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Tamara C. Valovich McLeod, Megan N. Houston and Cailee E. Welch

Concussions resulting from sports and recreational activities are a significant concern in the pediatric population. The number of children and adolescents sustaining sport-related concussions is increasing and, as a result, legislation has been passed in all 50 states to ensure appropriate recognition and referral of pediatric athletes following concussion. The developing brain may make the diagnosis, assessment, and management of concussion more challenging for health care providers and requires the use of specific age-appropriate assessment tools. Concussion management must also include considerations for cognitive and physical rest, a collaborative concussion management team that includes medical and school personnel, and more conservative stepwise progressions for returning to school and to physical activity.

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Katrina G. Ritter, Matthew J. Hussey and Tamara C. Valovich McLeod

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

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Tamara C. Valovich McLeod and Johna K. Register-Mihalik

Patient Scenario:

An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life.

Clinical Outcomes Assessment:

Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms.

Clinical Decision Making:

The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete’s symptoms.

Clinical Bottom Line:

Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.

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Brandy J. Mailer, Tamara C. Valovich McLeod and R. Curtis Bay

Context:

Clinicians often rely on the self-report symptoms of patients in making clinical decisions; hence it is important that these scales be reliable.

Objective:

To determine the test-retest reliability of healthy youth in completing a graded symptom scale (GSS), modified from the Head Injury Scale Self-Report Concussion Symptoms Scale (HIS).

Design:

Repeated-measures.

Setting:

Middle school classroom.

Patients or Other Participants:

126 middle school students.

Intervention:

A survey consisting of a demographic and life events questionnaire and a GSS asking about symptom severity and duration.

Main Outcomes Measures:

Score for each symptom on the severity and duration scale and a total symptom score (TSS) and the total number of symptoms endorsed (TSE) from the severity scale. Responses on a life events questionnaire were also recorded.

Results:

We found excellent reliability for TSS (ICC = .93) and TSE (ICC = .88) for the severity scale. We found moderate to excellent reliability on the individual symptoms of both the severity (ICC = .65-.89) and duration (ICC =.56-.96) scales.

Conclusions:

Healthy youth can reliably self-report symptoms using a GSS. This patient-oriented outcome measure should be incorporated into more investigations in this age group.

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Melissa C. Kay, Cailee E. Welch and Tamara C. Valovich McLeod

Clinical Scenario:

Concussions are one of the most common sport-related injuries affecting athletes participating at all levels across a variety of sports. It has been reported that up to 3.8 million concussive events occur per year that are sports-related. One significant issue with identifying concussions is that a clinical diagnosis is based on the presence of signs and symptoms, which are self-reported by the patient. In the adolescent population, injury to the brain is possible with even the slightest insult, which can affect recovery and predispose them to subsequent concussions. Recent legislative efforts have included athlete education as a means to improve concussion reporting. More specifically, all 50 US states and the District of Columbia have implemented concussion legislation that includes some type of concussion education protocol, but there is still little evidence to suggest that enhanced knowledge levels result in behavior changes, including improved concussion-reporting practices. It is unclear what factors make an adolescent athlete more or less likely to report the symptoms of a concussion.

Focused Clinical Question:

What factors positively or negatively influence secondary school athletes’ likelihood of reporting symptoms of sport-related concussions?

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Nicholas Hattrup, Hannah Gray, Mark Krumholtz and Tamara C. Valovich McLeod

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.

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Michelle L. Weber, Kelsey J. Picha and Tamara C. Valovich McLeod

Calcaneal apophysitis, or Sever's disease, is common among physically active youth between the ages of 8-15. This condition is related to skeletal growth during maturation and relief often comes once growth is complete. However, it is not feasible to limit participation in physical activity until growth ceases; therefore, it is important to determine effective interventions to regulate pain while continuing participation. A search of the literature yielded nine studies that met the inclusion criteria and were included for data analysis. Within these publications, many treatment methods were suggested, including nonsteroidal anti-inflammatory drugs (NSAIDs), taping, orthoses, heel lifts, stretching, activity modification, and ice. However, few of the treatment options were compared with a control group. Analysis revealed that clinicians should provide treatments with caution when treating patients suffering from Sever's disease, understanding that strong evidence is not supportive of one treatment option alone. Data are limited for individual treatments related to calcaneal apophysitis and more research in this area is warranted. Clinicians should work with patients on an individual basis to determine if one form of treatment provides a reduction of pain and allows that patient to continue with activity.

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Tamara C. Valovich McLeod and Gerard A. Gioia

Edited by John Parsons

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Alison R. Snyder and Tamara C. Valovich McLeod

Edited by Gary Wilkerson