Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth

Exercise Intolerance After Mild Traumatic Brain Injury Occurs in All Subtypes in the Adult Population

Thematically grouped symptom clusters are present during the acute timeline of post-mild traumatic brain injuries (mTBI), representing clinical profiles called subtypes. Exercise intolerance has not been evaluated within the subtype classifications and, because guidelines support early submaximal aerobic exercise, further knowledge is required in regard to the exercise capabilities among the concussion subtypes. This cross-sectional study (n = 78) aimed to characterize the presence of exercise intolerance within the clinical subtypes and to explore performance on the Buffalo Concussion Treadmill Test (BCTT) in the adult subacute (2-12 weeks post-injury) mTBI population. All participants were evaluated using the BCTT to determine exercise tolerance. We first used the Neurobehavioral Symptom Inventory (NSI) questionnaire to assign each participant a primary subtype(s). To further explore all five subtypes (headache, cognitive, vestibular, ocular motor, and mood), participants were assessed using a multitude of thematically grouped assessments including self-reported questionnaires, clinical tests of vestibular and ocular motor function, balance function, and computerized cognitive testing. Thirty-seven (47%) subjects were exercise tolerant and 41 (53%) were exercise intolerant. There was no difference in the distribution of primary subtypes between the exercise tolerant and exercise intolerant groups. In addition, no significant differences were found between the exercise tolerant and exercise intolerant groups on other thematically grouped subtype assessments. The exercise intolerant group had a significantly higher resting heart rate (HR), lower percentage of age-predicted maximum HR achieved, lower Borg Rate of Perceived Exertion (RPE), and could walk on the treadmill for less time (lower duration) compared with the exercise tolerant group. The current findings suggest that exercise intolerance is common and pervasive across all five mTBI subtypes. A comprehensive mTBI assessment should include evaluation for exercise intolerance regardless of the primary clustering of symptoms and across patient populations. Therefore, early referral to physical therapists, athletic trainers, or medical clinics that can perform the BCTT may be helpful to initiate appropriate exercise prescriptions for patients with mTBI.

Physical activity and recovery following concussion in collegiate athletes: a LIMBIC MATARS Consortium Investigation

OBJECTIVE

To investigate whether routine daily activities (RDA), non-prescribed exercise (Non-ERx), or prescribed exercise (ERx) were associated with recovery from sport-related concussion (SRC) in collegiate athletes.

MATERIALS AND METHODS

Data for this cross-sectional, retrospective chart review of collegiate athletes diagnosed with SRC (n = 285[39.6% female], age = 19.5 ± 1.4 years) were collected during the 2015-16 to 2019-20 athletic seasons. The independent variable was group (RDA, Non-ERx, ERx). Dependent variables included days from date of diagnosis to symptom resolution (Dx-SR) and SR to return to sport (SR-RTS).

RESULTS

Those in the Non-ERx group took nearly 1.3 times longer to achieve SR (IRR = 1.28, 95% CI: 1.11, 1.46) and, 1.8 times longer for RTS (IRR = 1.82, 95% CI: 1.11, 2.71) when compared to those in the RDA group. No other comparisons were significant.

CONCLUSION

Collegiate athletes in the Non-ERx group took approximately 1 week longer to achieve SR as compared to the RDA and ERx groups. Our findings suggest that if exercise is recommended following SRC, it must be clearly and specifically prescribed. If exercise parameters cannot be prescribed, or monitored, RDA appear to be similarly beneficial during recovery for collegiate athletes with concussion.

Brain changes: aerobic exercise for traumatic brain injury rehabilitation

Introduction

Traumatic Brain Injury (TBI) accounts for millions of hospitalizations and deaths worldwide. Aerobic exercise is an easily implementable, non-pharmacological intervention to treat TBI, however, there are no clear guidelines for how to best implement aerobic exercise treatment for TBI survivors across age and injury severity.

Methods

We conducted a PRISMA-ScR to examine research on exercise interventions following TBI in children, youth and adults, spanning mild to severe TBI. Three electronic databases (PubMed, PsycInfo, and Web of Science) were searched systematically by two authors, using keywords delineated from "Traumatic Brain Injury," "Aerobic Exercise," and "Intervention."

Results

Of the 415 papers originally identified from the search terms, 54 papers met the inclusion criteria and were included in this review. The papers were first grouped by participants' injury severity, and subdivided based on age at intervention, and time since injury where appropriate.

Discussion

Aerobic exercise is a promising intervention for adolescent and adult TBI survivors, regardless of injury severity. However, research examining the benefits of post-injury aerobic exercise for children and older adults is lacking.

Efficacy of aerobic exercise following concussion: a narrative review

Concussion is a type of mild traumatic brain injury which results in symptoms within the physical, cognitive, emotional, and sleep domains. Historically, guidelines established by expert opinion have recommended rest during the initial stages of recovery following a concussion until symptom resolution. However, recent recommendations have shifted to advise an initial period of 24-48 h of rest immediately following concussion with the gradual introduction of light-to-moderate intensity aerobic exercise thereafter. Given the relatively recent transition in recommendations, the aim of this review is to provide an overview of the current literature on the efficacy of aerobic exercise following concussion. The current literature is limited to studies assessing the impact of standardized aerobic exercise following concussion. Upon review, literature suggests participating in aerobic exercise below the point of symptom exacerbation is safe in both the acute and chronic post-concussion symptom stages of recovery and does not delay time to medical clearance. Future large-scale randomized controlled trials assessing the impact of aerobic exercise and differences between males and females would help support the current evidence suggesting aerobic exercise could improve time to recovery following concussion and identify any sex differences in response. As well, future studies with the purpose of identifying optimal aerobic exercise volume and intensity in the treatment of concussion could improve the specificity of the current guidelines.

Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial

BACKGROUND

Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents.

OBJECTIVE

To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response.

METHODS

This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days.

CONCLUSION

Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.

Adolescent and Parent Perceptions of the Impact of Concussion/mTBI on Family Functioning and Activity Levels in Recovery

OBJECTIVE

To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery.

SETTING

Outpatient research setting.

PARTICIPANTS

Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study.

DESIGN

Prospective ecological study with qualitative, semistructured interviews.

MAIN MEASURES

Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures.

RESULTS

Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies.

CONCLUSIONS

Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions.

Mobile Subthreshold Exercise Program (MSTEP) for concussion: study protocol for a randomized controlled trial

BACKGROUND

Subthreshold exercise, defined as aerobic exercise below the level that causes symptoms, has been utilized as a treatment for youth with persistent postconcussive symptoms (PPCS), but there is currently little evidence to guide use. In addition, prior studies of exercise for PPCS have all required multiple in-person visits. We developed a virtual approach for delivering subthreshold exercise to youth with PPCS called the Mobile Subthreshold Exercise Program (MSTEP), and we have now been funded to conduct a large national randomized controlled trial (RCT) to test its efficacy for reducing concussive symptoms and improving health-related quality of life.

METHODS

This investigation is an RCT comparing MSTEP to an active control. We will recruit 200 adolescents 11-18 years old with postconcussive symptoms persisting for at least 1 week but less than 1 year. Youth will be randomized to receive either 6 weeks of subthreshold exercise (MSTEP) or a stretching condition (control). Youth and parents will complete surveys of concussive symptoms at baseline, weekly during the intervention, and at 3 and 6 months. The primary outcomes will be trajectory of concussive symptoms and health-related quality of life over the 6 months of the study. Secondary outcomes will include depression, anxiety, and sleep quality. We will also assess potential mediators of treatment effects including moderate-vigorous physical activity and fear avoidance of concussive symptoms.

DISCUSSION

This multisite RCT of MSTEP will provide vital information regarding the efficacy of a virtually delivered subthreshold exercise program for youth with PPCS, and insight regarding potential mediators of treatment effects, including objectively measured physical activity and fear avoidance of concussive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04688255. Registered on December 29, 2020.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Physical Activity Following Sport-Related Concussion in Adolescents: A Systematic Review

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.

Neuropsychological and neuropsychiatric recovery from mild traumatic brain injury

PURPOSE OF REVIEW

Mild traumatic brain injury (mTBI) is a significant public health concern for children. This review summarizes recent literature on early symptoms and neuropsychiatric and neuropsychological outcomes following pediatric mTBI and highlights factors that predict prolonged recovery. Evidence-based recommendations for assessment and treatment are also discussed.

RECENT FINDINGS

Whereas most children recover within 1 month after mTBI, 10-30% of children experience lingering neuropsychiatric or neuropsychological symptoms 3 months or more after injury. For the subset who experience prolonged recovery, new or worsening emotional and behavioral symptoms are the most frequent concerns. Recent research has suggested that specific factors, including preinjury mental health concerns, female sex, and family characteristics, are associated with increased risk of experiencing prolonged recovery. Early management includes reassurance, brief rest (1-3 days), and gradual return to typical activities. When symptoms linger for more than 4 weeks, evaluation in a specialty clinic is recommended and multimodal therapies are considered. Active recovery models, which include gradual return to aerobic exercise and cognitive behavioral approaches, are promising for the management of prolonged symptoms.

SUMMARY

A minority of children with mTBI experience prolonged neuropsychiatric or neuropsychological concerns. While our understanding of pediatric mTBI is growing, and recommendations for assessment and management have been developed, many gaps remain.

The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis

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.

Physical Activity Interventions for Individuals With a Mild Traumatic Brain Injury:: A Scoping Review

OBJECTIVE

To document the characteristics, measured outcomes, and effectiveness of physical activity (PA) interventions designed to improve health-related outcomes in individuals with a mild traumatic brain injury (mTBI) to assist in rehabilitation quality improvement efforts of a TBI rehabilitation program.

METHODS

A scoping review following a 6-step iterative framework search across 5 databases (MEDLINE, CINAHL, PsycINFO, SPORTDiscuss, and EMBASE) and the gray literature (Google) was performed. Selected PA interventions were designed for individuals of all ages and any mechanism of injury (eg, sports-related and falls). Data were charted, collated, and summarized according to the Consensus on Exercise Reporting Template checklist and domains of the International Classification of Functioning, Disability and Health. Involvement of clinical experts ensured tailoring of the knowledge synthesis to meet clinical needs.

RESULTS

Thirty-five articles and 14 gray literature records were retained. Five types of PA interventions were identified with the majority being multimodal. Reporting of PA intervention characteristics was highly variable across studies; many details necessary for intervention replication are missing. Study outcomes focused primarily on improving body functions and symptoms of mTBI, and less frequently on activities, participation, and health-related quality of life. The methodological quality of studies varies.

CONCLUSIONS

Identified PA intervention types offer various management options for healthcare providers. PA interventions may improve a wide range of health-related outcomes supporting the inclusion of PA in the management of individuals of all ages with mTBI. Higher-quality research and better reporting about intervention characteristics is however needed.

Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms

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.

Concussion Management Practices for Youth Who Are Slow to Recover: A Survey of Canadian Rehabilitation Clinicians

Purpose: The objective of this study was to estimate the scope of concussion management practices for youth used by Canadian rehabilitation clinicians. A secondary objective was to determine the use of aerobic exercise as a management strategy. Method: Members of the Canadian Association of Occupational Therapists, Canadian Athletic Therapists Association, and Canadian Physiotherapy Association were invited to participate in an online cross-sectional survey. Two clinical vignettes were provided with a brief history. The respondents were asked about the type of treatments they would provide (e.g., manual therapy, education, aerobic exercise, return-to-learn or return-to-play protocol, goal setting). Results: The survey was completed by 555 clinicians. The top five treatment options were education, sleep recommendations, goal setting, energy management, and manual therapy. Just more than one-third of the clinicians prescribed aerobic exercise. Having a high caseload of patients with concussion (75%-100%) was a significant predictor of prescribing aerobic exercise. Conclusions: A wide variety of treatment options were selected, although the most common were education, sleep recommendations, energy management, and goal setting. Few clinicians used aerobic exercise as part of their concussion management strategy.

Treatment of non-sports related concussion in adolescents following an irritability algorithmic approach: a case series

Background: Concussion management evidence supports the efficacy of gradual active rehabilitation for return to sport in adolescents, however there is paucity of evidence for non-sports-related concussion management.Purpose: The purpose of this case series is to describe the feasibility and practicality of an irritability-based step-by-step model to guide rehabilitation.Case Descriptions: Three adolescent patients diagnosed with concussion during a non-sports related event are described. Each adolescent was classified as high, moderate, or low irritability level based on symptom exacerbation with Vestibular/Ocular-Motor Screening (VOMS), physical exertion based on age-predicted maximum heart rate, and cervicogenic factors. Each Patient's intervention was progressed following the proposed irritability-based algorithm.Outcomes: Patients were assessed using the Brain Injury Functional Status Patient-Reported Outcome Measure, VOMS testing, and a Numeric Pain Rating Scale. Concluding each plan of care, all patients met or exceeded the minimal clinically important difference for age, gender, and risk-adjusted predicted measure on all outcome assessments. All patients returned to school and age-appropriate activities without symptom exacerbation.Conclusion: An irritability-based algorithm model for non-sports-related concussion management may be a practical and feasible treatment approach for adolescents.

Sports-Related Concussions and the Pediatric Patient

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.

Feasibility of Early Active Rehabilitation for Concussion Recovery in Youth: A Randomized Trial

OBJECTIVE

The primary objective is to evaluate the feasibility (safety and acceptability) of implementing early active rehabilitation (AR) for concussion management in youth with symptoms persisting 2 weeks after injury. A secondary and exploratory objective was to estimate the potential efficacy of early AR compared with standard AR. We hypothesize that AR at 2-weeks postconcussion will be safe and acceptable to patients.

DESIGN

Randomized clinical trial.

SETTING

The Montreal Children's Hospital of the McGill University Health Center (MCH-MUHC), a tertiary care pediatric teaching hospital affiliated with McGill University in Montreal, Canada.

PARTICIPANTS

Twenty youth aged 9 to 17 years old with postconcussion symptoms for at least 2 weeks.

INTERVENTION

Active rehabilitation (aerobic exercise, coordination drills, visualization, and education/reassurance) was administered by physiotherapists in-person, and then continued as a home program.

METHODS

Twenty participants were randomized to either early AR (initiated 2 weeks after injury) or standard AR (initiated 4 weeks after injury).

RESULTS

Two adverse events (one in each group) were identified through an online survey more than one-month postconcussion. Postconcussion symptoms decreased over time for both groups.

CONCLUSIONS

The results from this pilot study indicate that a full clinical trial estimating the efficacy of early AR (starting 2 weeks after injury) is feasible. Further study is needed to determine the superiority of this strategy over current treatment approaches.

Mood-related changes in children and adolescents with persistent concussion symptoms following a six-week active rehabilitation program

PRIMARY OBJECTIVE

The purpose of this study is to explore changes in mood in youth with persistent post-concussion symptoms following participation in a six-week active rehabilitation program.

RESEARCH DESIGN

A pre-post test design was used.

METHODS AND PROCEDURES

Participants (N = 40 children and adolescents with concussion symptoms >2 weeks post-injury) were recruited from the concussion services at an urban children's rehabilitation hospital and the community. The program consisted of individualized low-intensity aerobic exercise, sport-specific drills, relaxation exercises and comprehensive education and support. The 6 week program was completed by participants in their home or local community with weekly check-ins with the research team. Data were analyzed using descriptive statistics and linear regressions.

MAIN OUTCOMES AND RESULTS

Outcome measures included the Beck Youth Inventories (youth), and the Child Behavior Checklist (parents). Results indicated significant improvements in anger and anxiety post-intervention with anger reduction being more pronounced in girls.

CONCLUSIONS

Active rehabilitation interventions may have positive effects on mood in youth recovering from concussion. Clinicians may wish to consider addressing anxiety and anger management strategies as part of comprehensive concussion management in youth.

Early Aerobic Exercise for the Treatment of Acute Pediatric Concussions

Sport-related concussion is a common injury that has garnered the attention of the media and general public because of the potential for prolonged acute symptoms and increased risk for long-term impairment. Currently, a growing body of evidence supports the use of various therapies to improve recovery after a concussion. A contemporary approach to managing concussion symptoms is to use aerobic exercise as treatment. To date, several studies on both pediatric and adult patients have established that controlled aerobic exercise is a safe and effective way to rehabilitate patients experiencing delayed recovery after concussion. However, less is known about the utility of an early exercise protocol for optimizing recovery after acute concussion and reducing the risk for persistent postconcussive symptoms, particularly in pediatric populations. Thus, the purpose of our paper was to review and evaluate the available literature on the implementation of aerobic exercise for the treatment of acute pediatric concussion.

The Role of Aerobic Exercise in Reducing Persistent Sport-related Concussion Symptoms

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.

Methodology and Implementation of a Randomized Controlled Trial (RCT) for Early Post-concussion Rehabilitation: The Active Rehab Study

Background: Sports-related concussion (SRC) is a complex injury with heterogeneous presentation and management. There are few studies that provide guidance on the most effective and feasible strategies for recovery and return to sports participation. Furthermore, there have been no randomized studies of the feasibility, safety, and efficacy of early rehabilitation strategies across multiple sports and age groups. This international cluster-randomized pragmatic trial evaluates the effectiveness of early multi-dimensional rehabilitation integrated with the current return to sport strategy vs. the current return to sport strategy alone.

Methods: The study is a cluster-randomized pragmatic trial enrolling male and female athletes from 28 sites. The sites span three countries, and include multiple sports, levels of play (high school, college, and professional), and levels of contact. The two study arms are Enhanced Graded Exertion (EGE) and Multidimensional Rehabilitation (MDR). The EGE arm follows the current return to sport strategy and the MDR arm integrates early, MDR strategies in the context of the current return to sport strategy. Each arm employs a post-injury protocol that applies to all athletes from that site in the event they sustain a concussion during their study enrollment. Participants are enrolled at pre-season baseline. Assessment timepoints include pre-season baseline, time of injury (concussion), 24–48 h post-injury, asymptomatic, and 1-month post-injury. Symptoms and activity levels are tracked post injury through the return to play process and beyond. Injury and recovery characteristics are obtained for all participants. Primary endpoints include time to medical clearance for full return to sport and time to become asymptomatic. Secondary endpoints include symptom, neurocognitive, mental status, balance, convergence insufficiency, psychological distress, and quality of life trajectories post-injury.

Discussion: Outputs from the trial are expected to inform both research and clinical practice in post-concussion rehabilitation across all levels of sport and extend beyond civilian medicine to care for military personnel.

Ethics and Dissemination: The study is approved by the data coordinating center Institutional Review Board and registered at clinicaltrials.gov. Dissemination will include peer-reviewed publications, presentation to patients and public groups, as well as dissemination in other healthcare and public venues of interest.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02988596

Trial Funding: National Football League.

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

OBJECTIVE

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

DESIGN

Quasi-experimental design.

SETTING

University sports medicine centers.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Pilot Randomized Controlled Trial of an Exercise Program Requiring Minimal In-person Visits for Youth With Persistent Sport-Related Concussion

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance. Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12-18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group. Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57% female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group. Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

Posttraumatic headache in pediatrics: an update and review

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.

Active recovery from concussion

PURPOSE OF REVIEW

Recent studies are challenging the utility of prolonged rest as treatment for concussion and postconcussion syndrome (PCS). The purpose of this paper is to review the evidence for active recovery from concussion and PCS.

RECENT FINDINGS

Emerging data identify the central role of autonomic nervous system (ANS) dysfunction in concussion pathophysiology. The exercise intolerance demonstrated by athletes after sport-related concussion may be related to abnormal ANS regulation of cerebral blood flow. As aerobic exercise training improves ANS function, sub-symptom threshold exercise treatment is potentially therapeutic for concussion. A systematic assessment of exercise tolerance using the Buffalo Concussion Treadmill Test has been safely employed to prescribe a progressive, individualized subthreshold aerobic exercise treatment program that can return patients to sport and work. Multiple studies are demonstrating the efficacy of an active approach to concussion management.

SUMMARY

Sustained rest from all activities after concussion, so-called 'cocoon therapy', is not beneficial to recovery. Evidence supports the safety, tolerability, and efficacy of controlled sub-symptom threshold aerobic exercise treatment for PCS patients. Further study should determine the efficacy and optimal timing, dose, and duration of subthreshold aerobic exercise treatment acutely after concussion because early intervention has potential to prevent PCS.

Design of an early intervention for persistent post-concussion symptoms in adolescents and young adults: A feasibility study

BACKGROUND

About 5-15 % of patients with concussion experience persistent post-concussion symptoms (PCS) longer than 3 months post-injury.

OBJECTIVE

To explore the feasibility of a new intervention for young patients with persistent PCS and long-term changes after intervention.

METHODS

Thirty-two consecutive patients (15-30 years) with persistent PCS 2-4 months post-injury were recruited from a cohort study or referred to a non-randomized feasibility study of an individually tailored, 8-week, multidisciplinary intervention. Assessment was performed at baseline, end of intervention (EOI), and at 3- and 12-month follow-up (FU). Main measures were The Experience of Service Questionnaire (ESQ), Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and The Quality of Life after Brain Injury - Overall Scale (QOLIBRI-OS).

RESULTS

Twenty-three (72%) patients completed the intervention. The ESQ demonstrated high patient satisfaction. There was a decrease of PCS and an increase in quality of life from baseline to EOI: RPQ score -8.9 points, 95% CI 4.5 to 13.3, p < 0.001; QOLIBRI-OS score +10.5 points, 95% CI 2.5 to 18.5, p = 0.010. Improvement was maintained at 3- and 12-month FU.

CONCLUSION

The new early intervention is feasible and may prevent chronification of PCS. An RCT is currently performed to evaluate the effect of the intervention.

Exercise is Medicine for Concussion

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.

Subsymptomatic Aerobic Exercise for Patients With Postconcussion Syndrome: A Critically Appraised Topic

Clinical Scenario: Patients who experience prolonged concussion symptoms can be diagnosed with postconcussion syndrome (PCS) when those symptoms persist longer than 4 weeks. Aerobic exercise protocols have been shown to be effective in improving physical and mental aspects of health. Emerging research suggests that aerobic exercise may be useful as a treatment for PCS, where exercise allows patients to feel less isolated and more active during the recovery process. Clinical Question: Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies relevant to the clinical question were selected. Of the 4 studies, 1 study was a randomized control trial and 3 studies were case series. All 4 studies investigated aerobic exercise protocol as treatment for PCS. Three studies demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled subsymptomatic aerobic exercise program. One study showed a decrease in symptoms in the aerobic exercise group compared with the full-body stretching group. Clinical Bottom Line: There is moderate evidence to support subsymptomatic aerobic exercise as a treatment of PCS; therefore, it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill test, Balke protocol, or rating of perceived exertion, as mentioned in this critically appraised topic, should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that the aerobic exercise protocol is more effective than the current standard of care in treating PCS.

Non-pharmacological rehabilitation interventions for concussion in children: a scoping review

PURPOSE

To summarise the extent, nature, and quality of current scholarly literature related to non-pharmacological, rehabilitation interventions following concussion, or mild traumatic brain injury in children.

METHODS

An electronic search was conducted from 1987 to 24 October 2017. Studies were included if they met the following criteria: (1) full text, peer reviewed, and written in English, (2) original research, (3) diagnosed concussion or mild traumatic brain injury, (4) described the evaluation of an intervention, (5) the outcome was a concussion impairment, and (6) the mean/median age was under 19. Quality assessment using the Down's and Black criteria was conducted.

RESULTS

Twenty-six studies published between 2001 and 2017 were identified. Interventions included rest, active rehabilitation, exercise, vestibular, oculomotor, cervicospinal therapy, education, early intervention, telephone counselling, mobile health application, Web-based Self-Management program, multimodal physical therapy, cognitive behavioural therapy, transcranial direct current stimulation, and acupuncture. The quality assessments ranged from poor to good.

CONCLUSIONS

The literature describing interventions following concussion in children is scarce. While both positive and negative results were obtained, there were methodological concerns in most studies limiting the ability to draw conclusions. Interventions incorporating aerobic exercise show promise as a concussion management strategy. Implications for rehabilitation Few studies have examined rehabilitation interventions for youth following concussion. Research ranging from rest to exercise highlights the uncertainty of the field. Low quality research limits the generalizability of results. The use of physical activity appears to be an emerging area of interest. Individualised, aerobic exercise should be used as part of clinical management.

Psychiatric Sequelae of Concussions

PURPOSE OF REVIEW

The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations.

RECENT FINDINGS

Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.