Objective: To determine the number of prior concussions associated with increased incidence of persistent postconcussive symptoms (PPCS) in a cohort of acutely concussed pediatric patients. Design: Prospective observational cohort study. Setting: Three university-affiliated concussion clinics. Participants: Two hundred seventy participants (14.9 ± 1.9 years, 62% male, 54% with prior concussion) were assessed within 14 days of concussion and followed to clinical recovery. Participants with a second head injury before clinical recovery were excluded. Measures: and Main Outcome: Concussion history, current injury characteristics, recovery time, and risk for prolonged recovery from current concussion. Results: There was no statistically significant change in PPCS risk for participants with 0, 1 or 2 prior concussions; however, participants with 3 or more prior concussions had a significantly greater risk of PPCS. Twelve participants sustained a subsequent concussion after clinical recovery from their first injury and were treated as a separate cohort. Our secondary analysis found that these participants took longer to recover and had a greater incidence of PPCS during recovery from their latest concussion. Conclusion: Pediatric patients with a history of 3 or more concussions are at greater risk of PPCS than those with fewer than 3 prior concussions.

Oculomotor dysfunction identified within the first 10 days of sport-related concussion (SRC) is a risk factor for Persisting Post-Concussion Symptoms (PPCS). Oculomotor rehabilitation is the recommended treatment for oculomotor dysfunction from the subacute period onwards. However, there are delays in initiating rehabilitation due to a limited number of specialized providers and associated healthcare costs. Delays in initiating treatment are associated with worse outcomes. We performed a retrospective, quasi-experimental trial to evaluate whether providing instructions for self-guided oculomotor rehabilitation in adolescents with 3 or more abnormal oculomotor findings after SRC (Experimental Arm, n = 27, mean age = 15.50 ± 1.53 years, 63.0% male, 5.74 ± 2.43 days since injury) reduced the number of persisting impairments at 4 weeks compared to a wait-and-see approach (Standard Care Arm, n = 106, mean age = 14.98 ± 1.87 years, 59.4% male, 5.69 ± 2.78 days since injury). A small difference was seen in the incidence of neck tenderness but there were no differences between groups in symptom severity or number of abnormal oculomotor findings at initial presentation. Overall, 50 out of 106 (47.2%) participants in the Standard Care Arm had PPCS compared to 7 out of 27 (25.9%) in the Experimental Arm, which was significantly different (Chi-squared = 3.966, p = 0.046). This corresponds to an absolute risk reduction of 21.3%. Results from our pilot study suggest these treatment guidelines are feasible to incorporate into a busy outpatient practice in a cost-effective manner. Prospectively designed randomized controlled trials are warranted to validate the effectiveness of this treatment.

PurposeTo compare clinical characteristics in patients with concussions sustained by prevalent, but understudied, mechanisms (work-related concussion [WRC] and motor vehicle collision [MVC]-related concussion) to sport-related concussion (SRC).MethodsRetrospective review of 281 electronic medical records from an outpatient concussion clinic. Time since injury (days), duration of care (days), amount of care (number of visits), and perceived health (Short-Form 12) were collected.ResultsThe time between injury and clinic presentation was significantly greater in WRC and MVC-related concussion compared to SRC. These groups were also older, had a longer duration of care, required more referrals for outside clinical services, and reported worse perceived mental and physical health versus SRC.ConclusionThese results suggest that clinical courses may be significantly different for individuals with SRC, WRC and MVC-related concussion, and that different management approaches and expectations may be necessary for these groups. Further research is indicated.

Objective: To assess sex differences in behavior and motivation of adolescent athletes with sport-related concussion (SRC) versus controls during a 2-week individualized aerobic exercise intervention. Setting: Academic center research laboratory. Participants: Participants were enrolled within 10 days of SRC (n = 32; 15.6 ± 1.4 years, 33% female, 6.18 ± 2.21 days from injury). Twenty-eight control participants (16.0 ± 1.6 years, 33% female) were recruited. Design: Randomized control trial with a 1:1 block randomization scheme stratified by participant sex. Main Measures: Clinical recovery time as determined by the study physician, heart rate threshold (HRt) on the Buffalo Concussion Treadmill Test, adherence rates (calculated as exercise volume completed/exercise volume prescribed), and behavioral assessments including the perceived competence scale (PCS) and the treatment self-regulation questionnaire (TSRQ). Results: Females achieved higher initial HRts ( P = .007), ie, the maximum HR during exercise testing. Males and females with a concussion showed minimal differences in motivation and perceived competence. Although it did not reach statistical significance ( P = .058), females in the low-volume group appeared to recover faster than the high-volume group. This trend was not seen in males. Seven (88%) of exercise-intolerant females had to stop an exercise bout early on 1 or more days due to more-than-mild symptom exacerbation versus 3 (17%) of exercise-intolerant males ( P = .002). Conclusion: Females with a concussion prescribed a high volume of aerobic exercise treatment appeared to take longer to recover than females with a concussion who were prescribed a lower volume, which was not seen in males. Increased training heart rate prescriptions due to higher initial HRts and symptom exacerbation during at-home exercise may have affected female exercise behavior. Although aerobic exercise benefits SRC recovery, this study highlights the need for future research to optimize exercise treatment prescriptions for females after SRC.

Aerobic exercise is safe and beneficial for adolescent athletes recovering from sport-related concussion (SRC). The results of systematic graded exercise testing are used to create individualized, subsymptom heart rate threshold (HRt) aerobic exercise treatment programs for adolescents after SRC. Many clinicians, however, do not have access to graded exercise tests. This article presents a safe, systematic, evidence-based exercise program that clinicians can prescribe, progress, and modify to help manage acute pediatric SRC without the need for formal exercise testing. The exercise prescription accounts for sex and days since injury but not age because our analysis indicates age does not significantly affect the HRt on graded exercise testing. This article provides clinicians without access to graded exercise testing a viable option for prescribing exercise treatment to adolescents in the early phase after SRC.