Graded Exercise Testing Predicts Recovery Trajectory of Concussion in Children and Adolescents.

OBJECTIVE: To determine whether graded exercise testing can predict recovery trajectory of concussion in children and adolescents. DESIGN: Prospective study. SETTING: Children's Hospital, Westmead, Australia. PARTICIPANTS: One hundred thirty-nine children aged 12 to 16 years at 5 to 7 days after an acute concussive injury. INTERVENTION: Graded exercise testing on a treadmill at the subacute phase to assess symptom provocation and determine clinical recovery indicating readiness to commence a return to activity (RTA) protocol. Exercise time to symptom exacerbation and clinical recovery were measured. MAIN OUTCOME MEASURES: Standard concussion assessment and clinical testing (neurocognitive, vestibular/ocular, and balance) were conducted to determine major clinical drivers/indicators. RESULTS: Participants (mean age 12.4 ± 2.8 years, 73% male) had a confirmed sport-related concussion. The main clinical drivers identified on exercise testing were headache, balance, and vestibular dysfunction. Participants fell into 1 of 2 groups, exercise-tolerant (54%) and exercise-intolerant (46%). Exercise-tolerant patients showed mild clinical indicators, no symptom exacerbation during 10.3 ± 3.3 minutes of exercise, were safely transitioned to a RTA protocol, and recovered within 10 days. Exercise-intolerant patients had high clinical indicators, significant symptom exacerbation at 4.2 ± 1.6 minutes of exercise, and prolonged recovery of 45.6 days. No adverse effects from exercise were reported in either group. Combined use of provocative exercise and clinical testing was 93% predictive of outcome. CONCLUSIONS: Exercise testing during the subacute phase after a concussion can predict longer recovery. Exercise testing can identify a unique window where patients can be safely transitioned to activity, enabling clinicians to better inform patients and families, allocate resources and streamline care.

Association of Simple Step Test With Readiness for Exercise in Youth After Concussion.

OBJECTIVES: We hypothesized that a submaximal step test would be associated with readiness to commence graded exercise in children and adolescents with concussion. METHODS: Children and adolescents aged 8 to 18 years performed standard concussion clinical assessment for vestibular/ocular and balance impairment, and exercise examination utilizing the 3-minute Kasch Pulse Recovery test (KPR) and a symptom-limited graded exercise test (GXT). Outcome measures included activity readiness and symptom exacerbation. RESULTS: Forty-five participants (mean age 13.2 ± 2.1 years, 76% male) had a confirmed concussion (73% sports-related). Some participants required follow-up testing giving 75 clinical presentations. Sensitivity and specificity of the KPR were 100% and 95.7%, respectively. Area under the receiver operating characteristics curve was 0.979. Activity readiness to GXT and KPR was strongly associated (χ = 21.672, P < .001), while symptom exacerbation showed a significant correlation between testing methods (r = 0.796, P < .001). Better exercise performance on GXT and KPR was significantly correlated with normal Vestibular/Ocular Motor Screening (rs = -0.380, P = .010, and rs = -0.281, P = .017, respectively) and Modified Balance Error Scoring System (rs = -0.452, P < .001, and rs = -0.301, P = .010, respectively). CONCLUSION: The KPR is a simple and practical tool to determine whether it is appropriate for a child or adolescent with concussion to commence graded exercise.

Feasibility of an inpatient exercise intervention for children undergoing hematopoietic stem cell transplant.

With improving survival rates following HSCT in children, QOL and management of short- and long-term effects need to be considered. Exercise may help mitigate fatigue and declines in fitness and strength. The aims of this study were to assess the feasibility of an inpatient exercise intervention for children undergoing HSCT and observe the changes in physical and psychological health. Fourteen patients were recruited, mean age 10 yr. A 6MWT, isometric upper and lower body strength, balance, fatigue, and QOL were assessed prior to Tx and six wk post-Tx. A supervised exercise program was offered five days per week during the inpatient period and feasibility assessed through uptake rate. The study had 100% program completion and 60% uptake rate of exercise sessions. The mean (± s.d.) weekly activity was 117.5 (± 79.3) minutes. Younger children performed significantly more minutes of exercise than adolescents. At reassessment, strength and fatigue were stabilized while aerobic fitness and balance decreased. QOL revealed a non-statistical trend towards improvement. No exercise-related adverse events were reported. A supervised inpatient exercise program is safe and feasible, with potential physiological and psychosocial benefits.

Physical activity and screen-time of childhood haematopoietic stem cell transplant survivors.

AIM: Reduced bone mineral density, impaired cardiovascular fitness and increased risk of obesity are well-known late effects of haematopoietic stem cell transplantation (HSCT) in survivors of childhood cancer. These comorbidities can be mitigated through physical activity and limiting screen-time (ST). This study aims to increase the understanding of physical activity and ST behaviours for children following HSCT. METHODS: Children were recruited from two oncology follow-up clinics and completed a questionnaire on their physical activity levels and screen-time. Children were classified as short (≤2 years) and long-term (>2 years) survivors. RESULTS: Fifty-eight children were eligible, of whom forty children of age 6-18 years (60% males) participated in the study. Less than half (47.5%) met the daily recommendations for physical activity and one-third met the ST recommendations. Late survivors reported higher daily physical activity and less ST than early survivors. Among late survivors, females reported higher daily physical activity and less ST than males. CONCLUSION: Our findings suggest that the majority of children following HSCT were not sufficiently active and had excessive screen-time; however, this was comparable to healthy populations. Appropriately designed physical activity and screen-time intervention programmes should be explored early following transplant for children undergoing HSCT.

Randomised controlled trial of online continuing education for health professionals to improve the management of chronic fatigue syndrome: a study protocol.

INTRODUCTION: Chronic fatigue syndrome (CFS) is a serious and debilitating illness that affects between 0.2%-2.6% of the world's population. Although there is level 1 evidence of the benefit of cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for some people with CFS, uptake of these interventions is low or at best untimely. This can be partly attributed to poor clinician awareness and knowledge of CFS and related CBT and GET interventions. This trial aims to evaluate the effect of participation in an online education programme, compared with a wait-list control group, on allied health professionals' knowledge about evidence-based CFS interventions and their levels of confidence to engage in the dissemination of these interventions. METHODS AND ANALYSIS: A randomised controlled trial consisting of 180 consenting allied health professionals will be conducted. Participants will be randomised into an intervention group (n=90) that will receive access to the online education programme, or a wait-list control group (n=90). The primary outcomes will be: 1) knowledge and clinical reasoning skills regarding CFS and its management, measured at baseline, postintervention and follow-up, and 2) self-reported confidence in knowledge and clinical reasoning skills related to CFS. Secondary outcomes include retention of knowledge and satisfaction with the online education programme. The influence of the education programme on clinical practice behaviour, and self-reported success in the management of people with CFS, will also be assessed in a cohort study design with participants from the intervention and control groups combined. ETHICS AND DISSEMINATION: The study protocol has been approved by the Human Research Ethics Committee at The University of New South Wales (approval number HC16419). Results will be disseminated via peer-reviewed journal articles and presentations at scientific conferences and meetings. TRIAL REGISTRATION: ACTRN12616000296437.