Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study.

OBJECTIVE: The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision-making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision-making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision-making of experienced physical therapists who treat individuals with concussion. METHODS: This grounded theory approach used semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for postconcussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was used to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness. RESULTS: Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision-making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patients' needs; and listening and observing. Clinician decision-making statements showed alignment with clinical practice guideline recommendations. CONCLUSION: Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes. IMPACT: Identified themes may broaden frameworks and guidelines for the management of individuals postconcussion specific to the field of physical therapy.

The Efficacy of Vestibular Rehabilitation Therapy for Mild Traumatic Brain Injury: A Systematic Review and Meta-analysis.

OBJECTIVE: Mild traumatic brain injury (mTBI) or concussion is a common yet undermanaged and underreported condition. This systematic review and meta-analysis aim to determine the efficacy of vestibular rehabilitation therapy (VRT) as a treatment option for mTBI. METHOD: This review and meta-analysis was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. It included randomized controlled trials and pre-VRT/post-VRT retrospective chart reviews. Records meeting the inclusion criteria were extracted from the following databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). RESULTS: Eight articles met the inclusion criteria, from which 6 randomized controlled trials were included in the meta-analysis. VRT demonstrated significant improvement in decreasing perceived dizziness at the end of the intervention program as shown by Dizziness Handicap Inventory (DHI) scores (standardized mean difference [SMD] = -0.33, 95% confidence interval [CI]: -0.62 to -0.03, P = .03, I2 = 0%). However, no significant reduction in DHI was evident after 2 months of follow-up (SMD = 0.15, 95% CI: -0.23 to 0.52, P = .44, I2 = 0%). Quantitative analysis also depicted significant reduction in both Vestibular/Ocular Motor Screening (SMD = -0.40, 95% CI: -0.60 to -0.20, P < .0001, I2 = 0%) and Post-Concussion Symptom Scale (SMD= -0.39, 95% CI: -0.71 to -0.07, P = .02, I2 = 0%) following the intervention. Finally, there was no significant difference between intervention groups on Balance Error Scoring System scores (SMD = -31, 95% CI: -0.71 to 0.10, P = .14, I2 = 0%) and return to sport/function (95% CI: 0.32-30.80, P = .32, I2 = 82%). CONCLUSIONS: Current evidence on the efficacy of VRT for mTBI is limited. This review and analysis provides evidence that supports the role of VRT in improving perceived symptoms following concussion. Although findings from this analysis suggest positive effects of VRT on included outcomes, the low certainty of evidence limits the conclusions drawn from this study. There is still a need for high-quality trials evaluating the benefit of VRT using a standardized approach.PROSPERO registration number: CRD42022342473.

Interdisciplinary rehabilitation for persisting post-concussion symptoms after mTBI: N=15 single case experimental design.

BACKGROUND: Despite clinical guidelines recommending an interdisciplinary approach to persisting post-concussion symptom (PPCS) management, evaluations of interdisciplinary interventions remain scant. OBJECTIVES: This pilot study aimed to explore the feasibility and preliminary efficacy of an interdisciplinary intervention for PPCSs. METHOD: A single-case experimental design with randomisation to multiple baselines (2, 4, or 6 weeks) was repeated across 15 participants (53% female) with mild traumatic brain injury (mean age 38.3 years, SD 15.7). The 12-week treatment incorporated psychology, physiotherapy, and medical interventions. Feasibility outcomes included recruitment and retention rates, adverse events, treatment adherence and fidelity. Patient-centred secondary outcomes included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), assessed 3 times per week during the baseline and treatment phases, and at the 1- and 3-month follow-ups. Other secondary outcomes included measures of mood, sleep and fatigue, physical functioning, health-related quality of life, illness perceptions, and goal attainment. Changes in PPCSs were evaluated using systematic visual analysis and Tau-U. Clinically significant changes in secondary outcomes were explored descriptively. RESULTS: 16/26 individuals assessed for eligibility were enroled (61% recruitment rate); 15 completed the post-treatment follow-ups, and 13 completed the 1- and 3-month follow-up assessments (81% retention rate). High treatment adherence and competence in delivering treatments was observed. Moderate-large effect sizes for reducing PPCSs were observed in 12/15 cases, with 7/15 reaching statistical significance. Improvements were maintained at the 1- and 3-month follow-ups and were accompanied by reductions in fatigue, sleep difficulties, and mood symptoms, and changes in illness perceptions. All participants had clinically significant improvements in at least 1 outcome, with 81% of individual therapy goals achieved. CONCLUSIONS: This pilot study provided preliminary support for a subsequent randomised controlled trial (RCT), with satisfactory recruitment, retention, treatment compliance, and treatment fidelity. Improvement was evident on participant outcomes including symptom reduction and goal attainment, suggesting that progressing to a phase-II RCT is worthwhile. Findings highlight the potential benefit of individualized interdisciplinary treatments.

Autonomic dysfunction and exercise intolerance in concussion: a scoping review.

PURPOSE: Concussion commonly results in exercise intolerance, often limiting return to activities. Improved understanding of the underlying mechanisms of post-concussive exercise intolerance could help guide mechanism-directed rehabilitation approaches. Signs of altered cardiovascular autonomic regulation-a potential contributor to exercise intolerance-have been reported following concussion, although it is not clear how these findings inform underlying mechanisms of post-concussive symptoms. Systematic summarization and synthesis of prior work is needed to best understand current evidence, allowing identification of common themes and gaps requiring further study. The purpose of this review was to (1) summarize published data linking exercise intolerance to autonomic dysfunction, and (2) summarize key findings, highlighting opportunities for future investigation. METHODS: The protocol was developed a priori, and conducted in five stages; results were collated, summarized, and reported according to PRISMA guidelines. Studies including injuries classified as mild traumatic brain injury (mTBI)/concussion, regardless of mechanism of injury, were included. Studies were required to include both autonomic and exercise intolerance testing. Exclusion criteria included confounding central or peripheral nervous system dysfunction beyond those stemming from the concussion, animal model studies, and case reports. RESULTS: A total of 3116 publications were screened; 17 were included in the final review. CONCLUSION: There was wide variability in approach to autonomic/exercise tolerance testing, as well as inclusion criteria/testing timelines, which limited comparisons across studies. The reviewed studies support current clinical suspicion of autonomic dysfunction as an important component of exercise intolerance. However, the specific mechanisms of impairment and relationship to symptoms and recovery require additional investigation.

Research Letter: Long-Term Outcomes Following Cognitive Rehabilitation for Mild Traumatic Brain Injury: A 5-Year Follow-Up of a Cohort From the SCORE Randomized Clinical Trial.

OBJECTIVE: To examine the functioning of military service members 5 years after completing a randomized controlled trial (RCT) of cognitive rehabilitation for mild traumatic brain injury (mTBI). SETTING: Home-based telephonic interview and internet-based self-ratings. PARTICIPANTS: Sixty-nine of the 126 (55%) active-duty service members who were enrolled in a 4-arm RCT of cognitive rehabilitation 3 to 24 months after mTBI and were successfully contacted by phone 5 years later. Original and 5-year follow-up participants in each of 4 RCT treatment arms included: psychoeducation ( n = 32 original, n = 17 follow-up), computer ( n = 30 original, n = 11 follow-up), therapist-directed ( n = 30 original, n = 23 follow-up), integrated ( n = 34 original, n = 18 follow-up). DESIGN: Inception cohort evaluated 5 years after completion of an RCT of cognitive rehabilitation. MAIN MEASURES: Postconcussion symptoms (Neurobehavioral Symptom Inventory total score), psychological distress (Symptom Checklist-90-revised Global Severity Index score), and functional cognitive/behavioral symptoms (Key Behaviors Change Inventory total average score). RESULTS: Participants' postconcussive symptoms and psychological distress improved at the 5-year follow-up. Functional cognitive/behavioral symptoms were not significantly improved, but therapeutic gains were maintained across time, to 5 years after completing the RCT. CONCLUSION: In this sample of military personnel, postconcussive symptoms and psychological distress significantly improved from posttreatment to 5 years after cognitive rehabilitation, regardless of treatment arm. Functional cognitive/behavioral symptoms significantly improved with treatment while treatment gains were maintained at the 5-year follow-up. Replication of these results with a larger sample and interim data between 18 weeks and 5 years post-treatment is needed.

Vestibular Rehabilitation Effectiveness for Adults With Mild Traumatic Brain Injury/Concussion: A Mini-Systematic Review.

OBJECTIVE: Millions of people suffer from traumatic brain injuries every year with common sequelae, including dizziness, disequilibrium, compromised vision, and gait abnormalities. Individuals suffering a mild traumatic brain injury (mTBI) or concussion may be prescribed bed rest, but for some, symptoms may persist and require different treatment options. The aim of this mini-systematic review was to synthesize the best available evidence regarding the effectiveness of vestibular rehabilitation therapy (VRT) as a treatment option for adults with mTBIs. METHOD: A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search term concepts were VRT and mTBI. Records meeting the inclusion criteria were extracted from the following databases: PubMed and CINAHL. A manual search of reference lists identified additional studies. Inclusion criteria were (a) participants with mTBI/concussion characterized by dizziness, balance, and/or other vestibular symptoms; (b) VRT as the primary treatment; and (c) self-reported and/or performance-based outcome measures. Data were extracted using a standardized tool, and studies were critically appraised. RESULTS: Five studies were included in the systematic review: one randomized controlled trial, two retrospective chart reviews, one pre-/post-intervention study, and one case series. Four of the five studies found VRT to be effective at reducing postconcussion symptoms after head injury. Self-reported measures were included in all studies; performance-based measures were included in four out of five studies. None of the studies reported adverse effects of intervention. CONCLUSIONS: Results suggest VRT is an effective treatment option for patients with persistent/lingering symptoms after concussion/mTBI, as demonstrated by self-reported and performance-based outcome measures. Results of this study emphasize the need for audiologists to be thoroughly familiar with VRT as an effective treatment for patients with persistent symptoms following mTBI.

The benefits of exercise for outcome improvement following traumatic brain injury: Evidence, pitfalls and future perspectives.

Traumatic brain injury (TBI), also known as a silent epidemic, is currently a substantial public health problem worldwide. Given the increased energy demands following brain injury, relevant guidelines tend to recommend absolute physical and cognitive rest for patients post-TBI. Nevertheless, recent evidence suggests that strict rest does not provide additional benefits to patients' recovery. By contrast, as a cost-effective non-pharmacological therapy, exercise has shown promise for enhancing functional outcomes after injury. This article summarizes the most recent evidence supporting the beneficial effects of exercise on TBI outcomes, focusing on the efficacy of exercise for cognitive recovery after injury and its potential mechanisms. Available evidence demonstrates the potential of exercise in improving cognitive impairment, mood disorders, and post-concussion syndrome following TBI. However, the clinical application for exercise rehabilitation in TBI remains challenging, particularly due to the inadequacy of the existing clinical evaluation system. Also, a better understanding of the underlying mechanisms whereby exercise promotes its most beneficial effects post-TBI will aid in the development of new clinical strategies to best benefit of these patients.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation.

Importance: Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. Objective: To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. Data Sources: Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. Study Selection: A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury. Data Extraction and Synthesis: Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Main Outcomes and Measures: All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). Results: Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus. Conclusions and Relevance: Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial.

BACKGROUND: Sport-related concussion is a public health problem, particularly in adolescents. Quality of life is reduced in adolescents with persistent post-concussive symptoms (symptoms >28 days). We replicated a previous randomised controlled trial to validate the safety, efficacy, and generalisability of, and objective adherence to, prescribed early targeted heart rate subsymptom threshold aerobic exercise compared with placebo-like stretching exercise for adolescent recovery from sport-related concussion and for reducing the risk of persistent post-concussive symptoms. METHODS: This randomised controlled trial was done at three community and hospital-affiliated sports medicine concussion centres in the USA. Male and female adolescent athletes (aged 13-18 years) presenting within 10 days of sport-related concussion were randomly assigned to individualised subsymptom threshold aerobic or stretching exercise at least 20 min daily, for up to 4 weeks after injury. Exercise adherence and intensity were measured by heart rate monitors. The primary outcome was clinical recovery (ie, return to baseline symptoms, normal exercise tolerance, and a normal physical examination) within the 4-week intervention period, and development of persistent post-concussive symptoms beyond 28 days after injury. This study is registered with ClinicalTrials.gov, NCT02959216. FINDINGS: Between Aug 1, 2018, and March 31, 2020, 118 adolescents were recruited (61 were randomly assigned to the aerobic exercise group and 57 to the stretching exercise group) and included in the intention-to-treat analysis. On survival analysis, controlling for sex, site, and mean daily exercise time, patients assigned to aerobic exercise were more likely to recover within 4 weeks after injury compared with those assigned to stretching exercise, with a 48% reduced risk of persistent post-concussive symptoms (hazard ratio for stretching vs aerobic exercise of 0·52 [95% CI 0·28-0·97], p=0·039). No adverse events were reported. INTERPRETATION: This multicentre study found that early treatment with subsymptom threshold aerobic exercise safely speeds recovery from sport-related concussion and reduces the risk for persistent post-concussive symptoms, an important result given the impact of delayed recovery on adolescent quality of life. Adherence was good and there were no adverse events from this non-pharmacological treatment. These results suggest that physicians should not only permit, but consider prescribing, early subsymptom threshold physical activity to adolescents as treatment for sport-related concussion and to reduce the risk of persistent post-concussive symptoms. FUNDING: American Medical Society for Sports Medicine.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score.

BACKGROUND: Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. METHODS AND FINDINGS: Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. CONCLUSIONS: In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

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.

Management of unfavorable outcome after mild traumatic brain injury: Review of physical and cognitive rehabilitation and of psychological care in post-concussive syndrome.

INTRODUCTION: Mild Traumatic Brain Injury (mTBI) is a public health issue with approximately 42 million people worldwide affected yearly. Most patients have a favorable short-term recovery but 10-20% are likely to develop post-concussive syndrome (association of physical, cognitive, and psychological difficulties after injury). Post-concussive syndrome can be associated with Post-Traumatic Stress Disorder (PTSD). There is to date no recommendation on the interventions that could be done to reduce post-concussive syndrome. The present review aims at summarizing the effect of therapeutic education, physical and cognitive rehabilitation and of psychological care in mTBI patients with post-concussive syndrome. METHODS: In the current international literature, we investigated the effects of therapeutic education, physical and cognitive rehabilitation and of psychological care in this population using the Medline database and we discussed the results of these studies. RESULTS: The application of a therapeutic education intervention within 3 months after mTBI has been found appropriate and effective to prevent post-concussion syndrome in several studies but the timeline of this intervention differs among the existing studies. Concerning physical disabilities, several pharmacological, rehabilitative and non-pharmacological techniques have shown some efficacy in reducing headache and vertigo; rTMS seems also promising in this context. The management of fatigue is also crucial and requires a multidisciplinary approach. We did not find any intervention in mTBI patients with post-concussive syndrome suffering from dysosmia and/or dysgueusia. No pharmacological treatment is currently recommended to reduce the cognitive symptoms of post-concussive syndrome after mTBI. Rehabilitation and brain-stimulation techniques have already proven their efficacy to reduce the cognitive impairment in this population. Even if the use of Virtual Reality software seems well tolerated in this population, its efficacy and additional value needs to be demonstrated in larger studies. Concerning the psychological care after mTBI, Cognitive and Behavioral Therapy interventions are the most frequently reported in this population, followed by psychoeducational interventions. PTSD management seems crucial in overall recovery of patients with post-concussive syndrome. CONCLUSION: Many studies have sought to demonstrate the effectiveness of various rehabilitation techniques, including different cognitive rehabilitation programs, technology-assisted rehabilitation, different types of brain stimulation and some pharmacological treatments. However, most of these studies are of a low level of scientific evidence and it would be necessary to carry out well-conducted prospective randomized trials in order to offer an appropriate and effective multidisciplinary management for patients with post-concussive syndrome after mTBI.

Personal Factors Associated With Postconcussion Symptoms 3 Months After Mild Traumatic Brain Injury.

OBJECTIVE: To describe personal factors in patients with mild traumatic brain injury (MTBI) and 2 control groups and to explore how such factors were associated with postconcussion symptoms (PCSs). DESIGN: Prospective cohort study. SETTING: Level 1 trauma center and outpatient clinic. PARTICIPANTS: Participants (N=541) included patients with MTBI (n=378), trauma controls (n=82), and community controls (n=81). MAIN OUTCOME MEASURES: Data on preinjury health and work status, personality, resilience, attention deficit/hyperactivity, and substance use. Computed tomography (CT) findings and posttraumatic amnesia were recorded. Symptoms were assessed at 3 months with the British Columbia Postconcussion Symptom Inventory and labeled as PCS+ if ≥3 symptoms were reported or the total score was ≥13. Predictive models were fitted with penalized logistic regression using the least absolute shrinkage and selection operator (lasso) in the MTBI group, and model fit was assessed with optimism-corrected area under the curve (AUC) of the receiver operating characteristic curve. RESULTS: There were few differences in personal factors between the MTBI group and the 2 control groups without MTBI. Rates of PCS+ were 20.8% for the MTBI group, 8.0% for trauma controls, and 1.3% for community controls. In the MTBI group, there were differences between the PCS+ and PCS- group on most personal factors and injury-related variables in univariable comparisons. In the lasso models, the optimism-corrected AUC for the full model was 0.79, 0.73 for the model only including personal factors, and 0.63 for the model only including injury variables. Working less than full time before injury, having preinjury pain and poor sleep quality, and being female were among the selected predictors, but also resilience and some personality traits contributed in the model. Intracranial abnormalities on CT were also a risk factor for PCS. CONCLUSIONS: Personal factors convey important prognostic information in patients with MTBI. A vulnerable work status and preinjury health problems might indicate a need for follow-up and targeted interventions.

Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms.

Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion.Method: Adolescents aged 12-20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal.Results: Injury-related factors alone did not predict self-perceived recovery (R2Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R2Adj Change =.188, p <.05). Physical symptoms (Bstand = -.292) and anxiety (Bstand = -.260) accounted for the most variance in self-perceived recovery.Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents' experiences after concussion.

[Formula: see text] The role of family burden on informant discrepancies between parents and youths with protracted recovery from mild traumatic brain injury.

Previous literature shows that family burden can lead to symptom-report discrepancies between parents and children. The present study sought to extend this research by investigating the influence of family burden factors, including socioeconomic status (SES) and family stress on informant discrepancies between parents and youths with mild traumatic brain injury (mTBI). Participants were clinically referred youths with mTBI ages 8-17, consecutively seen in a hospital-based neuropsychology concussion clinic (N = 81; females = 54.3%). Parents and children completed the Behavioral Assessment for Children System (BASC) and the Postconcussive Symptom Scale (PCSS). Parents rated changes in family stress related to the mTBI (categorized as "no change," "minor change," or "major change") and provided information to calculate SES. Results revealed that family stress but not SES influenced parent-child report discrepancies for the BASC Internalizing Symptoms Index (F = 8.72(2, 79), p <.000), and that the discrepancies were independent of postconcussive symptom severity. Clinical implications of these findings are discussed.

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.

Daily Life Physical Activity and Concussion Symptoms in Adolescents.

BACKGROUND.: Concussion is a common injury in an adolescent population with up to 30% experiencing persistent symptoms. Rehabilitation programs that include aerobic exercises can reduce persistent postconcussion symptoms. However, it is unclear if daily life physical activities can also reduce symptoms. PURPOSE.: To investigate whether the level of daily life physical activity reduces postconcussion symptoms in the adolescent population. METHODS.: Ten adolescents aged 11-18 years with a concussion self-reported their postconcussion symptoms and level of physical activity during the first, third, and sixth months after injury. The extent to which physical activity explained postconcussion health was analyzed using linear mixed-effects modeling. FINDINGS.: Higher levels of daily life physical activity were associated with fewer somatic and cognitive symptoms. IMPLICATIONS.: These findings suggest that daily life physical activity, including engagement in sports, physical education, or active games, should be encouraged by occupational therapists to promote concussion recovery.

Vision Therapy: Ocular Motor Training in Mild Traumatic Brain Injury.

Vision therapy in the form of ocular motor training is increasingly used to treat visual complaints, particularly in the setting of persistent symptoms after mild traumatic brain injury (mTBI). In this review, we discuss the rationale behind this intervention and the evidence for its utility. Although the efficacy of exercises for primary convergence insufficiency is plausible and supported by data, there is not yet strong evidence of benefit for the post-traumatic variant. It is not established that abnormalities in fixation, pursuit, and saccades in mTBI are the cause of post-concussive symptoms, or that these abnormalities arise from ocular motor damage rather than being secondary effects of cognitive problems with attention or executive control. The few studies to date have significant methodological weaknesses. More substantial evidence is required before vision therapy can be accepted as a useful tool in the rehabilitation of patients with brain trauma. ANN NEUROL 2020;88:453-461.

The Role of Subsymptom Threshold Aerobic Exercise for Persistent Concussion Symptoms in Patients With Postconcussion Syndrome: A Systematic Review.

In recent years, there has been a shift away from rest until total symptom resolution after concussion, due to the potential adverse consequences of inactivity. Aerobic exercise has been increasingly investigated for the treatment of postconcussion syndrome, whereby symptoms persist beyond 4 wks. The aim of this review was to systematically review the literature on subsymptom threshold aerobic exercise as a treatment for postconcussion syndrome. We conducted systematic literature searches in databases: MEDLINE (Ovid), CINAHL, PubMed, and Embase. After thorough review, 12 articles met the eligibility criteria and were included in the systematic review. The quality of selected studies was low to moderate. Subsymptom threshold aerobic exercise was associated with improvement in symptoms in patients with postconcussion syndrome for all included studies. The most commonly used protocols incorporated 20 mins of exercise at 80% of the heart rate that provoked symptoms, 5-6 days per week, with no adverse events documented. However, there was considerable variation in exercise protocols, and many studies incorporated subsymptom threshold aerobic exercise as part of a broader rehabilitation plan. Evidence supports subsymptom threshold aerobic exercise as a promising treatment for postconcussion syndrome. Further studies are required to delineate the optimal intensity, duration, and frequency of exercise for postconcussion syndrome in a variety of populations.