Policy change is a powerful tool capable of influencing health outcomes. Policy changes targeting seat belt use and child car seat regulations improved motor vehicle safety,1,2 earlier screening reduced mortality from colorectal3 and breast4 cancer, and immunization decreased cases, hospitalizations, and deaths from vaccine-preventable diseases,5 all leading to major advancements in public health.6 In the context of sport, policies surrounding automated external defibrillators, heat acclimatization, proper tackling, and sickle cell trait have increased safety and reduced sudden athlete death.7 Specific to concussion, policy change efforts have primarily focused on injury prevention as most pediatric concussions occur through sport-related mechanisms.8 Policy changes eliminating body checking in youth ice hockey9,10 and altering kickoff rules in college football11 both reduced concussion risk. To our knowledge, no studies have explored how policies targeting concussion management practices can affect recovery outcomes after injury.
Concussion management recommendations have evolved from prescribed rest until complete symptom resolution12 to current guidelines promoting physical activity as tolerated starting 24 to 48 hours after injury.13 Exercise interventions prescribed acutely after injury reduce symptom burden and overall recovery time.14–16 Broader, physiotherapy-based treatments similarly improve clinical presentation in individuals with concussion,17,18 but earlier enrollment in these programs is not consistently associated with shorter recoveries.18–21 Although mounting evidence supports the safety15,19,22 and effectiveness15,17 of acute concussion rehabilitation, practically implementing such management practices can be difficult within the recommended 48-hour window. For example, most children with concussion do not present to outpatient specialty clinics until 4 to 14 days after concussion.23–26 Poor health care access (eg, restricted finances, geographical remoteness) and limited clinic resources or personnel may further delay enrollment into postconcussion treatment programs. Thus, although it is optimal to initiate concussion rehabilitation within the acute postinjury period, such early enrollment is not always feasible.
The Montreal Children’s Hospital Concussion Clinic (MCHCC) is a publicly funded, interprofessional specialty clinic providing care to over 700 children and adolescents (5–17 y old) annually at no cost to families. Prior to September 2017, MCHCC policy prohibited enrollment into active rehabilitation services until at least 4 weeks following concussion, although slightly earlier entry was allowed based on the clinical judgment of the treating physiotherapist. Following a series of in-house pilot studies confirming safety and feasibility,22,27 the MCHCC policy was amended in September 2017 to begin active rehabilitation 2 weeks postconcussion, which was determined by clinic personnel to be the earliest that treatment could be feasibly initiated given the clinic’s available personnel, large patient volume, and available resources. Thus, the goal of this updated institutional policy was not to provide acute concussion rehabilitation but to promote considerably earlier treatment entry than previously allowed by balancing updated recommendations for treatment sooner after injury with the unique demands of the specific clinical site. However, the effect of this policy change on clinical recovery outcomes for children seeking care at this clinic remains unknown.
Our primary purpose was to determine whether children accessing care at the clinic postpolicy change enrolled into active, physiotherapy-based treatment services sooner after concussion as intended. Secondary purposes were to evaluate the effect of this policy change on clinical recovery time and symptom presentation in children with concussion. We hypothesized that children accessing care at the MCHCC postpolicy change would engage in treatment services earlier after injury, leading to faster recovery times and fewer postconcussion symptoms than children accessing care prepolicy change.
Methods
Study Design
The MCHCC prospectively collects and maintains clinical data on children with concussion presenting for evaluation and treatment. A secondary analysis of these prospective cohort data was conducted on patients seen at the MCHCC between September 2015 and August 2019. This study period corresponds to the 2 years immediately preceding and following the September 2017 policy change. No components of patient care besides earlier eligibility to begin aerobic exercise-based treatment services were altered with the policy change, and concussion management services otherwise remained consistent over the 4-year study period.
Patients
All pediatric concussion patients seen during the study period were eligible for inclusion. If a patient was treated for multiple concussions, only the most recent injury was included, and prior injuries were removed from the data set. A total of 2412 episodes of care were eligible. Due to a lack of manpower to manually review and extract additional data from all medical records, approximately one quarter (n = 600, 24.9%) of eligible cases were selected using a random number generator. To ensure equal representation, 150 patients were randomly selected from each of the 4 years included in the study period. This study was approved by the McGill University Health Centre (Pediatrics Review Board; #2019-4723).
Procedures
The MCHCC is an urban, single-site, publicly funded, interprofessional clinic specializing in the assessment and treatment of concussion in children aged 5–17 years old. It is located within a university-affiliated pediatric trauma center, and all patients must be diagnosed with a concussion by a licensed physician to access care. A trauma coordinator, who is a licensed physiotherapist or nurse, oversaw care for all patients. The trauma coordinator gathered demographic information, self-reported health history, and postconcussion information during a standard intake interview with patients and their caregiver. The trauma coordinator provided all patients with general education, reassurance, and energy conservation advice as encouraged by various associations and consensus groups.12 The trauma coordinator also created an individualized return-to-learn plan and oversaw postconcussive headache management as clinically indicated. Finally, the trauma coordinator managed referrals to other specialists when required. Most patients (∼90%) were referred to physiotherapists within the MCHCC for additional evaluation and treatment or clearance to return to sport, although in-house psychologists and neuropsychologists provided care for ∼10% of patients. The MCHCC also works closely with other medical professionals (emergency department physicians, occupational therapists, speech language pathologists, etc) within the Montreal Children’s Hospital and in the broader community as needed.
The treating physiotherapist completed a neurological examination, evaluated a variety of clinical domains (eg, balance, visual/vestibular, etc), prescribed personalized treatment, and, when applicable, oversaw return-to-sport programs. If clinically indicated, a physiotherapy-based active rehabilitation program was developed and consisted of (1) an individualized aerobic exercise-based program, with sport-specific exercises (eg, coordination exercises, agility and ball-handling drills, etc) added for those participating in sport22,28; (2) musculoskeletal approaches to address neck pain or dysfunction (eg, stretches, ice/heat, massage, etc); and (3) vestibular therapy for oculomotor or vestibular deficits (eg, static or dynamic balance exercises, gaze stabilization, etc). The treatment program (eg, type of exercise, frequency, duration, etc) was prescribed and reviewed by the physiotherapist at each clinic visit, but the patient completed all treatment sessions at home. Patients were followed approximately every 2 weeks until full recovery, which was defined as resolution of postinjury deficits (including symptoms), full return to school without accommodation, and successful completion of moderate to vigorous exercise without symptom recurrence.
Main Outcome Measures
Beyond the initial physiotherapy visit where a standardized assessment is performed, the evaluations and treatments provided to each patient vary based on individualized need as indicated by the clinical judgment of the treating physiotherapist. As such, a variety of variables, including but not limited to symptom, physiotherapy examination, exertion testing, and clinical recovery outcomes, may be collected at each visit. However, as this study evaluated the effect of the policy change on treatment initiation and clinical recovery more broadly, time to treatment, time to recovery, and symptom variables were selected as the primary outcomes of interest.
Time to treatment was defined as the number of days between concussion and the initiation of physiotherapy-based treatment services. Clinical recovery time was evaluated using 3 outcomes: (1) total recovery time, the number of days between concussion and full clinical recovery (see foregoing recovery definition); (2) time engaged in rehabilitation services, the number of days between the initiation of active rehabilitation and full clinical recovery; and (3) length of episode of care, the number of days between initial clinic presentation and full clinical recovery.
The Post-Concussion Symptom Inventory (PCSI) is a set of validated symptom checklists tailored to children and adolescents.29 Patients rated their preinjury symptoms (retrospective recall) and postinjury symptoms (the day of their clinic visit and/or the previous day) at each visit. Adolescents aged 13–17 years rated 20 symptoms from “not present” (0) to “severe” (6), and children aged 8–12 years rated 17 symptoms from 0 (“not present”) to 2 (“severe”). The total preinjury score, postinjury score, and change score (postinjury minus preinjury score) from each time point were analyzed.
A binary classification of persistent postconcussion symptoms (PPCS) was derived from the PCSI evaluation completed as close to (but not before) 4 weeks postinjury. PPCS was defined as 3 new or worse symptoms compared with preinjury levels at ≥28 days postinjury in line with prior literature.30
Statistical Analysis
All statistical analyses were completed in SAS (version 9.4, SAS Institute Inc). Descriptive statistics for patient and injury characteristics were compared using Mann–Whitney U (continuous) or chi-square (categorical) analyses. Recovery outcomes were analyzed using Kaplan–Meier and Cox proportional hazard models. All Cox models adjusted for sex, age, days to initial clinic presentation, a summary item from the PCSI, and prior concussion history, which were selected based on their relationship to concussion recovery outcomes.31 Individuals lost to follow-up prior to full recovery were censored at the date of their last in-person clinic visit. Odds ratios (ORs) were interpreted as32 small effect = 1.2 ≤ OR ≤ 1.71, medium effect = 1.72 ≤ OR ≤ 2.4, and large effect = OR > 2.4. Symptom outcomes were assessed using mixed linear models. Scores for up to the first 3 physiotherapy visits were available; thus, separate 3 (visit) by 2 (policy change group) linear mixed effect models were run for all PCSI outcomes. A repeated term was included to account for multiple observations from a single patient. Tukey post hoc analyses were performed as appropriate, and adjusted P values are reported throughout. Multivariable linear mixed models controlled for identical covariates as the Cox models, except days to initial clinic presentation, which was substituted for days to physio visit (ie, number of days between concussion and each of the 3 physiotherapy visits included in the model). Chi-square analyses assessed the proportion of patients with PPCS between policy change groups. Individuals without symptom reports at 4 weeks postconcussion were (1) labeled as “no PCSS” if they were clinically recovered and discharged before this time or (2) excluded from this analysis.
Many patients randomly selected to compose our sample (n = 178, 29.7%) were not seen in the clinic until 4 or more weeks postconcussion due to seeking initial care from another health care professional or delayed care seeking behaviors more generally. For these patients, the policy change would not affect their clinical care as patients presenting ≥4 weeks postinjury were always immediately eligible for treatment services. Instead of removing these patients from our database, we analyzed data from patients presenting ≤28 days postconcussion (acute care seekers) or ≥29 days postconcussion (chronic care seekers) in separate analyses. This approach avoids the potential for chronic care seekers unaffected by the policy change to mask findings in acute care seekers targeted by the policy change and establishes whether natural variations over the 4-year study period (eg, differences in clinic clientele) were present, which may potentially confound results.
Results
Physiotherapy-Based Treatment Services Began Significantly Earlier Postpolicy Change
For acute care seekers presenting within 4 weeks of injury, patients in the postpolicy change group were slightly older (P = .01) and more likely to self-report a history of attention deficit/hyperactivity disorder (P = .006; Table 1). Otherwise, no differences in patient characteristics were observed between groups. All patients regardless of policy change group reported to the clinic a median of 10 days following concussion (P = .99) where they began receiving trauma coordinator-led services as clinically indicated. Just under half of the patients (43.7%) sampled were not prescribed at-home, physiotherapy-based rehabilitation services due to patients achieving clinical recovery at their initial visit (n = 201) or being lost to follow-up prior to treatment eligibility (n = 57). For patients requiring active treatment, the postpolicy change group (median = 22 d [interquartile range: 17–27]) started at-home, physiotherapy-based rehabilitation services significant earlier than patients in the prepolicy change group as expected (median = 26 d [interquartile range: 24–30], P < .001).
Patient Characteristics Presented Separately By Policy Change and Clinic Presentation Group
| Acute care seekers (≤4 wk postinjury) | Chronic care seekers (>4 wk postinjury) | |||||
|---|---|---|---|---|---|---|
| Prepolicy change | Postpolicy change | P | Prepolicy change | Postpolicy change | P | |
| n = 220 | n = 202 | n = 80 | n = 98 | |||
| Age, median (IQR) | 14 (12–15) | 14 (12–16) | .01 | 15 (13–16) | 14 (12–16) | .12 |
| Gender, n (%) | ||||||
| Girls | 103 (46.8) | 108 (53.5) | .17 | 49 (61.2) | 65 (66.3) | .48 |
| Boys | 117 (53.2) | 94 (46.5) | 31 (38.8) | 33 (33.7) | ||
| Primary language, n (%) | ||||||
| French | 107 (48.6) | 104 (51.5) | .09 | 50 (62.5) | 72 (73.5) | .19 |
| English | 108 (49.1) | 98 (48.5) | 29 (36.3) | 26 (26.5) | ||
| Bilingual | 5 (2.3) | 0 (0) | 1 (1.2) | 0 (0) | ||
| Mechanism of injury, n (%) | ||||||
| Sport related | 150 (68.2) | 131 (64.9) | .47 | 57 (71.3) | 59 (60.2) | .12 |
| Nonsport related | 70 (31.8) | 71 (35.2) | 23 (28.9) | 39 (39.8) | ||
| Previous concussion, n (%) | ||||||
| Yes, 1 or more | 80 (36.4) | 80 (39.6) | .49 | 23 (28.8) | 31 (31.6) | .68 |
| No | 140 (63.6) | 122 (60.4) | 57 (71.2) | 67 (68.4) | ||
| Premorbid conditions, n (%) | ||||||
| Migraine | 90 (40.9) | 78 (38.6) | .63 | 30 (37.5) | 43 (43.9) | .39 |
| Dizziness | 55 (25.0) | 40 (19.8) | .20 | 19 (23.8) | 20 (20.4) | .59 |
| Sleep problems | 57 (25.9) | 48 (23.8) | .61 | 26 (32.5) | 25 (25.5) | .30 |
| Anxiety | 94 (42.7) | 96 (47.5) | .32 | 51 (63.8) | 52 (53.0) | .15 |
| Depression | 15 (6.8) | 23 (11.4) | .10 | 13 (16.3) | 10 (10.2) | .23 |
| Attention disorder | 17 (7.7) | 33 (16.3) | .006 | 9 (11.3) | 9 (9.2) | .65 |
| Learning disorder | 12 (5.5) | 20 (9.9) | .08 | 2 (2.5) | 6 (6.1) | .25 |
| Time to clinic presentation, median (IQR) | 10 (7–16) | 10 (7–17) | .99 | 49 (36–90) | 49 (38–91) | .85 |
| Time to rehabilitation start, median (IQR) | 26 (24–30) | 22 (17–27) | <.001 | 48 (37–87) | 49 (37–78) | .90 |
Note: Time to clinic is the number of days from concussion to the initial Montreal Children’s Hospital Concussion Clinic visit. Time to rehabilitation start is the number of days from concussion to when active rehabilitation services were initiated. Bilingual means equally comfortable in French and English. IQR indicates interquartile range.
Bold values indicate a statistically significant difference (P < .05)
Earlier Treatment Enrollment Postpolicy Change Improved Recovery for Acute Care Seekers
Kaplan–Meier curves revealed significant effects of the policy change on all time to recovery outcomes. The episode of care (prepolicy change = 40 [41] d; postpolicy change = 33 [28] d; χ2(1) = 8.91, P = .003), length of rehabilitation for individuals prescribed active therapy (prepolicy change = 49 [46] days; postpolicy change = 38 [25] d; χ2(1) = 8.16, P = .004), and total recovery time (prepolicy change = 52 [42] d; postpolicy change = 45 [30] d; χ2(1) = 8.32, P = .004) were significantly shorter postpolicy change, when patients were allowed to engage in rehabilitation earlier after concussion (Figure 1). In the multivariable Cox models, episode of care (χ2(1) = 11.55, P < .001, OR = 1.49; 95% confidence interval [CI], 1.19–1.88), rehabilitation services (χ2(1) = 9.47, P = .002, OR = 1.73; 95% CI, 1.22–2.45), and recovery (χ2(1) = 11.53, P < .001, OR = 1.49; 95% CI, 1.18–1.88) length remained significantly reduced postpolicy change even when controlling for other factors related to concussion recovery.
—Kaplan–Meier curves for length of rehabilitation services received (Panel A), episode of care (Panel B), and total recovery time (Panel C). Note: Figures reflect data for acute care seekers (those presenting ≤4 wk after injury) only. The x-axis represents time since concussion, probability of recovery is reflected on the y-axis.
Citation: Journal of Sport Rehabilitation 34, 3; 10.1123/jsr.2024-0097
Descriptive information for all symptom outcomes is presented in Table 2. A main effect of time (F2,321 = 11.2, P < .001) and group (F1,371 = 12.2, P < .001) was present for retrospective recall of preinjury (ie, baseline) symptom ratings such that the preinjury symptoms generally decreased over time and were higher in the postpolicy change group. Significant group by time interactions were present for current postinjury (F2,322 = 3.70, P = .03) and symptom change scores (F2,316 = 5.3, P = .005), suggesting that the postpolicy change group had greater symptom improvements over time. Both groups reported fewer total postinjury symptoms from visit 1 to visit 2 (P < .001), although only the postpolicy change group reported significantly fewer symptoms between visits 2 and 3 (P = .006). For the symptom change score, the postpolicy change group reported fewer symptoms between visits 1 and 2 (P = .02) only, and no differences were found in the prepolicy change group (Figure 2). In multivariable linear mixed effects models controlling for other modifiers of concussion recovery, the same effects were retained. Main effects of group (F1,363 = 13.5, P < .001) and visit (F2,308 = 10.3, P < .001) were present for preinjury scores, whereas interaction effects remained significant for postinjury (F2,309 = 3.7, P = .03) and symptom change (F2,308 = 5.6, P = .004) scores.
Descriptive Information for All Symptom Outcomes
| Clinic presentation | Time | Days since injury | PCSI pre | PCSI post | PCSI change | ||||
|---|---|---|---|---|---|---|---|---|---|
| Prepolicy change | Postpolicy change | Prepolicy change | Postpolicy change | Prepolicy change | Postpolicy change | Prepolicy change | Postpolicy change | ||
| Acute care seekers | Visit 1 | 26.4 (13.2) | 22.9 (11.4) | 5.1 (8.4) | 7.9 (10.7) | 12.4 (15.7) | 17.7 (20.3) | 7.3 (13.6) | 9.8 (14.9) |
| Visit 2 | 44.9 (18.4) | 41.7 (16.5) | 4.1 (7.5) | 8.0 (11.5) | 11.4 (14.1) | 13.4 (15.8) | 7.4 (13.1) | 5.4 (11.6) | |
| Visit 3 | 62.8 (17.4) | 63.5 (22.1) | 3.8 (5.1) | 6.2 (8.9) | 11.3 (17.0) | 11.0 (14.6) | 7.6 (14.5) | 4.8 (10.6) | |
| Chronic care seekers | Visit 1 | 77.3 (70.5) | 67.6 (47.6) | 12.4 (13.5) | 9.5 (11.2) | 35.1 (25.6) | 31.0 (27.5) | 22.7 (20.2) | 21.5 (21.4) |
| Visit 2 | 96.5 (72.5) | 80.9 (46.2) | 9.1 (10.2) | 7.6 (11.8) | 22.2 (21.9) | 19.8 (23.0) | 11.7 (14.6) | 12.2 (19.8) | |
| Visit 3 | 107.8 (54.5) | 112.8 (54.0) | 8.9 (9.9) | 4.9 (5.9) | 24.8 (21.5) | 17.0 (20.9) | 15.1 (19.3) | 12.1 (19.9) | |
Abbreviation: PCSI, Post-Concussion Symptom Inventory. Note: The acute care seekers were patients accessing care ≤ 4 weeks postconcussion, who were affected by the institutional policy change encouraging earlier enrollment into treatment services. The chronic care seekers had their initial clinic visit >4 weeks postinjury and were unaffected by the institutional policy change. The average number of days between concussion and the symptom assessment is presented for additional context.
—Visual representation of the average postinjury symptom total score (Panel A) and symptom change score (Panel B) across the first 3 physiotherapy visits. Note: Figures reflect data for acute care seekers (those presenting ≤4 wk after injury) only. The dashed lines are the prepolicy change group; the postpolicy change group is represented with solid lines. PCSI indicates Post-Concussion Symptom Inventory.
Citation: Journal of Sport Rehabilitation 34, 3; 10.1123/jsr.2024-0097
Although the policy change appeared to improve longitudinal symptom trajectories, it did not significantly alter risk of persisting symptoms. Sixty-nine patients in both the postpolicy change and prepolicy change groups experienced PPCS at 4 weeks (χ2(1) = 0.03, P = .87, OR = 0.97; 95% CI, 0.63–1.48).
Chronic Care Seekers Were Unaffected by the Policy Change
For chronic care seekers who presented to the clinic more than 4 weeks postconcussion, prepolicy change and postpolicy change groups did not differ on any demographic outcomes. As expected, the policy change had no effect on recovery outcomes for chronic care seekers. Kaplan–Meier curves revealed no significant differences in episode of care (prepolicy change = 50 [54] d; postpolicy change = 49 [49] d; χ2(1) = 0.51, P = .47), length of rehabilitation services (prepolicy change = 61 [51] d; postpolicy change = 57 [45] d; χ2(1) = 1.07, P = .30), or total recovery time (prepolicy change = 118 [73] d; postpolicy change = 113 [71] d; χ2(1) = 1.14, P = .29). The multivariable Cox models also failed to capture any significant effects of the policy change on recovery time outcomes (episode of care: χ2(1) = 0.04, P = .86, OR = 1.04 [0.71–1.50]; total recovery time: χ2(1) = 0.17, P = .68, OR = 1.08 [0.77–1.58]; and length of rehabilitation: χ2(1) = 0.54, P = .46, OR = 1.18 [0.76–1.81]).
Main effects of time were observed for retrospective preinjury (F2,182 = 15.91, P < .001), current postinjury (F2,185 = 89.00, P < .001), and symptom change (F2,182 = 51.3, P < .001) scores, with symptoms decreasing over time. However, no main effects of group (P > .17) or interaction (P > .51) effects were observed, suggesting that the magnitude and the rate of symptom decline did not differ between groups. These findings were retained in the multivariable models, with total preinjury (F2,182 = 16.3, P < .001), total postinjury (F2,185 = 81.7, P < .001), and symptom change (F2,185 = 49.3, P < .001) scores all continuing to decrease over time.
Nearly all patients (n = 146, 86.9%) who presented to the clinic late met the study definition of PPCS, with no differences in the proportion of PPCS observed between groups (prepolicy change = 85.3%, postpolicy change = 88.2%; χ2(1) = 0.29, P = .59). Chronic care seekers without PPCS presented following clinical recovery to obtain clearance to return to sport.
Discussion
An institutional policy change targeting concussion management practices led to significantly earlier enrollment into at-home, physiotherapy-based active rehabilitation services, which improved the rate of symptom resolution and overall recovery times in a pediatric specialty clinic. Children in the postpolicy change group began rehabilitation services a median of 4 days earlier but recovered a full week faster than patients in the prepolicy change group. In addition, no significant differences were observed for chronic care seekers presenting to the clinic ≥4 weeks postconcussion, who were unaffected by the policy change. These results held when controlling for other factors known to influence recovery from pediatric concussion, including age, sex, time to clinic presentation, initial symptoms, and prior concussion.
Policy change is an effective tool to improve human health, particularly when based on the evidence-based research.33,34 In the context of sport, policy change efforts have largely focused on preventing injury and sudden athlete death,7 including body checking9,10 (ice hockey) and kickoff11 (football) rules, which have effectively reduced concussion risk. To our knowledge, our study is the first to evaluate how changes to an institutional concussion management policy change affected recovery outcomes in children. Earlier enrollment into aerobic exercise programs and14,35 early presentation to concussion specialty clinics, which provide multimodal rehabilitation services, are related to expedited recovery times.21,36 Despite treatment beginning in the subacute postinjury period, our results suggest that the institutional policy change still led to significantly earlier enrollment into treatment services with positive benefits on clinical recovery outcomes in agreement with previous literature. Two prior studies directly evaluated the timing of physiotherapy-based rehabilitation services found no benefits of earlier treatment enrollment on clinical recovery.19,20 However, these studies included wider ranges of rehabilitation start times up to a year following concussion.19,20 These findings are similar to our chronic care seeker group and suggest that the effectiveness of active rehabilitation may be diluted when applied several weeks to months after concussion.
Although the updated institutional policy allowed treatment to begin 2+ weeks following injury, the median rehabilitation start time for the postpolicy change group was 22 days after concussion compared with 26 days for the prepolicy change group. Patients in both groups sought care roughly 10 days postconcussion, and follow-up appointments at the MCHCC are scheduled roughly every 2 weeks. Furthermore, although the prepolicy change guidelines were for treatment to begin at least 4 weeks following injury, slightly earlier enrollment into treatment services was allowed based on clinician judgment. Together, this likely explains why the postpolicy change group began rehabilitation services closer to 3 weeks after concussion and, despite the statistically significant difference, why the rehabilitation start times were generally similar between both groups. Thus, although the policy change effectively reduced time to treatment enrollment and had positive benefits on clinical recovery outcomes, treatment was still initiated several weeks postconcussion and did not meet current expert recommendations to begin treatment within the acute postinjury period. A recent meta-analysis also found that active rehabilitation is effective when applied acutely (≤2 wk) or chronically (>2 wk) after concussion, but effect sizes are larger when applied acutely.37 Therefore, clinical sites should strive whenever possible to offer rehabilitation enrollment within the acute postinjury period, which is likely to confer even greater clinical benefit.
Strengths
The use of stratified random sampling to ensure random patient selection equally across the 4-year study period increases the rigor of the study design. Multivariable models controlled for several key confounders of concussion recovery. Chronic care seekers served as a pseudocontrol group, and as expected, no significant effects of policy change were found for these individuals. Together, this increases confidence that differences observed in acute care seekers are related to the positive benefits of the policy change (eg, earlier treatment initiation) as opposed to other confounding factors or natural variation over the 4-year study period.
Limitations
This study performed a secondary analysis of prospective clinical cohort data. Although this design limits control (ie, lack of precision surrounding rehabilitation start times, nonstandardized treatments, etc), our findings are more generalizable to other real-world, clinical settings. Additional concussion management strategies (see “Methods” section) are delivered by the trauma coordinator. These interventions were not maintained in the clinic’s database and could not be analyzed. However, the initiation of these treatment services (eg, time to accessing care) was equivalent between groups and is unlikely to influence differences in recovery outcomes. Most patients were still unable to access physiotherapy-based interventions until roughly 3 weeks postinjury, and thus, treatment was not initiated within the acute postinjury period as recommended by current best evidence. More acute rehabilitation initiation in this clinic is not feasible due to available resources but would likely provide additional clinical benefit. Individuals who were lost to follow-up were censored at the date of their last in-person clinic visit. This skews time-to-event outcomes to shorter durations and, in combination with patients not requiring treatment, explains why the median episode of care is slightly shorter than the median length of rehabilitation services received for acute care seekers. Most chronic care seekers had PPCS; these patients likely have different physiological and/or behavioral presentations than acute care seekers and may not be directly comparable. Different PCSI versions are available based on the patient’s age. The proportion of children using each PCSI version did not differ by group, and this is unlikely to explain our results. Finally, the MCHCC predominately treats complicated cases with atypical recoveries. Although this publicly funded Canadian clinic provides free services to Quebec residents, concussion patients may generally struggle to access specialty care due to financial, geographic, or other reasons. Thus, our findings may not generalize well to other pediatric concussion populations, including typically recovering children or those seeking care in emergency departments, pediatrician offices, or other locations.
Clinical Implications
Standardized clinical policies are known to improve the quality and safety of patient care.38 Our findings suggest that policies targeting earlier entry into at-home, physiotherapy-based active rehabilitation services can improve clinical recovery outcomes following pediatric concussion. Thus, we recommend that health care providers caring for children with concussion encourage early enrollment into treatment services, and adopt standard institutional policies related to the timing of rehabilitation services which may facilitate this process. Such policies must align with clinic resources and should mandate 1 to 2 days of rest in agreement with current expert consensus.13 Prolonged concussion recovery has been linked to worse quality of life.39 Thus, earlier initiation of rehabilitation services may provide especially meaningful benefits for children at high likelihood of experiencing persistent symptoms after injury. In addition, clinicians should consider using symptom change scores for management decisions. Many postinjury symptoms are not specific to concussion, and clinicians using only postinjury checklists run the risk of attributing all reported symptoms to concussion when some may be unrelated. This may be particularly prudent when caring for patients with preexisting health conditions, who commonly report high symptom burdens in the absence of concussion.40
Conclusion
An institutional policy change led to earlier initiation of postconcussion treatment services, which had small, but significant, effects on recovery outcomes in youth with concussion. Children in the postpolicy change group had significantly shorter episodes of care, rehabilitation time, and total recovery time compared with youth in the prepolicy change group, who had to wait longer to access physiotherapy-based treatment services. No significant findings were observed in chronic care seekers reporting to the MCHCC ≥ 29 days following injury, which was expected as their access to rehabilitation services was unaffected by the policy change.
Acknowledgments
The authors would like to thank Kim Tran, who assisted with data extraction and management. Potential Conflicts of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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