SC, Zwibel H, Angelo N, Leder A, Mancini J. Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms. J Osteopath Med 2020; 120:2765216. [PMID: 32766808 DOI: 10.7556/jaoa.2020.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
CONTEXT Concussion, a type of mild traumatic brain injury, is a disruption in normal brain function due to head injury. New-onset symptoms from concussion vary, likely depending on the areas of the head and neck affected; they can be severe and debilitating. Current treatment options are limited and difficult to individualize. Osteopathic manipulative medicine (OMM) can aid musculoskeletal restrictions that can potentially improve concussion symptoms. OBJECTIVE To assess concussion symptom number and severity in participants with concussion who received either OMM or an educational intervention. METHODS A randomized controlled trial was conducted at the New York Institute of Technology Academic Health Care Center. Patients presenting to the center with concussion-like symptoms due to recent head injury within the previous 7 days provided consent and were randomized into 2 intervention groups, receiving either 1 OMM treatment (n=16) or 1 concussion education intervention (n=15). Participants were assessed before and after the intervention with the validated Symptom Concussion Assessment Tool fifth edition (SCAT-5) for quantification of number of symptoms and their severity. Collected data were analyzed using the Mann-Whitney U test and the repeated-measures analysis of variance. RESULTS Thirty-one participants were enrolled in the study; after 1 control participant was excluded due to incomplete data, 30 patient records were analyzed. The OMM intervention group had a significant decrease in symptom number (P=.002) and symptom severity (P=.001) compared with the concussion education group. CONCLUSION When used in the acute setting, OMM significantly decreased concussion symptom number and severity compared with concussion education. This study demonstrates that integration of OMM using a physical examination-guided, individualized approach is safe and effective in the management of new-onset symptoms of uncomplicated concussions. (Clinicaltrials.gov No. NCT02750566).
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Martinez C, Christopherson Z, Lake A, Myers H, Bytomski JR, Butler RJ, Cook CE. Clinical examination factors that predict delayed recovery in individuals with concussion. Arch Physiother 2020; 10:10. [PMID: 32514379 PMCID: PMC7251896 DOI: 10.1186/s40945-020-00081-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 05/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis. Methods The study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR. Results 80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR. Conclusions The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.
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Affiliation(s)
- Corina Martinez
- Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705 USA
| | - Zachary Christopherson
- Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705 USA
| | - Ashley Lake
- Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705 USA
| | - Heather Myers
- Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705 USA
| | | | - Robert J Butler
- St Louis Cardinals, St. Louis, MO USA.,Division of Physical Therapy, Department of Orthopedics, Duke University, 2200 W. Main Street, Durham, NC 27708 USA
| | - Chad E Cook
- Division of Physical Therapy, Department of Orthopedics, Duke University, 2200 W. Main Street, Durham, NC 27708 USA
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Sweeney EA, Wilson JC, Potter MN, Dahab KS, Denay KL, Howell DR. Symptom profiles and postural control after concussion in female artistic athletes. Brain Inj 2020; 34:928-933. [DOI: 10.1080/02699052.2020.1763464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Emily A. Sweeney
- Department of Orthopedics, University of Colorado School of Medicine , Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital Colorado , Aurora, CO, USA
| | - Julie C. Wilson
- Department of Orthopedics, University of Colorado School of Medicine , Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital Colorado , Aurora, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine , Aurora, CO, USA
| | - Morgan N. Potter
- Department of Physical Therapy, University of Delaware , Newark, DE, USA
| | - Katherine S. Dahab
- Department of Orthopedics, University of Colorado School of Medicine , Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital Colorado , Aurora, CO, USA
| | - Keri L. Denay
- Department of Family Medicine, University of Michigan Medical School , Ann Arbor, MI, USA
| | - David R. Howell
- Department of Orthopedics, University of Colorado School of Medicine , Aurora, CO, USA
- Sports Medicine Center, Children’s Hospital Colorado , Aurora, CO, USA
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24
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Wilson JC, Kirkwood MW, Potter MN, Wilson PE, Provance AJ, Howell DR. Early physical activity and clinical outcomes following pediatric sport-related concussion. J Clin Transl Res 2020; 5:161-168. [PMID: 33029564 PMCID: PMC7534529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/17/2020] [Accepted: 03/16/2020] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE The objective of the study was to evaluate the clinical outcomes among patients who did and did not report engaging in early physical activity (PA) following sport-related concussion. METHODS We evaluated pediatric patients seen within 21 days of concussion. The independent variable was early PA engagement (since the injury and before initial clinical evaluation). Dependent variables included demographics, injury details, medical history, Health and Behavior Inventory (HBI) score, and balance, vestibular, and oculomotor function tests. RESULTS We examined data from 575 pediatric patients: Sixty-nine (12%) reported engaging in early PA (mean age=14.3±2.4 years; 30% female). The no PA group (mean age=14.5±2.4 years; 35% female) had significantly longer symptom resolution times than the early PA group (median= 16 [interquartile range (IQR)=8-24] vs. 10.5 [IQR=4-17] days; p=0.02). When controlling for pre-existing headache history and time from injury-evaluation time, the early PA group demonstrated lower odds of reporting current headache (adjusted odds ratio=0.14; 95% CI=0.07, 0.26), and reported lower symptom frequency ratings than the no PA group (b=-5.58, 95% CI=-8.94, -2.22). CONCLUSIONS Patients who did not engage in early PA had longer symptom duration, greater odds of post-injury headache, and greater symptoms at initial clinical evaluation. We cannot determine if patients engaged in early PA due to the lower symptom burden and higher functioning at the time of assessment, or if early PA positively affected outcomes. However, as early PA was associated with better post-injury outcomes, clinicians may consider supervised and structured early PA programs as a method to improve clinical outcomes following concussion. RELEVANCE FOR PATIENTS Children and adolescents who were engaged in PA after concussion presented to a clinic with less severe symptoms and had symptoms that resolved sooner compared to those who did not engage in early PA after concussion.
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Affiliation(s)
- Julie C. Wilson
- 1Sports Medicine Center, Children’s Hospital Colorado, Aurora, Colorado, United States,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, United States,3Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michael W. Kirkwood
- 4Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, United States,5Rehabilitation Medicine, Children’s Hospital Colorado, Aurora, Colorado, United States
| | - Morgan N. Potter
- 6Department of Physical Therapy, University of Delaware, Newark, Delaware, United States
| | - Pamela E. Wilson
- 4Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, United States,5Rehabilitation Medicine, Children’s Hospital Colorado, Aurora, Colorado, United States
| | - Aaron J. Provance
- 1Sports Medicine Center, Children’s Hospital Colorado, Aurora, Colorado, United States,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David R. Howell
- 1Sports Medicine Center, Children’s Hospital Colorado, Aurora, Colorado, United States,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, United States,
Corresponding author: David R. Howell, PhD, ATC ATC. Sports Medicine Center, Children’s Hospital Colorado Department of Orthopedics, University of Colorado School of Medicine, 13123 E. 16th Avenue, B060 Aurora, Colorado - 80045, United States Phone: 720-777-1502
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25
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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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26
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Association of Simple Step Test With Readiness for Exercise in Youth After Concussion. J Head Trauma Rehabil 2020; 35:E95-E102. [PMID: 31246885 DOI: 10.1097/htr.0000000000000512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We hypothesized that a submaximal step test would be associated with readiness to commence graded exercise in children and adolescents with concussion. METHODS Children and adolescents aged 8 to 18 years performed standard concussion clinical assessment for vestibular/ocular and balance impairment, and exercise examination utilizing the 3-minute Kasch Pulse Recovery test (KPR) and a symptom-limited graded exercise test (GXT). Outcome measures included activity readiness and symptom exacerbation. RESULTS Forty-five participants (mean age 13.2 ± 2.1 years, 76% male) had a confirmed concussion (73% sports-related). Some participants required follow-up testing giving 75 clinical presentations. Sensitivity and specificity of the KPR were 100% and 95.7%, respectively. Area under the receiver operating characteristics curve was 0.979. Activity readiness to GXT and KPR was strongly associated (χ = 21.672, P < .001), while symptom exacerbation showed a significant correlation between testing methods (r = 0.796, P < .001). Better exercise performance on GXT and KPR was significantly correlated with normal Vestibular/Ocular Motor Screening (rs = -0.380, P = .010, and rs = -0.281, P = .017, respectively) and Modified Balance Error Scoring System (rs = -0.452, P < .001, and rs = -0.301, P = .010, respectively). CONCLUSION The KPR is a simple and practical tool to determine whether it is appropriate for a child or adolescent with concussion to commence graded exercise.
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27
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Howell DR, O'Brien MJ, Fraser J, Meehan WP. Continuing Play, Symptom Severity, and Symptom Duration After Concussion in Youth Athletes. Clin J Sport Med 2020; 30 Suppl 1:S42-S46. [PMID: 32132476 DOI: 10.1097/jsm.0000000000000570] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether continuing to play after a concussion is associated with higher symptom burden or prolonged symptom duration. DESIGN Patients who presented for care at a sport concussion clinic within the first 3 weeks of injury were asked whether they continued to play immediately after their injury. SETTING Sport concussion clinic within a regional tertiary care hospital. MAIN OUTCOME MEASURES Clinical outcomes including symptom severity, symptom duration, age, time from injury-clinical presentation, sex, sport type, previous concussion history, and whether or not they experienced loss of consciousness or amnesia at the time of injury were recorded. Univariable comparisons between those who did and did not report continuing play were conducted. Multivariable linear regression models were constructed to identify the independent association of continuing to play postinjury with symptom burden and symptom recovery time, while controlling for the effect of potential confounding variables. RESULTS A total of 516 patients were included in the study, assessed a mean of 12.1 ± 5.2 days postinjury (35% female, mean age = 14.5 ± 2.3 years). A total of 227 (44%) continued play after sustaining a concussion. Continuing to play postconcussion was independently associated with higher symptom severity during the initial clinical evaluation [β-coefficient = 6.144, 95% confidence interval (CI), 1.357-10.93], but not with symptom duration evaluation (β-coefficient = 1.794, 95% CI, -15.66 to 19.25). CONCLUSION Those who continued to play postconcussion presented with more severe symptoms after injury. Recognition of suspected concussion and removal from play on diagnosis confirmation may lead to better initial clinical outcomes after concussion among child and adolescent athletes.
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Affiliation(s)
- David R Howell
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
- Brain Injury Center, Boston Children's Hospital, Boston, Massachusetts
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado; and
| | - Michael J O'Brien
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
- Brain Injury Center, Boston Children's Hospital, Boston, Massachusetts
- Departments of Orthopaedic Surgery; and
| | - Joana Fraser
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts
- Brain Injury Center, Boston Children's Hospital, Boston, Massachusetts
- Departments of Orthopaedic Surgery; and
- Pediatrics, Harvard Medical School, Boston, Massachusetts
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28
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Stumph J, Young J, Singichetti B, Yi H, Valasek A, Bowman E, MacDonald J, Yang J, Fischer A. Effect of Exercise Recommendation on Adolescents With Concussion. J Child Neurol 2020; 35:95-101. [PMID: 31599706 DOI: 10.1177/0883073819877790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examined the effect of a noncontact, subsymptom exacerbation early exercise recommendation on recovery from sports-related concussion. Retrospective analysis of adolescents, 10-17 years old, with symptomatic concussion, within 30 days of injury was performed. Time to recovery was measured between the early exercise group and a comparison group. A total of 187 patients studied-112 in the exercise group and 75 in the comparison group; 55% were male (n = 103). The exercise group had a significantly longer duration of concussion symptoms (18.5 days vs 14, P = .002), although both groups recovered within the expected time to recovery for concussion. When analyzed separately, males experienced longer time to recovery from injury (19 days vs 14, P = .003), than females, respectively (18 days vs 14.5, P = .18). Recommendation of early exercise resulted in significantly longer recovery from concussion in male adolescents but had no significant effect in female adolescents; both groups recovered within the expected time frame.
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Affiliation(s)
- Justin Stumph
- Department of Family Medicine, Cleveland Clinic Health System, Cleveland, OH, USA
| | - Julie Young
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,School of Health and Rehabilitation Sciences, Ohio State University, Columbus, OH, USA
| | - Bhavna Singichetti
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Honggang Yi
- Department of Biostatistics, Nanjing Medical University, Nanjing, Jiangsu Province, China, USA
| | - Amy Valasek
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Eric Bowman
- Orthopedic Surgery and Sports Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - James MacDonald
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Jingzhen Yang
- Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA.,Center for Injury Research and Policy, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Anastasia Fischer
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
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29
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Howell DR, Taylor JA, Tan CO, Orr R, Meehan WP. The Role of Aerobic Exercise in Reducing Persistent Sport-related Concussion Symptoms. Med Sci Sports Exerc 2019; 51:647-652. [PMID: 30376513 DOI: 10.1249/mss.0000000000001829] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aerobic exercise has received increasing attention in the scientific literature as a component of management for individuals who sustain a concussion. Because exercise training has been reported to reduce symptoms and improve function for those experiencing persistent postconcussion symptoms, it represents a potentially useful and clinically pragmatic rehabilitation technique. However, the specific exercise parameters that best facilitate recovery from concussion remain poorly defined and unclear. This review will provide a summary of the current understanding of the role of subsymptom exercise to improve outcomes after a concussion and will describe the exercise parameters that appear to be important. The latter will take into account the three pillars of exercise dose-frequency, duration, and intensity-to examine what is currently known. In addition, we identify important gaps in our knowledge of exercise as a treatment for those who develop persistent symptoms of concussion.
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Affiliation(s)
- David R Howell
- Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,The Micheli Center for Sports Injury Prevention, Waltham, MA
| | - J Andrew Taylor
- Cardiovascular Research Laboratory, Spaulding Hospital Cambridge, Cambridge, MA.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | - Can Ozan Tan
- Cardiovascular Research Laboratory, Spaulding Hospital Cambridge, Cambridge, MA.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | - Rhonda Orr
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, The University of Sydney, Sydney, AUSTRALIA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA.,Sport Concussion Clinic, Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA.,Departments of Pediatrics and Orthopaedic Surgery, Harvard Medical School, Boston, MA
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30
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Abstract
A systematic approach is required for patients with a suspected concussion. Although standardized tools can aid in assessment, the diagnosis of concussion remains a clinical one. At the time of diagnosis, patients should be given both verbal and written review of the common symptoms of concussion, expected course of recovery, as well as strategies to manage symptoms. Most patients benefit from a brief period of rest, followed by a gradual reintroduction of activities, and a graduated return-to-sport protocol. Patients with prolonged recovery from a concussion may benefit from exercise, vestibular, and cognitive rehabilitation programs.
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Affiliation(s)
- Michael Robert Misch
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - Neha P Raukar
- Department of Emergency Medicine, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
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31
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Lecci L, Williams M, Taravath S, Frank HG, Dugan K, Page R, Keith J. Validation of a Concussion Screening Battery for Use in Medical Settings: Predicting Centers for Disease Control Concussion Symptoms in Children and Adolescents. Arch Clin Neuropsychol 2019; 35:265-274. [DOI: 10.1093/arclin/acz041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/15/2019] [Accepted: 07/18/2019] [Indexed: 02/02/2023] Open
Abstract
Abstract
Objective
Effective screening for concussion is increasingly important, and medical professionals play a critical role in diagnostic and return-to-play decisions. However, few well-validated measures are available to assist in those decisions. This study aims to determine whether previously validated measures assessing neurocognitive and neurobehavioral abilities can predict Centers for Disease Control (CDC) concussion symptom endorsement in a sample of child or youth athletes.
Method
Participants were 113 individuals, aged 6–17, representing 29 consecutive cases undergoing a post-concussion evaluation by a pediatric neurologist and 84 consecutive cases completing standardized baseline assessments (i.e., not being evaluated as a follow-up to a concussion). All participants completed the same standardized battery of tests comprised of the Connors’ Continuous Performance Test (CPT 3), the Balance Error Scoring System (BESS), and the NIH 4-Meter Gait Test as well as completing a checklist of CDC concussion symptoms.
Results
Regression analyses indicate that the screening battery explained 33% of the variance (d = 1.4) in concussion symptom endorsement, after controlling for age. The neurocognitive test alone (CPT 3) accounts for 21.5% of the variance (d = 1.05) in symptoms after controlling for age, and the neurobehavioral measures (BESS and NIH 4-Meter Gait) then account for an additional 11.5% variance (accounting for 18.6% variance, d = .96, when entered first). These effect sizes are considered large to very large and reflect a marked increase in predictive validity relative to existing measures commonly used in concussion assessments.
Conclusions
A relatively brief screening battery can function in medical settings to predict significant and substantial variability in CDC concussion symptoms in a pediatric sample.
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Affiliation(s)
- Len Lecci
- Department of Psychology, University of North Carolina Wilmington, Wilmington, NC 28403, USA
| | - Mark Williams
- Internal Medicine, New Hanover Regional Medical Center, Wilmington, NC 28403, USA
| | - Sasidharan Taravath
- Pediatric Neurology, New Hanover Regional Medical Center, Wilmington, NC 28403, USA
| | - Harrison G Frank
- Frank Institute for Health and Wellness, Wilmington, NC 28403, USA
| | - Kelly Dugan
- Department of Psychology, University of North Carolina Wilmington, Wilmington, NC 28403, USA
| | - Ryan Page
- Department of Psychology, University of North Carolina Wilmington, Wilmington, NC 28403, USA
| | - Julian Keith
- Department of Psychology, University of North Carolina Wilmington, Wilmington, NC 28403, USA
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32
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Howell DR, Brilliant AN, Oldham JR, Berkstresser B, Wang F, Meehan WP. Exercise in the first week following concussion among collegiate athletes: Preliminary findings. J Sci Med Sport 2019; 23:112-117. [PMID: 31522997 DOI: 10.1016/j.jsams.2019.08.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/30/2019] [Accepted: 08/31/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Our purpose was to examine the association between exercise after concussion with symptom severity, postural control, and time to symptom-resolution. DESIGN Longitudinal cohort. METHODS Collegiate athletes (n = 72; age = 20.2 ± 1.3 years; 46% female) with concussion completed a symptom questionnaire at initial (0.6 ± 0.8 days post-injury) and follow-up (2.9 ± 1.4 days post-injury) evaluations, and a postural control assessment at follow-up. Participants were grouped into those who exercised in between the time of injury and the follow-up evaluation and those who did not. Decisions regarding post-concussion exercise were made by a sports medicine team consisting of a single team physician and athletic trainers. RESULTS Thirteen athletes were not included in the current study, resulting in an 85% response rate. Thirteen of the athletes who completed the study exercised between evaluations (18%). There was no symptom resolution time difference between groups (median = 13 [IQR = 7-18] days vs. 13 [7-23] days; p = 0.83). Symptom ratings were similar between groups at the acute post-injury assessment (median PCSS = 18.5 [7.5-26] vs. 17 [14-40]; p = 0.21), but a main effect of group after adjusting for time from injury to assessment indicated the exercise group reported lower symptom severity than the no exercise group across both assessments (p = 0.044). The dual-task gait speed of the exercise group was higher than the no exercise group (0.90 ± 0.15 vs. 0.78 ± 0.16 m/s; p = 0.02). CONCLUSIONS Athletes who were recommended aerobic exercise after concussion did not have worse outcomes than those who were not. Exercise within the first week after concussion does not appear to be associated with detrimental clinical outcomes.
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Affiliation(s)
- David R Howell
- Sports Medicine Center, Children's Hospital Colorado, USA; Department of Orthopedics, University of Colorado School of Medicine, USA; The Micheli Center for Sports Injury Prevention, USA.
| | - Anna N Brilliant
- The Micheli Center for Sports Injury Prevention, USA; Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, USA
| | - Jessie R Oldham
- The Micheli Center for Sports Injury Prevention, USA; Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, USA
| | | | | | - William P Meehan
- The Micheli Center for Sports Injury Prevention, USA; Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, USA; Departments of Pediatrics and Orthopaedics, Harvard Medical School, USA
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33
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Abstract
OBJECTIVES (1) To examine how age influences initial symptom presentation following concussion; and (2) to determine whether specific symptom profiles are associated with duration of postconcussion symptoms, and whether they vary by age group. DESIGN A total of 689 patients (20% children 7-12 years of age, 69% adolescents 13-18 years of age, and 11% young adults 19-30 years of age) were seen and diagnosed with a concussion within 21 days after injury. Patients completed the Post-Concussion Symptom Scale (PCSS) and were followed until they no longer required care. SETTING Two specialty care sport concussion clinical practices. MAIN OUTCOME MEASURES Overall PCSS score was obtained, as well as severity ratings from somatic, vestibular-ocular, cognitive, sleep, and emotional symptom domains. We also calculated total symptom duration time. RESULTS No significant main effect of age, or age by sex associations were identified among the symptom domains. Females endorsed a higher somatic symptom severity rating than males (9.8 ± 6.7 vs 8.1 ± 6.7; P = 0.03). For patients between 7 and 12 years of age, higher somatic [β-coefficient = 1.57, 95% confidence interval (CI), 1.47-1.67] and cognitive (β-coefficient = 2.50, 95% CI, 2.32-2.68) symptom severities were associated with longer duration of concussion symptoms. Among adolescents, longer total symptom duration was associated with more severe somatic (β-coefficient = 1.25, 95% CI, 0.34-2.15) and vestibular-ocular (β-coefficient = 2.36, 95% CI, 1.49-3.23) symptoms. CONCLUSIONS Within 21 days after concussion, symptom-reporting behavior seems to be similar across the age spectrum, but the relationship between symptom profiles and time to symptom resolution varies by age. Although overall symptom ratings are beneficial in determining clinical pathways, symptom domain use may provide a beneficial method to determine individualized patient care that differs between children and adolescents after concussion.
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34
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Lundblad M. SYMPTOM INSTABILITY AND A PROPOSED CLASSIFICATION SYSTEM FOR THE PHYSICAL THERAPY MANAGEMENT OF SPORTS-RELATED CONCUSSION. Int J Sports Phys Ther 2019; 14:835-844. [PMID: 31598420 PMCID: PMC6769268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Individuals can experience headaches, dizziness, cervical dysfunction, balance disturbances, fatigue, and oculomotor impairments following a concussion. Patients with sports-related concussions are not a homogenous group but rather heterogenous groups with mixed clinical findings. PURPOSE The purpose of this clinical commentary is to propose a classification system developed specifically for the physical therapy management of sports-related concussions. DESCRIPTION The concept of "symptom instability" was introduced to assist with classifying patients. The time period post-concussion, symptom instability, and the ability to identify symptom triggers were used as defining criteria. The end result was a classification system with five clinical subgroups. RELATIONSHIP TO CLINICAL PRACTICE The classification system assists in forming homogeneous groups. The grouping of patients into these subgroups can allow for improved efficiency of organizing treatment plans. LEVEL OF EVIDENCE 5.
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Huber DL, Thomas DG, Danduran M, Meier TB, McCrea MA, Nelson LD. Quantifying Activity Levels After Sport-Related Concussion Using Actigraph and Mobile (mHealth) Technologies. J Athl Train 2019; 54:929-938. [PMID: 31411898 DOI: 10.4085/1062-6050-93-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Interest in identifying the effects of physical and mental activity on recovery after sport-related concussion is growing. Clinical studies of concussed athletes' activities require well-validated methods for tracking their intensity and timing. OBJECTIVE To develop and validate a novel multimodal approach to monitoring activity postconcussion using mobile (mHealth) technologies. DESIGN Cohort study. SETTING Translational research unit. PATIENTS OR OTHER PARTICIPANTS A total of 40 high school and collegiate football players were evaluated at preseason and followed longitudinally after either concussion (n = 25; age = 17.88 ± 1.74 years, height = 182.07 ± 8.08 cm, mass = 98.36 ± 21.70 kg) or selection as a nonconcussed control (n = 15; age = 18.27 ± 1.83 years, height = 180.01 ± 7.19 cm, mass = 93.83 ± 24.56 kg). MAIN OUTCOME MEASURE(S) Participants wore a commercial actigraph and completed a daily mobile survey for 2 weeks. Analyses focused on comparisons between groups for actigraph-based physical activity and self-reported physical and mental activity during the follow-up period. RESULTS For the first 2 days postinjury, objective measures showed fewer daily steps in concussed (6663 ± 2667 steps) than in control (11 148 ± 3381 steps) athletes (P < .001), and both objective and self-reported measures indicated less moderate to vigorous physical activity in concussed (27.6 ± 32.6 min/d and 25.0 ± 43.6 min/d, respectively) than in control (57.3 ± 38.6 min/d and 67.5 ± 40.1 min/d, respectively) athletes (both P values < .05). Correlations between objective and self-reported measures of moderate to vigorous physical activity were moderate across select 1-week and 2-week averages. We observed no group differences in self-reported mental activities. CONCLUSIONS Physical activity after sport-related concussion varied widely across athletes but on average was reduced during the acute and early subacute postinjury periods for both objective and self-reported measures. The lack of differences in mental activities between groups may reflect limited change in mental exertion postconcussion or difficulty accurately measuring mental activities. Assessing concussed athletes' activities using actigraphy and self-reported scales may help monitor their compliance with activity recommendations and be useful in studies aimed at better understanding the effects of physical activity on concussion recovery.
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Affiliation(s)
- Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Michael Danduran
- Department of Exercise Science, Marquette University, Milwaukee, WI
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
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Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med 2019; 75:471-482. [PMID: 31326205 DOI: 10.1016/j.annemergmed.2019.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
Abstract
Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.
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Lishchynsky JT, Rutschmann TD, Toomey CM, Palacios-Derflingher L, Yeates KO, Emery CA, Schneider KJ. The Association Between Moderate and Vigorous Physical Activity and Time to Medical Clearance to Return to Play Following Sport-Related Concussion in Youth Ice Hockey Players. Front Neurol 2019; 10:588. [PMID: 31244754 PMCID: PMC6563761 DOI: 10.3389/fneur.2019.00588] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/17/2019] [Indexed: 11/15/2022] Open
Abstract
Design: Prospective cohort study. Background: The recommendations regarding the optimal amount and type of rest for promoting recovery following concussion are based on expert opinion rather than evidence-based guidelines due to current a lack of high-level studies. There is an evident need for more research into the parameters of rest and activity and its effects on recovery from concussion. Objective: To evaluate the association between the amount of moderate and vigorous physical activity (MVPA) during the first 3 days following concussion diagnosis and time to medical clearance (days) to return to play in youth ice hockey players. Methods: Thirty youth ice hockey players (12–17 years) that were diagnosed with a concussion sustained during ice hockey were recruited to participate. The exposure was the cumulative amount of MVPA (minutes), measured using a waist-worn Actigraph accelerometer. Participants were dichotomized into high (≥148.5) and low (<148.5) activity groups based on the median of cumulative time spent in MVPA over the first 3 days following injury diagnosis. Results: Participants in both the low and high activity group reported to the clinic at a median time of 4 days post-injury (low activity IQR: 3–5 days; high activity IQR: 3–7 days). The low activity group completed a median time of 110.7 min (IQR: 76.2–131.0 min) in MVPA, whereas the high activity had a median of 217.2 min (IQR 184.2–265.2 min) in MVPA. Kaplan Meier survival curves with Log-rank tests of hypothesis revealed the high activity group took significantly more time to be medically cleared to return to play (p = 0.041) compared to the low activity group. Conclusion: The results from this study suggest that more time in MVPA early in the recovery period may result in a greater time to medical clearance to return to full participation in ice hockey. Future research, using valid measures of activity, are required to better understand the relationship between early activity and recovery following concussion in youth.
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Affiliation(s)
- Justin T Lishchynsky
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada
| | - Trevor D Rutschmann
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada
| | - Clodagh M Toomey
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,School of Allied Health, University of Limerick, Limerick, Ireland
| | - Luz Palacios-Derflingher
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Keith O Yeates
- Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Psychology, Faculty of Arts, University of Calgary, Calgary, AB, Canada
| | - Carolyn A Emery
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Neuroscience, Faculty of Science, University of Calgary, Calgary, AB, Canada
| | - Kathryn J Schneider
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Root JM, McNamara B, Ledda M, Madati PJ. Pediatric Patient Compliance With Recommendations for Acute Concussion Management. Clin Pediatr (Phila) 2019; 58:731-737. [PMID: 30931591 DOI: 10.1177/0009922819839230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Emerging evidence supports an active approach for acute pediatric concussion management. The current practices of pediatric emergency providers following acute concussions has not been well studied. We prospectively enrolled 134 pediatric patients with an acute concussion. Providers completed a real-time survey to assess their recommendations for time off from school and sports. Seven to 10 days post-injury, patient compliance with provider recommendations was assessed. Forty-seven (35.1%) providers recommended moderate time off from school. In this cohort (n = 44), 14 (31.8%) patients took more than 2 days off from school. When minimal rest was prescribed (n = 80), 26 (32.5%) patients took more than 2 days off from school, P = .94. One third of our pediatric emergency providers are still recommending moderate time off from school. Regardless of physician prescriptions, patients took a similar amount of time off from school. Our study questions the influence of physician recommendations on management of acute pediatric concussions.
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Affiliation(s)
- Jeremy M Root
- 1 Children's National Health System, Washington, DC, USA
| | - Brittany McNamara
- 1 Children's National Health System, Washington, DC, USA.,2 GW Medical Faculty Associates, Washington, DC, USA
| | - Matt Ledda
- 1 Children's National Health System, Washington, DC, USA.,3 Johns Hopkins University, Washington, DC, USA
| | - Ponda J Madati
- 1 Children's National Health System, Washington, DC, USA
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Abstract
PURPOSE OF REVIEW Here, we summarize the current scientific literature on the management of sports-related concussion (SRC) in the acute period (< 6 weeks post-injury) with a focus on rest, return to learn, return to play, and emerging treatments. RECENT FINDINGS While relative rest is recommended for the first 24-48 h following acute SRC, the most recent guidelines highlight the lack of evidence for complete rest and in fact show that prolonged cognitive and physical rest can be detrimental. Gradual return to learn and play is recommended. Return to sport should only occur once the patient is symptom free. While there are no FDA-approved medications for acute treatment of concussion, there is preclinical data for the benefit of omega 3 fatty acids. Evidence is limited around the benefits of treating sleep disorders, vestibular-ocular dysfunction, and neck pain in the acute period. After 24-48 h of rest, SRC patients may gradually resume cognitive and physical activity. More research is needed to determine if any supplements, medications, and/or physical therapy are indicated in the management in acute SRC.
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Affiliation(s)
- Anjali Gupta
- Sports Medicine, Emergency Medicine, Stanford-O’Connor Hospital, The Permanente Medical Group, 2105 Forest Ave, San Jose, CA 95128 USA
| | - Greg Summerville
- Sports Medicine, The Permanente Medical Group, Kaiser South San Francisco Medical Center, 1200 El Camino Real, South San Francisco, CA 94080 USA
| | - Carlin Senter
- Primary Care Sports Medicine, UCSF Orthopedic Institute, University of California, San Francisco, 1500 Owens St, San Francisco, CA 94158 USA
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Howell DR, Wilson JC, Brilliant AN, Gardner AJ, Iverson GL, Meehan WP. Objective clinical tests of dual-task dynamic postural control in youth athletes with concussion. J Sci Med Sport 2019; 22:521-525. [DOI: 10.1016/j.jsams.2018.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 11/26/2022]
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Yang J, Yeates K, Sullivan L, Singichetti B, Newton A, Xun P, Taylor HG, MacDonald J, Pommering T, Tiso M, Cohen D, Huang Y, Patterson J, Lu ZL. Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion. BMJ Open 2019; 9:e028386. [PMID: 31015276 PMCID: PMC6501995 DOI: 10.1136/bmjopen-2018-028386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Although current guidelines for the early clinical management of sports-related concussion (SRC) call for a gradual return-to-activity, the optimal level of rest needed to promote recovery remains unknown. This paper describes the protocol of the Rest Evaluation for Active Concussion Treatment (ReAct) study which objectively measures physical and cognitive rest following SRC and its relation to recovery among youth athletes. METHODS AND ANALYSIS Youth athletes aged 11-17 years are recruited preinjury and enrolled within 72 hours following a physician-diagnosed concussion. Injury information and acute clinical presentation are assessed at the time of injury. Youth participants are prospectively followed to objectively monitor daily physical and cognitive rest using two electronic devices: ActiGraph (to measure physical rest and sleep) and Narrative Clip (to measure cognitive rest), along with self-reported postconcussive symptoms using daily surveys. Other concussion outcomes, including functional outcomes, are assessed by surveying youth and their parents at three time points: (1) within 72 hours of injury, (2) at day 7 postenrolment and (3) at symptom resolution (or a maximum of 45 days postconcussion). ETHICS AND DISSEMINATION This study has received ethical approval from the Institutional Review Board (IRB) at the participating institution (IRB at Nationwide Children's Hospital, IRB16-00613). The results of the study will be presented at national and international scientific conferences and published in peer-reviewed journals.
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Affiliation(s)
- Jingzhen Yang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Keith Yeates
- Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Lindsay Sullivan
- Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Bhavna Singichetti
- Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Alison Newton
- Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Pengcheng Xun
- Department of Epidemiology and Biostatistics, Indiana University, Bloomington, Indiana, USA
| | - H Gerry Taylor
- Pediatrics, The Ohio State University, Columbus, Ohio, USA
- Center for Biobehavioral Health, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - James MacDonald
- Pediatrics, The Ohio State University, Columbus, Ohio, USA
- Sports Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Thomas Pommering
- Pediatrics, The Ohio State University, Columbus, Ohio, USA
- Sports Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Michael Tiso
- Sport and Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Daniel Cohen
- Pediatrics, The Ohio State University, Columbus, Ohio, USA
- Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Yungui Huang
- Research Information Solution and Innovation, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Jeremy Patterson
- Research Information Solution and Innovation, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Zhong-lin Lu
- Psychology, The Ohio State University, Columbus, Ohio, USA
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Howell DR, Potter MN, Kirkwood MW, Wilson PE, Provance AJ, Wilson JC. Clinical predictors of symptom resolution for children and adolescents with sport-related concussion. J Neurosurg Pediatr 2019; 24:54-61. [PMID: 30994475 DOI: 10.3171/2018.11.peds18626] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to determine which variables assessed during an initial clinical evaluation for concussion are independently associated with time until symptom resolution among pediatric patients. METHODS Data collected from a prospective clinical registry of pediatric patients with concussion were analyzed. The primary outcome variable was time from injury until symptom resolution. Predictor variables assessed within 10 days after injury included preinjury factors, Health and Behavior Inventory scores, headache severity, and balance, vestibular, and oculomotor test performances. The researchers used univariate Cox proportional models to identify potential predictors of symptom resolution time and constructed a multivariate Cox proportional hazards model in which total duration of concussion symptoms remained the outcome variable. RESULTS The sample consisted of 351 patients (33% female, mean age 14.6 ± 2.2 years, evaluated 5.6 ± 2.6 days after concussion). Univariate Cox proportional hazards models indicated that several variables were associated with a longer duration of symptoms, including headache severity (hazard ratio [HR] 0.90 [95% CI 0.85-0.96]), headache frequency (HR 0.83 [95% CI 0.71-0.96]), confusion (HR 0.79 [95% CI 0.69-0.92]), forgetfulness (HR 0.79 [95% CI 0.68-0.92]), attention difficulties (HR 0.83 [95% CI 0.72-0.96]), trouble remembering (HR 0.84 [95% CI 0.72-0.98]), getting tired often (HR 0.86 [95% CI 0.76-0.97]), getting tired easily (HR 0.86 [95% CI 0.76-0.98]), dizziness (HR 0.86 [95% CI 0.75-0.99]), and abnormal performance on the Romberg test (HR 0.59 [95% CI 0.40-0.85]). A multivariate Cox proportional hazards model indicated that an abnormal performance on the Romberg test was independently associated with a longer duration of symptoms (HR 0.65 [95% CI 0.44-0.98]; p = 0.038). CONCLUSIONS For children and adolescents evaluated within 10 days after receiving a concussion, abnormal performance on the Romberg test was independently associated with a longer duration of symptoms during recovery. In line with findings of other recent studies investigating predictors of symptom resolution, postural stability tests may provide useful prognostic information for sports medicine clinicians.
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Affiliation(s)
- David R Howell
- 1Sports Medicine Center and.,2Department of Orthopedics and
| | | | - Michael W Kirkwood
- 3Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado.,4Rehabilitation Medicine, Children's Hospital Colorado; and
| | - Pamela E Wilson
- 3Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado.,4Rehabilitation Medicine, Children's Hospital Colorado; and
| | | | - Julie C Wilson
- 1Sports Medicine Center and.,2Department of Orthopedics and
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Silverberg ND, Otamendi T. Advice to Rest for More Than 2 Days After Mild Traumatic Brain Injury Is Associated With Delayed Return to Productivity: A Case-Control Study. Front Neurol 2019; 10:362. [PMID: 31037065 PMCID: PMC6476280 DOI: 10.3389/fneur.2019.00362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/25/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: Recent expert agreement statements and evidence-based practice guidelines for mild traumatic brain injury (mTBI) management no longer support advising patients to “rest until asymptomatic,” and instead recommend gradual return to activity after 1–2 days of rest. The present study aimed to: (i) document the current state of de-implementation of prolonged rest advice, (ii) identify patient characteristics associated with receiving this advice, and (iii) examine the relationship between exposure to this advice and clinical outcomes. Methods: In a case-control design, participants were prospectively recruited from two concussion clinics in Canada's public health care system. They completed self-report measures at clinic intake (Rivermead Post-concussion Symptom Questionnaire, Personal Health Questionnaire-9, and Generalized Anxiety Disorder-7) as well as a questionnaire with patient, injury, and recovery characteristics and the question: “Were you advised by at least one health professional to rest for more than 2 days after your injury?” Results: Of the eligible participants (N = 146), 82.9% reported being advised to rest for more than 2 days (exposure group). This advice was not associated with patient characteristics, including gender (95% CI odds ratio = 0.48–2.91), race (0.87–6.28) age (0.93–1.01), a history of prior mTBI(s) (0.21–1.20), or psychiatric problems (0.40–2.30), loss of consciousness (0.23–2.10), or access to financial compensation (0.50–2.92). In generalized linear modeling, exposure to prolonged rest advice predicted return to productivity status at intake (B = −1.06, chi-squared(1) = 5.28, p = 0.02; 64.5% in the exposure group vs. 40.0% in the control were on leave from work/school at the time of clinic intake, 19.8 vs. 24% had partially returned, and 11.6 vs. 24% had fully returned to work/school). The exposure group had marginally (non-significantly) higher post-concussion, depression, and anxiety symptoms. Conclusions: mTBI patients continue to be told to rest for longer than expert recommendations and practice guidelines. This study supports growing evidence that prolonged rest after mTBI is generally unhelpful, as patients in the exposure group were less likely to have resumed work/school at 1–2 months post-injury. We could not identify patient characteristics associated with getting prolonged rest advice. Further exploration of who gets told to rest and who delivers the advice could inform strategic de-implementation of this clinical practice.
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Affiliation(s)
- Noah D Silverberg
- Rehabilitation Research Program, GF Strong Rehab Centre, Vancouver, BC, Canada.,Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada
| | - Thalia Otamendi
- Sport and Exercise Psychology Laboratory, School of Kinesiology, University of British Columbia, Vancouver, BC, Canada
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Howell DR, Oldham JR, Brilliant AN, Meehan WP. Trouble Falling Asleep After Concussion Is Associated With Higher Symptom Burden Among Children and Adolescents. J Child Neurol 2019; 34:256-261. [PMID: 30669925 DOI: 10.1177/0883073818824000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Our objective was to identify factors associated with trouble falling asleep postconcussion. Patients seen for care after sport-related concussion were assessed ≤10 days postinjury and were between 6 and 19 years of age. Outcomes included symptoms (Post-Concussion Symptom Scale), postural steadiness, missed school, and medical history. There were 261 patients (49% female; mean age=14.8±2.5 years): 45% reported trouble falling asleep. A greater proportion of patients who reported trouble falling asleep missed ≥2 days of school (64% vs 49%; P = .02). Patients who reported trouble falling asleep endorsed more severe symptom severity than those who did not (median=38 vs 18; P < .001). After covariate adjustment, confusion (aOR = 1.95, 95% CI = 1.131-3.375), missing ≥2 days of school (aOR = 4.52, 95% CI = 1.553-13.16), and noise sensitivity (aOR = 1.48, 95% CI = 1.1.042-2.010) were independently associated with trouble falling asleep. Sleep disturbances are associated with poorer clinical outcomes after concussion. Inclusion of sleep assessments may help to provide early therapeutic pathways for pediatric concussion patients.
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Affiliation(s)
- David R Howell
- 1 Sports Medicine Center, Children's Hospital Colorado, Aurora, CO, USA.,2 Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.,3 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Jessie R Oldham
- 3 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.,4 Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.,5 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA, USA
| | - Anna N Brilliant
- 3 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.,5 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA, USA
| | - William P Meehan
- 3 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.,5 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA, USA.,6 Departments of Orthopaedic Surgery and Pediatrics, Harvard Medical School, Boston, MA, USA
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Abstract
Although concussions are common, they are complex, variable, and not entirely understood in terms of pathophysiology and treatment. The incidence of concussion is expected to continue to rise with the increased participation of youth in sports and improved awareness. The role of orthopedic surgeons in concussion management is murky. However, the existing literature does provide a foundation from which orthopedic surgeons who are exposed to concussed patients can function. [Orthopedics. 2019; 42(1):12-21.].
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Abstract
PURPOSE OF REVIEW Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers. RECENT FINDINGS The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA. SUMMARY PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.
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Halstead ME, Walter KD, Moffatt K, LaBella CR, Brooks MA, Canty G, Diamond AB, Hennrikus W, Logan K, Nemeth BA, Pengel KB, Peterson AR, Stricker PR. Sport-Related Concussion in Children and Adolescents. Pediatrics 2018; 142:peds.2018-3074. [PMID: 30420472 DOI: 10.1542/peds.2018-3074] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.
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Affiliation(s)
| | - Kevin D. Walter
- Department of Orthopaedic Surgery, Pediatric Sports Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Kody Moffatt
- Creighton University School of Medicine, Omaha, Nebraska
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Howell DR, Zemek R, Brilliant AN, Mannix RC, Master CL, Meehan WP. Identifying Persistent Postconcussion Symptom Risk in a Pediatric Sports Medicine Clinic. Am J Sports Med 2018; 46:3254-3261. [PMID: 30265817 DOI: 10.1177/0363546518796830] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although most children report symptom resolution within a month of a concussion, some patients experience persistent postconcussion symptoms (PPCS) that continues for more than 1 month. Identifying patients at risk for PPCS soon after an injury can provide useful clinical information. PURPOSE To determine if the Predicting Persistent Post-concussive Problems in Pediatrics (5P) clinical risk score, an emergency department (ED)-derived and validated tool, is associated with developing PPCS when obtained in a primary care sports concussion setting. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We conducted a study of patients seen at a pediatric sports medicine concussion clinic between May 1, 2013, and October 1, 2017, who were <19 years of age and evaluated within 10 days of a concussion. The main outcome was PPCS, defined as symptoms lasting >28 days. Nine variables were used to calculate the 5P clinical risk score, and we assessed the association between the 5P clinical risk score and PPCS occurrence. The secondary outcome was total symptom duration. RESULTS We examined data from 230 children (mean age, 14.8 ± 2.5 years; 50% female; mean time from injury to clinical assessment, 5.6 ± 2.7 days). In univariable analyses, a greater proportion of those who developed PPCS reported feeling slowed down (72% vs 44%, respectively; P < .001), headache (94% vs 72%, respectively; P < .001), sensitivity to noise (71% vs 43%, respectively; P < .001), and fatigue (82% vs 51%, respectively; P < .001) and committed ≥4 errors in tandem stance (33% vs 7%, respectively; P < .001) than those who did not. Higher 5P clinical risk scores were associated with increased odds of developing PPCS (adjusted odds ratio [OR], 1.62 [95% CI, 1.30-2.02]) and longer symptom resolution times (β = 8.40 [95% CI, 3.25-13.50]). Among the individual participants who received a high 5P clinical risk score (9-12), the majority (82%) went on to experience PPCS. The area under the curve for the 5P clinical risk score was 0.75 (95% CI, 0.66-0.84). After adjusting for the effect of covariates, fatigue (adjusted OR, 2.93) and ≥4 errors in tandem stance (adjusted OR, 7.40) were independently associated with PPCS. CONCLUSION Our findings extend the potential use for an ED-derived clinical risk score for predicting the PPCS risk into the sports concussion clinic setting. While not all 9 predictor variables of the 5P clinical risk score were independently associated with the PPCS risk in univariable or multivariable analyses, the combination of factors used to calculate the 5P clinical risk score was significantly associated with the odds of developing PPCS. Thus, obtaining clinically pragmatic risk scores soon after a concussion may be useful for early treatments or interventions to mitigate the PPCS risk.
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Affiliation(s)
- David R Howell
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.,The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Anna N Brilliant
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina L Master
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Abstract
Sport-related concussion (SRC) is a physiological brain injury that produces cerebral and systemic effects, including exercise intolerance. Exercise intolerance after concussion is believed to be the result of autonomic nervous system (ANS) dysfunction. Ventilation is inappropriately low for the level of exercise intensity, raising arterial carbon dioxide (PaCO2) levels. Elevated PaCO2 increases cerebral blood flow (CBF) out of proportion to exercise intensity, which is associated with symptoms that limit exercise performance. Thus, elevated exercise PaCO2 may signal incomplete recovery from SRC. This article reviews recent observational and experimental data and presents the evidence that subthreshold aerobic exercise normalizes the cerebrovascular physiological dysfunction and is "medicine" for patients with concussion and persistent postconcussive symptoms (PPCS). It discusses the systematic evaluation of exercise tolerance after concussion using the Buffalo Concussion Treadmill Test (BCTT) and reviews the utility of the Buffalo Concussion Bike Test (BCBT), the data from which are used to establish an individualized heart rate "dose" of subthreshold exercise to safely speed recovery, which also may work in the acute recovery phase after SRC with the potential to reduce the incidence of PPCS. Evaluation and treatment approaches based on the physiology of concussion suggest that exercise is medicine for concussion, potentially adding a new dimension to concussion care to help safely speed recovery and prevent PPCS in some patients.
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Affiliation(s)
- John J Leddy
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Mohammad N Haider
- UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Michael Ellis
- Pan Am Concussion Program, Section of Neurosurgery, Department of Surgery and Pediatrics, University of Manitoba, Winnipeg, Manitoba, CANADA
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY
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Abstract
Objective: To develop a tool for assessing intentions to continue or change activities for recovery following mild traumatic brain injury (mTBI) and determine if they are dependent on injury context or activity type. Method: Adult volunteers with no (or no recent) history of mTBI were randomly allocated to one of two vignette conditions, each with a different injury context. The vignette described an mTBI due to a motor vehicle accident (MVA, n = 76) or sport (SPORT, n = 89). Volunteers reported their rest or activity plans for 39 behaviours comprising three behaviour types (cognitive, physical, and restful). Results: Compared to a cut-score representing no change, on average there was a significant (p <= .001) planned decrease in physical and cognitive behaviours (MVAphysicalt(53) = 7.373; SPORTphysicalt(41) = 9.281; MVAcognitivet(41) = 9.367; SPORTcognitivet(51) = −3.521) and a significant planned increase in restful behaviours, such as sleep (MVArestfult(72) = 10.006; SPORTrestfult(86) = 9.566). An overall within-group effect for behaviour-type was not identified and there was no effect of condition (MVA vs. SPORT). Conclusion: The acute rest and activity plans for a simulated mTBI are behaviour specific and not dependent on context. An expectation for blanket-rest was not was observed but rest was planned for specific behaviours. This tool could be used to guide discussions with mTBI patients about their recovery so that their plans align with advice, and it could aid further research into the relation between intended and actual rest and activity and the effect on eventual outcomes.
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