Effect of Exercise Recommendation on Adolescents With Concussion

Changes in Physician Recommendations for Early Physical Activity After Pediatric Concussion: A Retrospective Study

OBJECTIVES

This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations.

DESIGN

Retrospective observational study.

SETTING

Concussion clinics associated with a pediatric hospital.

PATIENTS

Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed.

INDEPENDENT VARIABLES

The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities).

MAIN OUTCOME MEASURES

Physician PA recommendations.

RESULTS

From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% ( P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury ( P < 0.05). A significantly increased odds of recommending "light activity" (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and "noncontact PA" (OR = 2.21, 95% CI, 1.28-2.05), compared with "no activity" within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending "light activity" or "noncontact PA."

CONCLUSIONS

Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted.

The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients

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).

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

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.

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Active Rehabilitation Following Acute Mild Traumatic Brain Injury: A Systematic Review

Purpose:

Following mild traumatic brain injury (mTBI), patients are often advised to restrict physical activity until full symptom resolution followed by gradual return to activity. However, extended rest periods may prolong recovery and contribute to persistent symptoms. Emerging evidence suggests early active rehabilitation that increases heart rate without exacerbating symptoms may improve mTBI patient recovery. This review aims to: (1) appraise evidence on active rehabilitation intervention for mTBI recovery within one-month of injury (i.e., exercise type, duration, intensity, etc.); and (2) recommend evidence-based rehabilitation protocols.

Method:

Pubmed, CINAHL, PsychARTICLES, SportDISCUS, and AMED databases were searched using key terms “mild Traumatic Brain Injury”, “Rehabilitation”, “Acute”, and their synonyms. Evidence was appraised using Cochrane RoB-2 and ROBINS-I.

Results:

434 citations were initially identified with seven papers systematically reviewed. Within the reviewed articles, only three were randomized controlled trials with low risk of bias, and four were non-randomized trials with low to moderate risk of bias. Findings highlighted that a range of active rehabilitation protocols were used with different exercise modalities (primarily treadmills and static cycling), durations (9–20 min, or until symptomatic, for 30–50 days or symptoms resolved), and intensities (low, moderate or high). Active rehabilitation did not cause any serious adverse events (i.e., death, hospitalisation etc.), and six studies reported that it did not exacerbate mTBI symptoms in any participants (with one participant having symptom worsening in one study). Overall, the majority of reviewed studies ( n = 4) showed that active rehabilitation decreased time to mTBI symptom resolution compared to controls (strict rest/stretching exercises).

Conclusions:

Individualized active rehabilitation prescribed within one-month post-mTBI appears to be safe and effective at decreasing recovery time to symptom resolution in mTBI. However, there is a lack of consensus regarding specific intervention protocols that needs to be addressed before adoption within clinical practice.

Wirksamkeit manualtherapeutischer Techniken in Kombination mit vestibulärer Rehabilitation nach sportbedingten Gehirnerschütterungen – Eine systematische Übersichtsarbeit randomisiert kontrollierter Studien

Hintergrund Die Rehabilitation nach leichter, sportbedingter Gehirnerschütterung erfordert eine komplexe Behandlung unter Berücksichtigung der muskuloskelettalen, insbesondere zervikogenen, und vestibulären Beteiligung. Das empfohlene Rehabilitationskonzept der vollständigen Ruhe bis zur Beschwerdefreiheit wird inzwischen neu bewertet. Aktuelle Studien deuten auf positive Auswirkungen einer frühen Mobilisierung und multimodaler Physiotherapie hin. Der medizinische Nutzen ausgewählter manualtherapeutischer Techniken wird in mehreren klinischen Studien untersucht. Bisher konnten jedoch keine eindeutigen Empfehlungen für manualtherapeutische Techniken nach einer Gehirnerschütterung ausgesprochen werden.

Ziel Analyse und Zusammenfassung vorhandener randomisiert kontrollierter Studien (RCTs) zur Untersuchung der Wirksamkeit manualtherapeutischer Techniken in Kombination mit vestibulärer Rehabilitation auf Symptomfreiheit und Wiedererlangung der sportlichen Belastbarkeit bei Patienten nach sportbedingten Gehirnerschütterungen.

Methode Systematische Recherche in den Datenbanken ClinicalTrials.gov, WHO-ICTRP, EBSCO, PubMed und PEDro mit den Suchbegriffen concussion, physiotherapy, manual therapy und mild traumatic brain injury. Eingeschlossen wurden RCTs zur Untersuchung manualtherapeutischer Techniken nach sportbedingten Gehirnerschütterungen oder milden Formen eines Schädelhirntraumas. Die Bewertung der methodischen Qualität erfolgte Anhand der PEDro-Skala.

Ergebnisse Publikationen zu 2 RCTs mit guter und moderater methodischer Qualität (PEDro-Skala: 7–8/10 Punkten) sowie eine Folgestudie wurden inkludiert. Als primärer Outcome-Parameter wurde in allen Studien der Zeitraum der ärztlichen Freigabe zur Rückkehr zum Sport angegeben. Sekundäre Outcome-Parameter bezogen sich auf Symptomfreiheit, Postconcussion Scale, Numeric Pain Rating Scale, Balance Confidence Scale, Dizziness-Handicap-Index, Sport Concussion Assessment Tool 2 und Joint-Position-Error-Test. Die Ergebnisse aller inkludierten Studien ergaben signifikante Unterschiede zugunsten der Interventionsgruppen. Die eingeschlossenen klinischen Studien waren jedoch in Bezug auf Design, Methodik und Auswahl der Techniken heterogen, was einen direkten Vergleich erschwerte.

Schlussfolgerung Abgeschlossene klinische Studien deuten darauf hin, dass manualtherapeutische Techniken als Teil eines multimodalen Rehabilitationsprogramms nach Gehirnerschütterungen und leichten Schädelhirntraumata von Nutzen sein können. Aufgrund der geringen Anzahl an RCTs und deren heterogenen Studiendesigns ist eine Bewertung der Wirksamkeit spezifischer manualtherapeutischer Techniken derzeit nicht möglich. Weitere hochwertige Studien sind erforderlich.