Frequency and Outcomes of a Symptom-Free Waiting Period After Sport-Related Concussion

Concussion Symptomatology by Symptom Resolution Time in US High School Athletes: Findings From the National Athletic Treatment, Injury and Outcomes Network High School Surveillance Program (NATION-SP)

CONTEXT

Concussions incurred during high school athletics are a significant health concern, and studies examining concussions with a symptom resolution time (SRT) of 15 to 28 days have been limited.

OBJECTIVE

To compare concussions that had an SRT of 15 to 28 days with concussions that had an SRT of greater than 28 days among US high school athletes.

DESIGN

Descriptive epidemiology study.

SETTING

Secondary school athletic training clinics.

PATIENTS OR OTHER PARTICIPANTS

Secondary school athletes.

MAIN OUTCOME MEASURE(S)

Concussion frequency, symptom number, and symptom prevalence.

RESULTS

Among all 917 reported concussions (of which 50.8% had missing SRT), 88 had an SRT recorded as 15 to 28 days, and 29 had an SRT recorded as greater than 28 days. Greater frequencies of concussions with an SRT of 15 days or more were reported in boys' sports (n = 78) than girls' sports (n = 39). Boys' football (51.7%) and girls' basketball (11.5%) accounted for the largest proportions of all reported concussions with an SRT of 15 to 28 days; boys' football (58.6%) accounted for the greatest proportion of concussions reported with an SRT greater than 28 days. The average number of symptoms was 6.3 ± 3.4 for concussions with an SRT of 15 to 28 days and 7.2 ± 3.8 for those with an SRT greater than 28 days. The most frequently reported symptoms in concussions with both SRT of 15 to 28 days and greater than 28 days were headache, dizziness, sensitivity to light, and difficulty concentrating. The prevalence of irritability was higher in concussions with an SRT of 15 to 28 days as compared with concussions with an SRT greater than 28 days (26.1% versus 13.8%); visual problems (48.3% versus 35.2%) and hyperexcitability (24.1% versus 15.9%) were more prevalent in concussions with an SRT greater than 28 days, although differences were not statistically significant.

CONCLUSIONS

Symptom prevalence and total count were comparable between concussions with an SRT of 15 to 28 days and those with an SRT of greater than 28 days with no statistically significant difference, suggesting that symptom burdens within these groups are more similar than they are different.

The Interval Between Concussions Does Not Influence Time to Asymptomatic or Return to Play: A CARE Consortium Study

INTRODUCTION

The purpose of this study was to determine if the time interval between two concussive events influences the number of days to asymptomatic status, days to return to play, or performance on common post-concussion assessments following the second concussion.

METHODS

Data from 448 collegiate athletes and service academy cadets with two concussions (time between concussions: median 295.0 days [interquartile range: 125.0-438.2]), 40.0% female) were analyzed from Concussion Assessment Research and Education (CARE) Consortium institutions between 2014 and 2020. Days between concussions was the primary predictor variable. Primary outcome measures included time to asymptomatic and time to return to play following the second concussion. Secondary outcome measures included total number of symptoms, total symptom severity, Balance Error Scoring System total score, and Standardized Assessment of Concussion total score within 48 h of their second concussion.

RESULTS

Time between concussions did not significantly contribute to the multivariate time to asymptomatic (p = 0.390), time to return to play (p = 0.859), or the secondary outcomes (p-range = 0.165-0.477) models. Time to asymptomatic (p = 0.619) or return to play (p = 0.524) did not differ between same-season and different-season concussions. Sex significantly contributed to the return to play (p = 0.005) multivariate model. Delayed symptom onset and immediate removal from play/competition significantly contributed to the total number of symptoms (p = 0.001, p = 0.014) and symptom severity (p = 0.011, p = 0.022) multivariate models.

CONCLUSION

These results suggest that in a population with a large period between injuries, the time between concussions may not be relevant to clinical recovery.

Histological comparison of repeated mild weight drop and lateral fluid percussion injury models of traumatic brain injury (TBI) in female and male rats

Traumatic brain injury (TBI) heterogeneity has led to the development of several preclinical models, each modeling a distinct subset of outcomes. Selection of an injury model should be guided by the research question and the specific outcome measures of interest. Consequently, there is a need for conducting direct comparisons of different TBI models. Here, we used immunohistochemistry to directly compare the outcomes from two common models, lateral fluid percussion (LFP) and repeat mild weight drop (rmWD), on neuropathology in adult female and male Wistar rats. Specifically, we used immunohistochemistry to measure the effects of LFP and rmWD on cerebrovascular and tight junction disruption, inflammatory markers, mature neurons and perineuronal nets in the cortical site of injury, cortex adjacent to injury, dentate gyrus, and the CA2/3 area of the hippocampus. Animals were randomized into either LFP or rmWD groups. The LFP group received a craniotomy prior to LFP (or corresponding sham procedure) three days later, while rmWD animals underwent either weight drop or sham (isoflurane only) on each of those four days. After a recovery period of 7 days, animals were euthanized, and brains were harvested for analysis of RECA-1, claudin-5, GFAP, Iba-1, CD-68, NeuN, and wisteria floribunda lectin. Overall, our observations revealed that the most significant disruptions were evident in response to LFP, followed by craniotomy-only, while rmWD animals showed the least residual changes compared to isoflurane-only controls. These findings support consideration of rmWD as a mild, transient injury. LFP leads to longer-lasting disruptions that are more closely associated with a moderate TBI. We further show that both craniotomy and LFP produced greater disruptions in females relative to males at 7 days post-injury. These findings support the inclusion of a time-matched experimentally-naïve or anesthesia-only control group in preclinical TBI research to enhance the validity of data interpretation and conclusions.

Estimating the Relationship Between the Symptom-Free Waiting Period and Injury Rates After Return-to-Play from Concussion: A Simulation Analysis Using CARE Consortium Data

BACKGROUND

A key component of return-to-play (RTP) from sport-related concussion is the symptom-free waiting period (SFWP), i.e., the period during which athletes must remain symptom-free before permitting RTP. Yet, the exact relationship between SFWP and post-RTP injury rates is unclear.

OBJECTIVE

We design computational simulations to estimate the relationship between the SFWP and rates of repeat concussion and non-concussion time-loss injury up to 30 days post-RTP for male and female collegiate athletes across 13 sports.

METHODS

We leverage N = 735 female and N = 1,094 male post-injury trajectories from the National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium.

RESULTS

With a 6-day SFWP, the mean [95% CI] rate of repeat concussion per 1,000 simulations was greatest in ice hockey for females (20.31, [20.16, 20.46]) and American football for males (24.16, [24.05, 24.28]). Non-concussion time-loss injury rates were greatest in field hockey for females (153.66, [152.59, 154.74]) and wrestling for males (247.34, [246.20, 248.48]). Increasing to a 13-day SFWP, ice hockey for females (18.88, [18.79, 18.98]) and American football for males (23.16, [23.09, 24.22]) exhibit the greatest decrease in repeat concussion rates across all sports within their respective sexes. Field hockey for females (143.24, [142.53, 143.94]) and wrestling for males (237.73, [236.67, 237.90]) exhibit the greatest decrease in non-concussion time-loss injury rates. Males receive marginally smaller reductions in injury rates for increased SFWP compared to females (OR = 1.003, p ≤ 0.002).

CONCLUSION

Longer SFWPs lead to greater reductions in post-RTP injury rates for athletes in higher risk sports. Moreover, SFWPs should be tailored to sport-specific post-RTP injury risks.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, systematic review of Level I to IV studies.

Pediatric Minor Traumatic Brain Injury : Growing Skull Fracture, Traumatic Cerebrospinal Fluid Leakage, Concussion

Traumatic brain injury (TBI) is a major public health issue that causes significant morbidity and mortality in the pediatric population. Pediatric minor TBIs are the most common and are widely underreported because not all patients seek medical attention. The specific management of these patients is distinct from that of adult patients because of the different physiologies in these age groups. This article focuses on minor TBIs, particularly growing skull fractures, traumatic cerebrospinal fluid leakage, and concussion.

Assessment of a collaborative concussion management strategy in a school-based sport program: Prospective cohort study

OBJECTIVE

To analyze the implementation of a concussion management protocol in which a team physiotherapist is involved in the identification of concussions and return-to-play (RTP) decisions.

DESIGN

A prospective injury surveillance cohort study in a school-based Canadian football program (4 teams; grades 8 to 12) over 4 years. For years 1 to 2, the team physician made all RTP decisions; over years 3 to 4, the team physiotherapist was allowed to make some RTP decisions using pre-established criteria defined in the protocol.

SETTING

A high school in Québec, Que.

PARTICIPANTS

Male student athletes between 11 and 17 years old.

MAIN OUTCOME MEASURES

Same-season recurrence (SSR) of concussion symptoms following RTP.

RESULTS

A total of 119 concussions were identified (55 during the first 2 years and 64 during the last 2 years) during 27,741 athlete-exposures in 672 athlete-years for an incidence rate of 4.3 per 1000 athlete-exposures. During years 1 to 3, no SSR was observed following RTP clearance. During year 4 there was 1 case of SSR that occurred 11 days after clearance. The overall SSR rate of concussion symptoms following RTP clearance was 0.8%.

CONCLUSION

A very low rate of SSR was achieved whether the team physician made all RTP decisions or the team physiotherapist was allowed to make some of the RTP decisions through the terms of the protocol.

Age-Group Differences and Annual Variation in Return-To-Play Practices After Sport-Related Concussion

OBJECTIVE

To examine return-to-play (RTP) practice differences between high school and collegiate athletes, as well as the stability (ie, year-by-year) in these practices over a 5-year period. We hypothesized that similar protocols for treatment will be comparable across competition levels and that these practices will vary year-to-year.

DESIGN

Prospective cohort study.

SETTING

Nine high schools and 4 National Collegiate Athletic Association Division III colleges in Southeastern Wisconsin.

PARTICIPANTS AND INDEPENDENT VARIABLES

Two-hundred seventy-three (N = 273) athletes with sport-related concussions (SRCs). Independent predictors included competition level (high school, n = 88 vs collegiate, n = 185) and year-of-injury.

OUTCOME MEASURES

Athletes were evaluated prospectively for differences in symptom duration, symptom free waiting period (SFWP), and time to RTP, as well as longitudinal changes in management.

RESULTS

High school and collegiate athletes experienced comparable median symptom duration (high school, 6.0 days, interquartile range (IQR) = 3.5-11.0; college, 6.0 days, IQR = 4.0-9.0, P = 0.95), SFWP (high school, 5.0 days, IQR = 3.0-8.0; college, 5.0 days, IQR = 3.0-7.0, P = 0.12), and total time to RTP (high school, 10.5 days, IQR = 7.0-16.0; college, 11.0 days, IQR = 8.0-14.0 days, P = 0.94). A Cox regression analysis revealed a nonsignificant trend toward longer SFWPs in high school athletes (P = 0.055; hazard ratio = 1.347, confidence interval = 0.99-1.83). Among football players, SFWPs in 2017 (Median = 3.5 days, IQR = 1.5-5.0 days) were significantly longer than those in 2014 (Median = 5.0 days, IQR = 4.0-8.5 days, P = 0.029) after correction for multiple comparisons.

CONCLUSION

Similar postinjury and RTP management practices were observed at the high school and collegiate levels after SRCs. Symptom duration and time from injury to unrestricted RTP were comparable, although high school athletes may have longer SFWPs.

Mode and Intensity of Physical Activity During the Postacute Phase of Sport-Related Concussion: A Systematic Review

INTRODUCTION

Sports-related concussions (SRCs) have received attention due to their prevalence in youth. An SRC results from a strong force causing neurological impairment. Recent research has recommended rehabilitation within the first week post-SRC after 24 to 48 hours of rest. The postacute phase is defined as 48 hours to 7 days post-SRC. It is imperative to evaluate the most effective mode and intensity of physical activity to reduce symptoms and improve outcomes.

METHODS

CINAHL, PubMed, SPORTDiscus, and Web of Science databases were used to search the terms "brain concussion" AND "exercise" and variations of these terms. The evidence level for each study was evaluated using the 2011 Oxford Center for Evidence-Based Medicine Guide. The methodological rigor of each study was evaluated using a scale adapted from Medlicott and Harris.

RESULTS

Two thousand sixty-eight records were identified. Six studies were included in this systematic review. Three studies were classified as moderately strong. The remaining 3 studies were considered weak. Five of the studies used either a cycle ergometer or a treadmill. The sixth study used walking, cycling, and swimming, as well as sports drills. All of these modes of exercise were determined to be safe. All studies utilized low- and moderate-intensity interventions, which were found to be nondetrimental and showed improved recovery time and symptom resolution. Five of the studies also incorporated components of high-intensity exercise that was also found to be nondetrimental, and they showed a positive influence on recovery time and symptom resolution. However, all activity in each of the reviewed studies started at a low level and progressed up to a higher level only as each individual client's symptoms permitted.

DISCUSSION

Overall, this review found that various modes of activity at light-, moderate-, and high-intensity levels are efficacious and can be safely used during the postacute phase of SRC.

CONCLUSION

Though the volume of literature at this time is limited, therapists should consider prescribing closely monitored individualized exercise programs utilizing progressive intensities when treating patients during the postacute phase of SRC.

Concussion-Recovery Trajectories Among Tactical Athletes: Results From the CARE Consortium

CONTEXT

Assessments of the duration of concussion recovery have primarily been limited to sport-related concussions and male contact sports. Furthermore, whereas durations of symptoms and return-to-activity (RTA) protocols encompass total recovery, the trajectory of each duration has not been examined separately.

OBJECTIVE

To identify individual (eg, demographics, medical history), initial concussion injury (eg, symptoms), and external (eg, site) factors associated with symptom duration and RTA-protocol duration after concussion.

DESIGN

Cohort study.

SETTING

Three US military service academies.

PATIENTS OR OTHER PARTICIPANTS

A total of 10 604 cadets at participating US military service academies enrolled in the study and completed a baseline evaluation and up to 5 postinjury evaluations. A total of 726 cadets (451 men, 275 women) sustained concussions during the study period.

MAIN OUTCOME MEASURE(S)

Number of days from injury (1) until the participant became asymptomatic and (2) to complete the RTA protocol.

RESULTS

Varsity athlete cadets took less time than nonvarsity cadets to become asymptomatic (hazard ratio [HR] = 1.75, 95% confidence interval = 1.38, 2.23). Cadets who reported less symptom severity on the Sport Concussion Assessment Tool, third edition (SCAT3), within 48 hours of concussion had 1.45 to 3.77 times shorter symptom-recovery durations than those with more symptom severity. Similar to symptom duration, varsity status was associated with a shorter RTA-protocol duration (HR = 1.74, 95% confidence interval = 1.34, 2.25), and less symptom severity on the SCAT3 was associated with a shorter RTA-protocol duration (HR range = 1.31 to 1.47). The academy that the cadet attended was associated with the RTA-protocol duration (P < .05).

CONCLUSIONS

The initial total number of symptoms reported and varsity athlete status were strongly associated with symptom and RTA-protocol durations. These findings suggested that external (varsity status and academy) and injury (symptom burden) factors influenced the time until RTA.

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

INTRODUCTION

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

OBJECTIVE

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

DESIGN

Retrospective cohort.

SETTING

A concussion sub-specialty clinic at an academic institution.

PATIENTS

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

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury

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.

Concussion incidence and time-loss in Australian football: A systematic review

OBJECTIVES

Australian football is associated with a risk of concussion. However, despite the extensive and varied nature of literature devoted to this issue, concussion incidence has not been systematically evaluated. To address this, we aimed to conduct a meta-analysis of concussion incidence in Australian football.

DESIGN

Systematic review. Prospero registration number: CRD42017064290.

METHODS

A systematic search of 14 databases using the terms 'concussion', and 'Australian football' (and variations) was used to obtain records that reported concussion incidence per 1000 players hours across age, sex, and level-of-play. Data were grouped based on how time-loss was applied to the concussion definition.

RESULTS

Forty-two studies met inclusion criteria. Incidence rates based on a possible time-loss definition per 1000 player hours, ranged from 2.24 to 17.63 at the elite level, and 0.35 to 14.77 at the community/amateur level. Return-to-play details were reported by six studies and only two studies measured head-impacts in real-time. Several limitations were identified with this literature. First, insufficient return-to-play details precluded a meta-analysis of incidence rates. Second, no longitudinal studies across levels-of-play were found. Third, concussion incidence data for junior and female players were notably scarce.

CONCLUSIONS

There was limited scope to determine concussion burden (i.e., incidence and severity) and only preliminary data for player exposure to head-impacts. To address these limitations, injury surveillance should capture sufficient information to permit comparisons within and across levels-of-play. This will also help determine the influence of interventions aimed at reducing the frequency and severity of concussive-injuries.

Patient, Injury, Assessment, and Treatment Characteristics and Return-to-Play Timelines After Sport-Related Concussion: An Investigation from the Athletic Training Practice-Based Research Network

OBJECTIVES

To describe the patient, injury, assessment and treatment characteristics, as well as return-to-play timelines and clinical findings at discharge for adolescent patients after sport-related concussion.

DESIGN

Retrospective analysis of electronic medical records.

SETTING

Athletic training facilities of secondary school members of the Athletic Training Practice-Based Research Network (AT-PBRN).

PATIENTS

In total, 1886 patient records were reviewed. [1204 (63.8%) male, 682 (36.2%) female, age = 15.3 ± 1.9 years, height = 169.5 ± 13.5 cm, mass = 70.3 ± 17.0 kg]. Patients were diagnosed with a concussion by an athletic trainer or team/directing physician.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Descriptive analysis of patient, injury, assessment, treatment, and participation status characteristics, as well as discharge information.

RESULTS

Injury demographic forms were completed for 1886 concussion cases. A concussion-specific evaluation form was completed for 55.9% (n = 1054) of cases. Treatment documentation was completed on 829 patients (44.0% of initial documented cases). Discharge forms were completed for 750 patients (40.0% of initial documented cases). Most cases were coded as 850.9-Concussion (85.5%, n = 642) and occurred during an in-season game (49.4%, n = 308). Time lost from competition was 24.9 ± 39.9 days.

CONCLUSIONS

Most concussion cases documented in this study were not on-field emergencies, as indicated by their normal clinical examinations and the lack of immediate referral to an emergency department. However, certain aspects of the clinical examination were often not assessed during the initial evaluation. These findings describe concussion assessment and recovery in adolescents and reinforce the need for a standardized approach to concussion assessment and appropriate documentation.

Treatments and rehabilitation in the acute and chronic state of traumatic brain injury

Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.

Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA Concussion Study (1999-2001) and CARE Consortium (2014-2017)

OBJECTIVE

We compared data from the National Collegiate Athletic Association (NCAA) Concussion Study (1999-2001) and the NCAA-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium (2014-2017) to examine how clinical management, return to play (RTP) and risk of repeat concussion in collegiate football players have changed over the past 15 years.

METHODS

We analysed data on reported duration of symptoms, symptom-free waiting period (SFWP), RTP and occurrence of within-season repeat concussion in collegiate football players with diagnosed concussion from the NCAA Study (n=184) and CARE (n=701).

RESULTS

CARE athletes had significantly longer symptom duration (CARE median=5.92 days, IQR=3.02-9.98 days; NCAA median=2.00 days, IQR=1.00-4.00 days), SFWP (CARE median=6.00 days, IQR=3.49-9.00 days; NCAA median=0.98 days, IQR=0.00-4.00 days) and RTP (CARE median=12.23 days, IQR=8.04-18.92 days; NCAA median=3.00 days, IQR=1.00-8.00 days) than NCAA Study athletes (all p<0.0001). In CARE, there was only one case of repeat concussion within 10 days of initial injury (3.7% of within-season repeat concussions), whereas 92% of repeat concussions occurred within 10 days in the NCAA Study (p<0.001). The average interval between first and repeat concussion in CARE was 56.41 days, compared with 5.59 days in the NCAA Study (M difference=50.82 days; 95% CI 38.37 to 63.27; p<0.0001).

CONCLUSION

Our findings indicate that concussion in collegiate football is managed more conservatively than 15 years ago. These changes in clinical management appear to have reduced the risk of repetitive concussion during the critical period of cerebral vulnerability after sport-related concussion (SRC). These data support international guidelines recommending additional time for brain recovery before athletes RTP after SRC.

Sport-Related Concussion in Children and Adolescents

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.

Pediatric Traumatic Brain Injury and Concussion

PURPOSE OF REVIEW

This article summarizes the impact and complications of mild traumatic brain injury and concussion in children and outlines the recent evidence for its assessment and early management. Useful evidence-based management strategies are provided for children who have a typical recovery following concussion as well as for those who have persistent postconcussion syndrome. Cases are used to demonstrate the commonly encountered pathologies of headache, cognitive issues, and mood disturbances following injury.

RECENT FINDINGS

A clinical risk score using risk factors for poor recovery (eg, female sex, adolescence, previous migraine, and a high degree of acute symptoms) can be used to help the clinician plan follow-up in the community. Prolonged periods of physical and cognitive rest should be avoided. Multidisciplinary treatment plans are often required in the management of persistent postconcussion syndrome.

SUMMARY

A paucity of research exists for the treatment of postconcussion syndrome. Current treatments target individual symptoms.

Post-concussion recovery in children and adolescents: A narrative review

Objectives

To determine if current evidence supports a slower recovery from concussion in children and adolescents when compared to adults, and to assess current management guidelines in view of this evidence.

Design

Narrative review.

Methods

We examined key recent research studies relating to the question “do children take longer to recover from concussion than adults?” Concussion management strategies and a sample of guidelines from different organisations were analysed in view of the current literature.

Results

Recovery has been defined as return to baseline on self-reported concussion symptoms or measures of cognitive deficit. Some studies have compared measures of recovery between children and young adults, and a number of cross-sectional studies have compared groups of children of different ages. The findings varied; however, most studies suggested that children may take longer to recover than adults. Age-related differences have been considered when designing guidelines for the management of concussion.

Conclusions

In view of the differences in time to recovery in children, this review supports the use of more conservative concussion management guidelines in children than in adults.

Predictors of clinical recovery from concussion: a systematic review

OBJECTIVE

A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury.

DESIGN

Systematic review.

DATA SOURCES

PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus and Web of Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies published by June of 2016 that addressed clinical recovery from concussion.

RESULTS

A total of 7617 articles were identified using the search strategy, and 101 articles were included. There are major methodological differences across the studies. Many different clinical outcomes were measured, such as symptoms, cognition, balance, return to school and return to sports, although symptom outcomes were the most frequently measured. The most consistent predictor of slower recovery from concussion is the severity of a person's acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms-with greater risk for girls than boys.

CONCLUSION

The literature on clinical recovery from sport-related concussion has grown dramatically, is mostly mixed, but some factors have emerged as being related to outcome.

Rest and treatment/rehabilitation following sport-related concussion: a systematic review

AIM OR OBJECTIVE

The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded.

RESULTS

Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care.

SUMMARY/CONCLUSIONS

A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039570.