脑震荡后返校学习

本研究基于风险管理理论，以提升体育类专业大学生风险识别能力与预防意识为目标，编制运动性脑震荡风险检查表与评估表，采用文献资料法、德尔菲法等多种方法识别风险因子、确定核心风险并提出预防策略。结果显示，研究识别出4个一级指标、9个二级指标及36个三级风险因子，核心风险源为学生心理行为偏差、教师教学防护缺失等；构建了学生、教师、环境及其他三个维度的预防策略体系。结论表明，本研究明确了体育类专业大学生运动性脑震荡的风险构成与核心风险源，提出的三维预防策略可为高校相关防控教育提供理论与实证参考，也为运动性脑震荡公共卫生防控提供新思路。

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Background The Translational Science Benefit Model (TSBM) was developed to broadly capture systematic measures of health and societal benefits from scientific research, beyond traditional outcome measures. We aimed to develop a systematic process for the application of the TSBM and to then provide an example of a novel application of the TSBM to an ongoing Return-to-Learn (RTL) after youth concussion project involving partnerships with community stakeholders. Methods We invited investigators, project advisory board, and participants of the RTL project to participate in a modified Delphi process. We first generated a list of potential translational benefits using the indicators of the TSBM as guideposts. We then prioritized the benefits on an adapted Eisenhower matrix. Results We invited 35 concussion care or research experts to participate, yielding 20 ranked translational benefits. Six of these recommendations were ranked high priority, six were regarded as investments, and eight were ranked as either low yield or low priority. Discussion This study found that activities such as education and training of stakeholders, development of policy and consensus statements, and innovation in dissemination, were perceived as higher priority than other activities. Our approach using a modified Delphi process and incorporating the TSBM can be replicated to generate and prioritize potential benefits to society from research studies.

Outpatient sports-related concussion (SRC) management continues to evolve as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC. Early active rehabilitation has replaced strict cognitive and physical rest. With this paradigm shift in management, pragmatic approaches are highly sought by busy clinicians that provide direction to individualized treatment, which can potentially expedite symptom resolution. Treatment strategies that address domain-based symptom constellations continue to be developed by clinician researchers. Although the optimal timing and dose of these domain-specific therapies has yet to be determined, future directions of SRC treatment will answer these and other questions regarding SRC management.

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OBJECTIVE Return-to-learn (RTL) recommendations and management protocols for athletes after sport-related concussion (SRC) remain heterogeneous. With respect to academics after SRC, the current systematic review evaluated 3 outcome measures in each included study: 1) RTL definition, 2) RTL duration, and 3) factors associated with longer RTL. METHODS Studies published before December 2022 that addressed RTL after an SRC were identified via a compressive literature search of the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed databases. Studies solely examining nonsport-related concussion/traumatic brain injury studies were excluded. Study quality was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Modified Newcastle-Ottawa Scale for risk of bias. For each study included, the design, participants, interventions, outcomes, results, and conclusions were extracted. RESULTS Of 1838 studies identified, 21 met the inclusion criteria. These studies represented 8475 athletes (aged 5-27 years) who sustained an SRC. A total of 17/21 (81%) provided an RTL definition. Of the studies that defined RTL as any RTL, the median (range) was 5 (2.5-35.3) days, while the median (range) of those that defined RTL as full RTL without accommodations was 17.5 (3-49) days. Female gender (7/9 studies) and initial symptom severity (3/3 studies) were consistently associated with delayed RTL. Single studies identified anxiety, attention-deficit/hyperactivity disorder (ADHD), and integrated performance management as potential factors for delayed RTL. Age (0/5 studies), concussion history (2/6), depression history (0/1), migraine history (0/2), learning disability (0/1), school type (public vs private) (0/2), and early air travel after SRC (0/1) did not appear to have consistent effects on RTL. CONCLUSIONS Across 21 primary studies, RTL definitions varied greatly, and similarly, a wide range of days to RTL was seen at 3-35 days. Female gender and initial symptom severity were most consistently associated with prolonged RTL. Certain factors such as a history of ADHD/anxiety showed potential effects but require further investigation. Management guidelines should consider these findings while recognizing the need for more comprehensive research to confirm and quantify the impact of various factors on RTL duration.

While evidence supports the gradual return to participation in collegiate athletics following a concussion, limited evidence exists of the return to learn (RTL) procedures for a successful return to the higher education classroom. The objective of this study was to determine what academic supports and hindrances are present for NCAA student-athletes during the RTL process following a concussion from academic professionals’ perspectives. In this qualitative study with purposive recruitment strategies, academic support professionals (5=female, 4=male, age=44.2±13.9 years, experience=11.6±10.4 years) and faculty athletic representatives (5=female, 5=male, age=48.6±7.8 years, experience=3.9±5.6 years) volunteered to complete virtual interviews. We conducted semistructured one-on-one interviews with academic support professionals and faculty athletic representatives to understand better their lived experiences supporting student-athletes during the RTL process. Communication, multidisciplinary collaboration, and student-athlete support were described as essential components of streamlined RTL. Participants also highlighted the importance of stakeholder education on concussions and the RTL process to facilitate collaborative care. Our work highlights the need for strong communication and collaboration that results in student support and informed stakeholders, ultimately facilitating successful RTL practices for student-athletes in higher education. Clearly defined institutional policies and procedures are needed regarding RTL.

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OBJECTIVE Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. METHODS A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. RESULTS Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (β = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (β = 0.15, p < 0.001) predicted longer RTL. CONCLUSIONS In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

We conducted a narrative review and content analysis to (i) determine the extent to which research on return to learn (RTL) following sport-related concussion (SRC) has considered social determinants of health (SDoH) or health equity and (ii) provide recommendations to enhance the incorporation of SDoH and health equity into considerations of how best to support concussed students as they RTL following injury. We coded 32 studies from a systematic review focused on clinical recovery following SRC, including RTL (Putukian et al., 2023). The review informed the latest Concussion in Sport Group consensus statement (Patricios et al., 2023). We examined studies to determine whether the SDoH domains and subcategories, derived from the US Department of Health and Human Services Healthy People 2020 and 2030 websites, were addressed. Pairs of raters coded articles independently and resolved disagreements through discussion. SDoH remain largely unrepresented in studies on return to school following concussion. Future research is needed to better characterize how SDoH and health equity factors influence return to school following concussion to ensure that concussed and recovering students are supported.

Youth concussion is common but there is a paucity of information on symptoms students report to school personnel and a gap in understanding what accommodations schools can provide.

Aim To understand academic support structures for Washington state public high school students with concussion during the COVID-19 pandemic. Materials & methods Prospective, repeated cross-sectional study of 21 schools in 2020 and 2021. Results About 28% of schools reported not providing any return-to-learn (RTL) accommodations for students with concussion throughout the COVID-19 pandemic. RTL accommodation provision was associated with larger student body size (β = 0.002) and higher graduation rate (β = 0.261) but was not associated with presence of RTL school policy. About 38.1% of schools received no guidance on how to provide RTL accommodations during the COVID-19 pandemic, and many reported that students with concussion struggled more. Conclusion Schools struggled to provide RTL accommodations for students with concussion during the COVID-19 pandemic, highlighting the need for evidence-based guidance and resource allocation to vulnerable schools.

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OBJECTIVE Return-to-learn (RTL) after sport-related concussion (SRC) is an important yet understudied topic. The authors sought to do the following: 1) describe patterns of RTL among athletes by school level (i.e., middle school, high school, college); and 2) evaluate the predictive value of school level on RTL duration. METHODS A retrospective, single-institution cohort study of adolescent and young adult athletes 12-23 years old who sustained an SRC between November 2017 and April 2022 and who presented to a multidisciplinary specialty concussion clinic was conducted. The independent variable was school level, trichotomized into middle school, high school, and college. Time to RTL was the primary outcome and was defined as days from SRC to return to any academic activities. ANOVA was used to compare RTL duration across school levels. A multivariable linear regression was performed to evaluate for predictive value of school level on RTL duration. Covariates included the following: sex, race/ethnicity, learning disorder, psychiatric conditions, migraines, family history of psychiatric conditions/migraines, initial Post-Concussion Symptom Scale score, and number of prior concussions. RESULTS Of 1007 total athletes, 116 (11.5%) were in middle school, 835 (83.0%) were in high school, and 56 (5.6%) were in college. The mean RTL times (in days) were as follows: 8.0 ± 13.1 (middle school), 8.5 ± 13.7 (high school), and 15.6 ± 22.3 (college). One-way ANOVA showed a statistically significant difference between groups (F[2, 1007] = 6.93, p = 0.001). A Tukey post hoc test revealed a longer RTL duration in collegiate athletes when compared to middle school (p = 0.003) and high school (p < 0.001) athletes. Collegiate athletes had longer RTL duration compared to other school levels (β = 0.14, p < 0.001). There was no difference between middle school and high school athletes (p = 0.935). The subanalysis revealed a longer RTL duration in high school freshmen/sophomores (9.5 ± 14.9 days) when compared to juniors/seniors (7.6 ± 12.6 days; t = 2.05, p = 0.041), and being an older (junior/senior) high school athlete was predictive of shorter RTL duration (β = -0.11, p = 0.011). CONCLUSIONS When examining patients who presented to a multidisciplinary sport concussion center, RTL duration was longer in collegiate athletes when compared to middle and high school athletes. Younger high school athletes had longer time to RTL compared to their older counterparts. This study provides insight into how varying scholastic environments may contribute to RTL.

Objective: Although concussions affect millions of young adults annually, researchers have yet to assess factors that may affect future implementation of post-concussion academic supports within higher education. Therefore, we sought to evaluate preimplementation outcomes of the acceptability, feasibility, appropriateness, and readiness for change of the Post-Concussion Collegiate Return-to-Learn (RTL) Protocol among university stakeholders. Setting: An online survey. Participants: A convenience sample (N = 49; 63.3% female) of athletic trainers (ATs; n = 25, age = 30.1 ± 7.6 years) and university faculty/staff (n = 24, age = 38.3 ± 9.9 years) across the National Collegiate Athletic Association (NCAA) Power 5 Conferences from January to February 2022. Design: A cross-sectional study. Main Measures: To compare preimplementation outcome measures using the Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM), Intervention Appropriateness Measure (IAM), and Organizational Readiness for Implementing Change (ORIC) regarding the RTL protocol between ATs and university faculty/staff. Additional outcomes included internal and external barriers to implementing at their respective institutions. Statistical analyses were conducted using Mann-Whitney U tests, with effect sizes estimated using eta-squared coefficient (η2). Results: Quantitative analyses yielded no statistically significant group differences (Ps > .05) across the AIM, FIM, and IAM outcomes, indicating both groups perceived the protocol to be acceptable, feasible, and appropriate. Moreover, ATs reported higher agreement regarding motivation, desire, willingness to do “whatever it takes,” commitment, and determination to implement the novel protocol than faculty/staff. Further, ATs reported higher agreement regarding their institution's confidence to keep track of its progress, support adjustment, maintain momentum, manage institutional politics, coordinate tasks, encourage investment, and handle the challenges of future implementation of the RTL protocol. Conclusions: Preliminary findings suggest ATs and university faculty/staff across the NCAA Power 5 Conferences may perceive the RTL protocol to be acceptable, feasible, and appropriate for future use; however, noteworthy internal and external barriers may influence its uptake. Future research should utilize implementation frameworks to support the protocol's adoption and reach.

COPYRIGHT © 2023 Bevilacqua and McPherson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Commentary: Establishing the college Return to Learn team for concussion: a practical approach

Return to learn (RTL) is the individualized process of coordinating cognitive care and reintegration for students into the academic setting after any sport and recreational-related concussion (SRRC). The guidelines for RTL are based on empirical evidence, however, implementation differs by institution. The purpose of the policy analysis is to evaluate RTL guidelines after SRRC of student-athletes in New England secondary school public school systems. A review of the six New England states’ policies surrounding RTL was conducted. The Comprehensive Analysis of Physical Activity Framework was referenced to identify the analytic components of existing legislation and because of the relatively new implementation of RTL-specific policy, a novel policy analysis tool was utilized. States with RTL-specific language scored on average 7.9 to 11.1 points higher when compared to states without RTL-specific language. This difference was associated with disparities in access to RTL resources for residents according to their geographic location. Lobbying efforts should be targeted toward states without RTL-specific language to provide equal care and opportunities for student-athletes to receive RTL services. RTL policy provides a responsibility to assist students who have suffered from an SRRC and can serve to improve health outcomes and academic achievement.

INTRODUCTION: Adolescents sustaining sport-related concussion (SRC) often experience difficulties with the return-to-learn (RTL) process. While initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. METHODS: A retrospective single-institution cohort study of adolescent athletes 12-23-years-old evaluated within 5 days of a diagnosed SRC from 11/2017-10/2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was cognitive symptom score, consisting of 4 symptoms for a total possible score of 24. Primary and secondary outcomes were time-to-RTL and total length-of-care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of Cognitive Symptom Ratio (CSR), defined as cognitive symptom score divided by Post-Concussion Symptom Scale (PCSS) score, on RTL duration. RESULTS: Of 653 athletes evaluated within 5 days of their concussion, 343 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (IQR 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of “difficulty concentrating” (n = 212, 61.3%). Median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = .004). When initial PCSS was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = .367). When dichotomized based on frequency distribution, a higher proportion of low CSR patients achieved RTL by 7 days post-injury (82.2% vs. 69.9%, p = .007), a difference not seen at 14 days (92.2% vs. 87.3%, p = .133). CONCLUSIONS: Acute cognitive symptom scores can predict who may be at increased risk for prolonged RTL and which patients with normal PCSS scores may experience difficulties once resuming school activities.

Background Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education. Objective To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery. Methods Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group’s overall ratings. Results Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol . Conclusion There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

Objective To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC). Design Systematic review and meta-analysis. Data sources 8 databases searched through 22 March 2022. Eligibility criteria Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool. Results 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I2=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I2=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I2=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns. Conclusion Most athletes have full RTL by 10 days but take twice as long for an RTS. PROSPERO registration number CRD42020159928.

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Concussion or mild traumatic brain injury (mTBI) is a common phenomenon in the United States, with up to 3.6 million sport-related mTBIs diagnosed annually. Return to learn protocols have been developed to facilitate the reintegration of students into school after mTBI, however, the implementation of return to learn protocols varies significantly across geographic regions and school districts. An integrative review of the literature was performed using Whittemore and Knalf's methodology. A search of published literature was conducted using the PRISMA checklist. Database searches were conducted from March 2,019 to October 2,021 using the terms “mild traumatic brain injury” and “return to learn.” Twenty-eight publications were included. Three themes were derived from this review: lack of policy, poor staff education on concussion symptoms and stakeholder communication breakdown. The development of communication patterns and use of a return to learn protocol could facilitate a gradual return to full academic workload after concussion.

OBJECTIVE To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

There is a growing body of research showing that cerebral pathophysiological processes triggered by pediatric mild traumatic brain injury (pmTBI) may extend beyond the usual clinical recovery timeline. It is paramount to further unravel these processes, because the possible long‐term cognitive effects resulting from ongoing secondary injury in the developing brain are not known. In the current fMRI study, neural processes related to cognitive control were studied in 181 patients with pmTBI at sub‐acute (SA; ~1 week) and early chronic (EC; ~4 months) stages post‐injury. Additionally, a group of 162 age‐ and sex‐matched healthy controls (HC) were recruited at equivalent time points. Proactive (post‐cue) and reactive (post‐probe) cognitive control were examined using a multimodal attention fMRI paradigm for either congruent or incongruent stimuli. To study brain network function, the triple‐network model was used, consisting of the executive and salience networks (collectively known as the cognitive control network), and the default mode network. Additionally, whole‐brain voxel‐wise analyses were performed. Decreased deactivation was found within the default mode network at the EC stage following pmTBI during both proactive and reactive control. Voxel‐wise analyses revealed sub‐acute hypoactivation of a frontal area of the cognitive control network (left pre‐supplementary motor area) during proactive control, with a reversed effect at the EC stage after pmTBI. Similar effects were observed in areas outside of the triple‐network during reactive control. Group differences in activation during proactive control were limited to the visual domain, whereas for reactive control findings were more pronounced during the attendance of auditory stimuli. No significant correlations were present between task‐related activations and (persistent) post‐concussive symptoms. In aggregate, current results show alterations in neural functioning during cognitive control in pmTBI up to 4 months post‐injury, regardless of clinical recovery. We propose that subacute decreases in activity reflect a general state of hypo‐excitability due to the injury, while early chronic hyperactivation represents a compensatory mechanism to prevent default mode interference and to retain cognitive control.

ABSTRACT Description In June 2021, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management and rehabilitation care for those who have symptoms in the post-acute period following mild traumatic brain injury (mTBI). This synopsis describes some of the clinically important recommendations. Methods In January 2020, VA and DoD leaders assembled a joint VA/DoD guideline development team of multidisciplinary clinical stakeholders that developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and refined 19 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The process closely conformed to the National Academy of Medicine’s tenets for trustworthy clinical practice guidelines. Recommendations This synopsis describes clinically important recommendations for the management and rehabilitation of mTBI. Outpatient primary care providers are the target audience for this synopsis and guideline. The current recommendations are an update from the 2016 VA/DoD Clinical Practice Guidelines for the Management of Concussion-Mild Traumatic Brain Injury.

Background: Concussion is a complicated injury that affects many facets of life in children and adolescents. Neurocognitive and self-reported symptom outcomes are commonly used to understand post-concussion effects. The degree to which concussion affects quality-of-life (QoL) and school performance remains difficult to determine among this age group. Purposes and Hypotheses: Our first purpose was to compare QoL domains using the Patient-Reported Outcomes Measurement Information System (PROMIS) among concussed children to healthy children. We hypothesized that concussed children would report worse QoL than controls. Our second purpose was to identify school-related difficulties that children encounter post-concussion. We hypothesized that the majority of patients would report moderate-to-high academic concerns. Methods: We conducted a multi-site study of patients evaluated at pediatric sports medicine centers and healthy controls undergoing pre-participation physical examinations. All participants were less than 19 years of age and those with a concussion were evaluated <14 days post-injury. Our primary outcomes were derived from PROMIS and Concussion Learning Assessment and School Survey (CLASS) questionnaires. The CLASS was completed only among the concussed group. We compared PROMIS outcomes using Mann Whitney U tests and constructed linear regression models to control for the effect of age and sex. Results: Forty-four individuals participated: 22 with concussion and 22 controls. No significant differences were noted between groups in regard to sex or age. On average, the concussion group missed 2.8 days of school, required 25 days for symptom resolution, and 40 days until return to sports clearance (Table 1). The concussion group reported significantly worse mobility, fatigue, pain interference, and pain visual analog scale (VAS) ratings than the control group (Table 2). After adjusting for age and sex, the concussion group still had significantly worse mobility (β=6.6; 95% CI=4.8,8.4), fatigue (β=6.8; 95% CI=4.5,9.2), pain interference (β=6.1; 95% CI=3.5,8.7), and pain VAS ratings (β=4.5; 95% CI=3.7,5.3) than healthy controls. Among the concussed cohort, 52% reported a moderate or very high overall concern related to the perceived effect their concussion had on school performance with 50% reporting that headaches interfered with their schoolwork and 55% reporting that reading/English were the most troubling classes (Table 3). Conclusion: Within 14 days of injury, concussed children reported significantly worse mobility, fatigue and pain outcomes relative to healthy controls, and reported troubling academic concerns related to their injury. Assessment of patient-reported outcomes following concussion may provide valuable insights to direct management plans beyond typical assessments of concussion symptoms or neurocognitive function. Table 1. Characteristics of concussion and control groups. Continuous variables are presented as means (sd) and categorical variables are presented as n (%). Variable Concussion (n=22) Control (n=22) P value Female sex 12 (55%) 12 (55%) 1.00 Age (years) 13.5 (3.4) 14.8 (1.7) 0.11 Assessment time (days post-injury) 7.6 (3.6) - - Number of school days missed (days) 2.8 (1.7) - - Symptom resolution time (days) 25.1 (16.4) - - Return to play time (days) 40.1 (26.5) - - Table 2. Comparison between concussion and control groups on PROMIS outcome measures. Data are presented as median [interquartile range]. Domain Concussion Control P value Mobility 8 [2-9] 0 [0-0] < 0.001 Anxiety 2 [0-8] 2 [0-6] 0.63 Depressive 2.5 [1-5] 1 [0-2] 0.05 Fatigue 8 [6-12] 1 [0-3] < 0.001 Peer relationships 16 [12-16] 15 [12-16] 0.55 Pain interference 9 [5-12] 0 [0-2] < 0.001 Pain VAS rating 5 [3-6] 0 [0-1] < 0.001 Table 3. School-related difficulties reported by concussion patients on the CLASS survey. Factor Response % (n) Concern about injury affecting school performance Very concernedModerately concernedMildly concernedNot concerned 19% (4)33% (7)29% (6)19% (4) School factor most concerned about Grades droppingAbility to learn, remember, concentrateAmount of work/falling behindOther 52% (10)21% (4)16% (3)11% (2) Types of problems experienced after concussion Headaches interferingCan’t pay attention in classToo tiredHomework is taking longerDifficulty studying for testsDifficulty taking notesDifficulty understanding material 50% (11)45% (10)41% (9)27% (6)27% (6)23% (5)14% (3) Classes/subjects producing the most trouble after concussion Reading/EnglishMathScienceSocial Studies/HistoryForeign LanguagePhysical EducationArtMusic 55% (12)32% (7)18% (4)14% (3)9% (2)9% (2)5% (1)5% (1) Grades affected since injury? YesNot yet, but worried they mightNo 39% (7)33% (6)28% (5) Kind of help needed in returning to school Rest breaksExtra time to complete workI don’t knowReduced homeworkShortened dayNo testsShorter classes 55% (12)45% (10)32% (7)27% (6)23% (5)14% (3)5% (1) Best person at school to coordinate support Guidance counselorHomeroom teacherAthletic trainerPrincipal/Assistant PrincipalSchool nurseCoachSchool psychologistSpecial education teacher 27% (6)27% (6)18% (4)18% (4)14% (3)14% (3)5% (1)5% (1)

This person-centered study examined pre-injury psychological and neurodevelopmental risk factors in youth experiencing persistent concussion symptoms (PCS). Latent class analysis (LCA) was used to empirically define groups of children and adolescents experiencing PCS, and compare their functional outcomes. 126 pediatric patients (Mean age = 15.94 years; 65.1% female) experiencing PCS (Mean time since injury = 315 days) participated in a clinical neuropsychological consultation and evaluation within the Minds Matter Concussion Program at Children’s Hospital of Philadelphia. LCA models were run using pre-injury variables (mood and anxiety concerns, attention and learning challenges). Functional outcomes (neuropsychological performance, academic decline, symptom magnification) were then compared across the resulting classes. Statistical indicators [Akaike Information Criteria (804.59), adjusted Bayesian Information Criteria (801.01), Bootstrap Likelihood Ratio Test (p < 0.001)] indicated that a two-class model provided the best fit. Class 1 (n = 58) was predominately females (78.3%) with comorbid pre-injury developmental (46.6% learning challenges, 54.6% attention concerns) and psychological concerns (75.6% anxiety, 48.9% mood concerns). Class 2 (n = 68) was half females (49.8%) with fewer comorbid pre-injury developmental (14.6% learning challenges, 22.5% attention concerns) and psychological concerns (39.3% anxiety, 0% mood concerns). The two classes did not significantly differ on functional outcomes. Standardized testing scores were within the average range across the sample. Pre-injury risk factors contribute to persistent symptom experience and functional complaints in the absence of objective cognitive impairment. Given the incidence across groups, these findings highlight the importance of understanding psychological and neurodevelopmental factors, as well as sex-based differences when directing referrals and treatment of PCS within a multidisciplinary program.

ABSTRACT Objective To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion. Study Design We performed a prospective cohort study of children and adolescents (8–18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss. Results 167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5–4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03–0.08, p < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28–2.45, p = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p < 0.001; Cohen’s d = 0.87). Conclusions Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.

Considerably less attention has been paid to psychological and social sequelae of concussion in youth athletes compared with neurocognitive outcomes. This narrative review consolidates the literature on postconcussive emotional and psychosocial functioning in school-aged children and adolescents, highlighting athlete-specific findings. MEDLINE and PsycINFO databases were queried for pediatric concussion studies examining psychological and/or social outcomes, and 604 studies met search criteria (11 of those specific to sport). Results were organized into domains: emotional and social dysfunction, behavioral problems, academic difficulties, sleep disturbance, headache, and quality of life. The small body of literature regarding psychological and social issues following pediatric concussion suggests behavioral disturbances at least temporarily disrupt daily life. Extrapolation from samples of athletes and nonathletes indicates postconcussive anxiety and depressive symptoms appear, although levels may be subclinical. Social and academic findings were less clear. Future well-controlled and adequately powered research will be essential to anticipate concussed athletes’ psychosocial needs.

No abstract available

Background: Post-concussion sequelae in adolescents include physical, cognitive, and psychosocial effects that may result in reduced quality of life (QOL) and academic challenges when returning to school. The COVID-19 pandemic resulted in altered teaching and learning models outside the traditional in-person classroom, and elevated psychosocial stress and isolation among adolescents. It is unknown whether these changes affected QOL or academic challenges post-concussion. Hypothesis/Purpose: To compare self-reported QOL and academic challenges among concussed adolescents prior to and during the COVID-19 pandemic. Methods: Concussed adolescents were enrolled from secondary schools and children’s medical centers across seven sites into the Sport Concussion Outcomes in Pediatrics (SCOPE) study (PRiSM Concussion RIG). Participants completed demographics, medical history, symptom report, the Concussion Learning Assessment and School Survey (CLASS) and QOL via PROMIS Pediatric Global 25 during their first evaluation visit. Participants were grouped by date ranges: September 2018-January 2020 (Pre-COVID-19) and September 2020-May 2021 (COVID-19). No participants were enrolled between February-August 2020 (cessation of clinical research activities during this time.). Results: A total of 141 patients were enrolled. Mean age=14.9±2.4 years, 61% self-reported as male, 82% white and 85% not Hispanic or Latino, 5.2+3.1 days post-injury (range=1-14 days). Seventy-four patients were enrolled prior to COVID, and 67 were enrolled during COVID (Table 1). No significant differences were found between the ‘Pre-COVID-19’ group versus ‘During COVID-19’ group in symptom resolution, symptom severity score, QOL, or academic concerns (Table 2). The only difference was the ‘person at school who is best to coordinate support.’ A significantly lower proportion of participants who sustained their concussion during COVID-19 reported their principal/assistant principal would be the best person to coordinate support compared to those who sustained their concussion before the COVID-19 pandemic. In contrast, a significantly higher proportion of those who sustained their concussion during the COVID-19 pandemic reported their coach would be the best person to coordinate support. Conclusion: In this convenience yet nationally representative sample, students who sustained a concussion during the pandemic did not report increased academic concerns or reduced QOL compared to those whose injury was prior to the pandemic. Median symptom severity was lower during the pandemic, though not statistically significant. These findings could represent shifted priorities of the principal/assistant principal but still adequate support from medical and school-based staff; less academic stress and greater flexibility during the COVID-19 pandemic; or may represent limitations in the CLASS instrument to detect differences that occurred during the pandemic. Table 1 Participant characteristics by group. Data are presented as mean (standard deviation) or n (% within group). Table 2 Clinical and Quality of Life characteristics (via PROMIS Pediatric Global 25) between groups, assessed at the initial post-concussion assessment. Data are presented as median [interquartile range] and compared using Mann Whitney U tests.

Objective: The relationship between health-related quality of life (HRQoL) and injury type has not been analyzed for young athletes. We hypothesized that there would be no difference in HRQoL between injured athletes, injured nonathletes, and normative data for healthy youth (NDHY) or among athletes with acute, overuse, or concussion injuries. Design: Cross-sectional clinical cohort. Setting: Primary care sports medicine clinics at 3 academic institutions. Participants: Patients aged 8 to 18 years presenting with injury. Independent Variables: Injury type and athletic participation. Main Outcome Measures: Health-related quality of life measured 1 month after injury through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 v2.0 assessed pain interference, peer relationships, depression, fatigue, anxiety, and mobility. One-way analysis of variance was performed with P values of <0.05 considered significant. Concussion Learning Assessment and School Survey (CLASS) evaluated academic performance. Results: Three hundred fifty-seven patients (36% male), with average age of 14.2 years, completed HRQoL and CLASS surveys following injury. There were 196 overuse injuries (55%), 119 acute injuries (33%), and 42 concussions (12%). Ninety-four percent were athletes. Six percent were nonathletes; 90.5% of concussed patients reported grades worsening. Concussed athletes reported more fatigue (P = 0.008) compared with other injury types but no worse than NDHY. Athletes with overuse injuries had lower mobility (P = 0.005) than other injury types and NDHY. Patients with lower HRQoL were female, older age, or required surgery. No other domains had significant differences by injury type nor did HRQoL differ between the athletes, nonathletes, and NDHY. Conclusions: With the exception of injuries requiring surgery, HRQoL of injured young athletes was similar to NDHY in most domains.

OBJECTIVE Recent research supports initiating physical activity as soon as 24 to 48 hours after concussion to reduce persistent postconcussive symptoms. However, this practice has not been widely adopted. The objective of this study was to evaluate the association of early physical activity with patient-reported and functional outcomes for pediatric patients following a concussion. METHODS A retrospective cohort of patients who presented to a pediatric sports medicine clinic (48% female, mean age14.3 ± 2.6 years, and mean 9.8 ± 5.7 days postconcussion) were evaluated. Patients were grouped based on whether they reported engaging in physical activity prior to presenting to the clinic. Patient- and parent-reported symptom frequency (Health and Behavior Inventory), 11 different clinical outcomes (including missed school, memory recall, and balance assessments), the presence of symptoms persisting beyond 28 days, and a subgroup analysis of those patients receiving exercise versus symptom-limiting activity prescriptions were examined. Outcomes were compared between physical activity groups using the Mann-Whitney U-test and the chi-square test. To adjust for the effect of potential confounders, a logistic binary regression model was constructed. RESULTS In total, 211 pediatric patients were included, 35 (17%) of whom reported early physical activity. A greater proportion of the no physical activity group reported a headache (85% vs 60%, p = 0.001). The no physical activity group also reported higher patient-reported (23.1 ± 13.4 vs 15.0 ± 13.4, p < 0.001) and parent-reported (19.4 ± 12.7 vs 11.2 ± 10.3, p = 0.001) symptom frequency at the initial visit. The early physical activity group had a lower proportion of patients with persistent symptoms (44% vs 22%, p = 0.02) and a shorter time to symptom resolution (15.6 ± 12.4 days vs 27.2 ± 24.2 days, p = 0.02). After adjusting for potential confounders, early physical activity was associated with 5.8 lower odds of experiencing persistent symptoms (adjusted OR 5.83, 95% CI 2.05-16.61; p = 0.001). CONCLUSIONS A significant association between early physical activity and decreased symptom burden was observed. A lower proportion of those patients who engaged in early physical activity experienced persistent symptoms 28 days postinjury. However, low rates of early physical activity prior to the initial clinic visit were also observed, indicating that this approach may not be well known by acute care or primary care providers, or is not widely adopted by patients and families.

Objectives The objectives were 1) to compare the effects of adolescent sport-related concussion (SRC) and sport-related extremity fracture (SRF) on academic outcomes including change in school grades and school attendance; and 2) to determine which specific academic accommodations were most helpful during recovery from these injuries. Methods A prospective cohort study was conducted to compare changes in school grades, school attendance and academic accommodations among students (grades 8–12) with an SRC or SRF. School grades were extracted from student immediate pre- and post-injury report cards. Students completed attendance log books and an exit interview to determine which accommodations were helpful and how accommodating they perceived their school to be during their recovery. Results Overall, 124 students (92 with SRC and 32 with SRF) submitted both pre- and post-injury report cards. Students who sustained an SRC or SRF experienced similar decreases in grades post-injury (SRC: -1.0%; 95% CI: -2.1, 0.1 and SRF: -0.9%: 95% CI: -2.1, 0.3). Students with an SRC missed significantly more days of school compared to those with an SRF (median of 4 days [IQR: 1, 7] versus 1 day [IQR: 0, 4], p<0.0001). In total, 60/113 (53.1%) SRC students reported their school to be very accommodating while only 31/77 (40.3%) SRF students reported their school to be very accommodating (p = 0.082). Conclusions Students who sustain an SRC miss significantly more days of school but demonstrate similar changes in school grades post-injury compared to those with an SRF. Future studies are needed to identify the pre- and post-injury factors associated with poor academic functioning following concussion and identify measures that can be taken to help optimize academic outcomes in these patients.

Background: The endorsement of symptoms upon initiation of a graduated return-to-activity (GRTA) protocol has been associated with prolonged protocols. It is unclear whether there are specific symptom clusters affecting protocol durations. Purpose: To describe the endorsement of specific concussion symptom clusters at GRTA protocol initiation and examine the association between symptom cluster endorsement and GRTA protocol duration. Study Design: Cohort study; Level of evidence, 2. Methods: This study was conducted among cadets enrolled at 3 US service academies. Participants completed an evaluation upon GRTA protocol initiation. Participants endorsing symptoms were binarized based on 6 symptom clusters (cognitive, emotional, insomnia, physical, sensitivity, and ungrouped). The primary outcome of interest was GRTA protocol duration based on symptom cluster endorsement severity. Prevalence rates were calculated to describe symptom cluster endorsement. Kaplan-Meier survival estimates and univariate and multivariable Cox proportional hazards regression models were calculated for all 6 symptom clusters to estimate GRTA protocol duration while controlling for significant covariates. Results: Data from 961 concussed participants were analyzed. Of these, 636 participants were asymptomatic upon GRTA protocol initiation. Among the 325 symptomatic participants, the physical symptom cluster (80%) was most endorsed, followed by the cognitive (29%), insomnia (23%), ungrouped (19%), sensitivity (15%), and emotional (9%) clusters. Univariate results revealed a significant association between endorsing cognitive (hazard ratio [HR], 0.79; p = .001), physical (HR, 0.84; p < .001), insomnia (HR, 0.83; p = .013), sensitivity (HR, 0.70; p < .001), and ungrouped (HR, 0.75; p = .005) symptom clusters and GRTA protocol duration. Endorsing physical (HR, 0.84; p < .001) and sensitivity (HR, 0.81; p = .036) clusters maintained a significant association with GRTA protocol duration in the multivariable models. Conclusion: Participants endorsing physical or sensitivity symptom clusters displayed GRTA protocols prolonged by 16% to 19% compared with participants not endorsing that respective cluster after controlling for significant covariates.

OBJECTIVE To evaluate the effectiveness of a newly implemented return to learn (RTL) concussion protocol in an adolescent athletic population.

Background: Current consensus and position statements recommend that concussed patients be asymptomatic upon the initiation of the graduated return to activity (RTA) protocol. However, a significant number of concussed patients are beginning their RTA protocols while endorsing symptoms. Purpose: To characterize symptom endorsement at the beginning of the RTA protocol and examine the association between symptom endorsement and RTA protocol duration in service academy cadets. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort study was conducted with cadets at 3 US service academies. Postconcussion symptom inventories were recorded upon the initiation of an RTA protocol. The Sport Concussion Assessment Tool Symptom Inventory was used to classify participants into 3 groups (0 symptoms, 1 symptom, and ≥2 symptoms) upon the initiation of the RTA protocol. The primary outcome of interest was RTA protocol duration. Kaplan-Meier survival estimates were calculated to estimate RTA protocol duration by symptom endorsement, sex, varsity status, academic break, and time to graduated RTA initiation. Univariate and multivariable Cox proportional hazards models were used to estimate the association between symptom endorsement at the initiation of the RTA protocol and RTA protocol duration (α < .05). Results: Data were analyzed from 966 concussed cadets (36% women). Headache (42%) and faintness/dizziness (44%) were the most commonly endorsed symptoms on the Sport Concussion Assessment Tool-Third Edition and the Brief Symptom Inventory-18, respectively. Univariate results revealed a significant association between endorsing ≥2 symptoms and RTA protocol duration. In the multivariable model, endorsing ≥2 symptoms maintained a statistically significant association with RTA protocol duration. Significant associations were observed between RTA protocol duration and nonvarsity status (27% longer), women (15% longer), academic breaks (70% longer), and time to the initiation of the RTA protocol (1.1% longer daily incremental increase) after controlling for covariates. Conclusion: Symptom endorsement at the initiation of an RTA protocol was associated with RTA protocol duration. Cadets who had returned to preinjury baseline symptom burden or improved from baseline symptom burden and endorsed ≥2 symptoms at the initiation of the RTA protocol took longer to RTA.

Background: Organizations recommend that athletes should be asymptomatic or symptom-limited before initiating a graduated return-to-play (GRTP) protocol after sports-related concussion, although asymptomatic or symptom-limited is not well-defined. Hypotheses: (1) There will be a range (ie, beyond zero as indicator of “symptom-free”) in symptom severity endorsement when athletes are deemed ready to initiate a GRTP protocol. (2) Baseline symptom severity scores and demographic/preinjury medical history factors influence symptom severity scores at the commencement of the GRTP protocol. (3) Greater symptom severity scores at GRTP protocol initiation will result in longer protocol duration. (4) Symptom severity scores will not differ between those who did and did not sustain a repeat injury within 90 days of their initial injury. Study Design: Cohort study; Level of evidence, 2. Methods: Across 30 universities, athletes (N = 1531) completed assessments at baseline and before beginning the GRTP protocol, as determined by local medical staff. Symptom severity scores were recorded with the symptom checklist of the Sport Concussion Assessment Tool–3rd Edition. Nonparametric comparisons were used to examine the effect of medical, demographic, and injury factors on symptom endorsement at GRTP protocol initiation, as well as differences in symptom severity scores between those who did and did not sustain a repeat injury within 90 days. A Cox regression was used to examine the association between symptom severity scores at GRTP protocol initiation and protocol duration. Results: Symptom severity scores at the time when the GRTP protocol was initiated were as follows: 0 to 5 (n = 1378; 90.0%), 6 to 10 (n = 76; 5.0%), 11 to 20 (n = 42; 3.0%), and ≥21 (n = 35; 2.0%). Demographic (sex and age), medical (psychiatric disorders, attention-deficit/hyperactivity disorder, learning disorder), and other factors (baseline symptom endorsement and sleep) were significantly associated with higher symptom severity scores at the GRTP initiation (P < .05). The 4 GRTP initiation time point symptom severity score groups did not significantly differ in total time to unrestricted RTP, χ2(3) = 1.4; P = .73. When days until the initiation of the GRTP protocol was included as a covariate, symptom severity scores between 11 and 20 (P = .02; hazard ratio = 1.44; 95% CI, 1.06-1.96) and ≥21 (P < .001; hazard ratio = 1.88; 95% CI, 1.34-2.63) were significantly associated with a longer GRTP protocol duration as compared with symptom severity scores between 0 and 5. Symptom severity scores at GRTP initiation did not significantly differ between those who sustained a repeat injury within 90 days and those who did not (U = 29,893.5; P = .75). Conclusion: A range of symptom severity endorsement was observed at GRTP protocol initiation, with higher endorsement among those with higher baseline symptom endorsement and select demographic and medical history factors. Findings suggest that initiation of a GRTP protocol before an absolute absence of all symptoms is not associated with longer progression of the GRTP protocol, although symptom severity scores >10 were associated with longer duration of a GRTP protocol. Results can be utilized to guide clinicians toward optimal GRTP initiation (ie, balancing active recovery with avoidance of premature return to activity).

CONTEXT Implementation of a stepwise return-to-play (RTP) protocol has become the standard management strategy for high school athletes to ensure a safe RTP after concussion. The detailed characteristics of the recovery timeline throughout the steps of an RTP protocol have not been delineated among the adolescent population. OBJECTIVE To investigate the days spent in each step of the stepwise RTP protocol in an adolescent population and examine the effects of age and sex on recovery time. DESIGN Cross-sectional study. SETTING Local schools. PATIENTS OR OTHER PARTICIPANTS Student-athletes from 57 schools. INTERVENTION(S) A total of 726 patients with concussion (age = 15.5 ± 1.2 years, males = 454, females = 272) were included. The 7-step RTP protocol consists of the following steps: (1) complete cognitive rest, (2) full return to school, (3) light exercise, (4) running progression, (5) noncontact training drills and weight training, (6) full-contact practice or training, and (7) return to game play. The data were obtained by certified athletic trainers as a part of statewide standardized concussion-management protocol. MAIN OUTCOME MEASURE(S) Days spent in steps 0 to 6 as well as a breakdown of days by sex and age. RESULTS The average total RTP days were 20.2 ± 13.9. Half of this time was spent in the return-to-school phase (steps 2-3: 10.2 ± 10.0 days). Compared with 17-year-old participants, younger participants (age = 14-16 years) took 3 or 4 days longer to start step 3 and to reach step 6 (P < .05). Females took longer to reach step 6 than males (21.6 ± 15.5 versus 19.3 ± 12.7 days) because they took longer to reach step 3 (14.7 ± 11.4 days) than males (13.0 ± 10.0 days; P < .05). CONCLUSIONS Our study provides an estimated stepwise concussion recovery timeline for adolescent student-athletes. Clearance to start step 3 was the benchmark for the recovery timeline, as the duration of the exercise portion of the protocol was consistent across the age and sex groups.

No abstract available

Abstract Recommendations for returning students to sports and school after concussion are well developed, but at present there are no specific guidelines for returning students to physical education (PE). Many schools utilize current return-to-play protocols for returning students to PE after concussion, which can result in students being prohibited from participation in the PE curriculum until they are symptom free, fully recovered, and medically cleared for all activities. Amid growing evidence that participation in exercise and other “normal” activities facilitates recovery from concussion, students should be allowed to return to PE class even while still experiencing concussion symptoms. A new return-to-physical education (RT-PE) process is presented here that helps to return students safely and successfully to PE while they are recovering from concussion and are still symptomatic. This process mirrors the existing return-to-play protocol, but with important differences. A key component of the proposed RT-PE process is good communication between the student, parents, PE teacher, school nurse and outside medical providers.

Pediatric concussion frequently disrupts school participation, yet approaches to returning to the academic environment remain inconsistently implemented despite growing consensus on the benefits of early, supported school re-entry. This review synthesizes the extant literature on the evidence, clinical guidelines, educational policy, and multidisciplinary practice to examine return to school related issues for youth following concussion and to identify gaps between established recommendations and real-world applications. Across national and international guidelines, early return to school with symptom-limited cognitive activity is consistently endorsed, while prolonged cognitive rest and delayed academic re-entry are no longer supported. Additionally, students commonly experience learning, sensory, emotional, and environmental challenges that extend beyond school re-entry alone, especially in secondary settings with greater demand variability, highlighting limitations of narrowly framed "return-to-learn" (RTL) and "return-to-school" (RTS) models. Evidence indicates that concussion-related school difficulty reflects an interaction among personal factors such as symptom burden and cognitive endurance, with medical guidance, environmental demands, and institutional constraints, with older students potentially facing disproportionate challenges. Although multidisciplinary care models-including school-based teams, rehabilitation providers, and mental health and medical professionals-are widely recommended, operational guidance for role delineation, communication, and accommodation fidelity remains limited, oftentimes resulting in delays in implementation. As a result, practices related to returning students to the academic environment vary widely across schools and jurisdictions, contributing to inequitable access to effective supports. This review emphasizes the need to facilitate supported return to full school participation rather than solely academic reintegration and outlines practical strategies and research priorities to improve implementation and outcomes.

Supplemental Digital Content is Available in the Text. Objective: The need to have a pediatric-specific concussion management protocol on Return to School (RTS) and Return to Activity (RTA) after concussion has been recognized internationally. The first step to evaluate the protocol effectiveness is to establish whether children and youth are adhering to these recommendations. The objective of this study was to explore the prevalence and predictors of adherence to RTS and RTA concussion management protocols for children/youth. Design: A prospective cohort of children/youth with concussion. Setting: Childhood Disability Research Centre. Participants: One hundred thirty-nine children/youth aged 5 to 18 years, diagnosed with concussion and symptomatic upon enrollment, were followed for up to 6 months. Primary recruitment occurred from a Children's Hospital Emergency Department. Intervention: Provision of RTS/RTA guidelines. Main Outcome Measures: Measurement of adherence came from multiple sources, including the child's and parent's knowledge of protocols, research personnel evaluations, and self-reported stages of RTS/RTA and Post-Concussion Symptom Scale (PCSS) scores. Results: Spearman correlations and logistic regression were used, investigating the relationship between PCSS and progression of protocols and determining predictors of adherence. Significant negative associations between total PCSS score and stage of RTS/RTA protocols were found. Fifty-three percent and 56% of the participants adhered to the RTS and RTA protocols, respectively. Conclusions: Children's knowledge of protocols and total PCSS scores significantly predicted adherence to RTS/RTA and may be the most important factors in predicting adherence during recovery from concussion.

Objectives: Growing evidence suggests that there may be significant long term sequellae of cumulative concussions, which may include prolonged cognitive deficits and physical symptoms. There are a growing number of concussions each year in high school athletes that occur during sports. The objective of this study is to investigate the impact of cerebral concussions on athletes to gain a deeper understanding of sports related cerebral concussions that will ultimately lead to development of better management and prevention strategies. The hypothesis of the current study is that adolescent athletes who suffer from sports-related concussions demonstrate neurocognitive and neuropsychological deficits that affect both athletic and academic performance. To date, no current guidelines exist for return to academic activities, such as classroom attendance and schoolwork. Methods: A review of prospectively collected data of all student athletes who suffered a concussion during athletics in a single high school from 2006 to 2010. The following validated patient-reported outcome scores were used to assess function and symptom scores pre- and post-injury: Impact Score, and SAC score. Concussed athletes completed baseline and post injury Immediate Post-concussion Assessment and Cognitive Test (ImPACT), and SAC testing on the same day. Athletes then followed the Zurich consensus guidelines for RTP. Documented concussions were categorized by time missed from participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7- to 9-day return, 10- to 21-day return, >21-day return, no return). All clinical notes from a single athletic trainer were reviewed for each athlete. The clinical data collected included patient demographics, history of concussions/migraine headaches/ depression/ anxiety, current concussion components, sideline (SAC) and computer-based (ImPact) neurocognitive testing, physical exertion post-concussion, and the total number of days to return to play. Results: There were 120 concussions that occurred during athletics in a single high school between 2006 and 2011. There were 104 athletes (107 concussions) included in our study (64 males, 40 females). The average age at time of injury was 16 ± 1.24 years (Range 14-20). There were 62 injuries with an on Field SAC exam (Average 25 ± 3), 81 patients had a SAC exam 1 day after injury, 43 patients had both on field and post day 1 injury SAC exams (Mean Difference in scores 3±4). The average time until asymptomatic was 20 (Range 4-147) days, and average time for RTP was 39 (Range 6-147) days. In this cohort of high school athletes, RTP within the first week after concussion was unlikely. There were 7 athletes who had documented academic accommodations. Conclusion: Athletes that suffered a concussion during athletic play were unlikely to return to sports in less than a week. We found the Zurich consensus exertion protocol was important to differentiate athletes that were asymptomatic at rest, but had return of symptoms with exertional stress. Based on these results athletes were able to safely return to play without re-injury once the SAC and ImPACT test returned to baseline. In addition, athletes subjectively had an improvement in symptoms when academic accommodations were instituted as well.

Improvements have been made in the management of concussions, and this includes the methods for advising concussed patients about the processes to be followed for return to play (RTP) in sports, return to learn (RTL) in schools, and return to work (RTW) on the job. The aim of management is to facilitate return by a graduated process of steps during which an individual’s thresholds for exacerbation of symptoms are used as a guide, with advice given not to exceed these thresholds. There are no available objective biomarkers to guide these processes and so advice and monitoring are based on clinical findings.