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Objectives: This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations., Design: Retrospective observational study., Setting: Concussion clinics associated with a pediatric hospital., Patients: Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed., Independent Variables: The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities)., Main Outcome Measures: Physician PA recommendations., Results: From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% ( P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury ( P < 0.05). A significantly increased odds of recommending "light activity" (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and "noncontact PA" (OR = 2.21, 95% CI, 1.28-2.05), compared with "no activity" within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending "light activity" or "noncontact PA.", Conclusions: Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration., Design: Prospective, cohort design., Setting: Nationwide Children's Hospital, Sports Concussion Clinic., Participants: Five hundred ten patients (9-19 years of age) within 30 days of concussion injury., Main Outcome Measures: Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion., Results: Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery., Conclusions: Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery., Clinical Relevance: Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction.

Objective: To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic., Study Design: A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses., Results: Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59)., Conclusions: Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To explore head-upright tilt table (HUT) signs of autonomic dysfunction in a cohort of youth with persistent postconcussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have postural tachycardia syndrome (POTS) on initial testing., Design: Prospective cohort design., Setting: Nationwide Children's Hospital, Neurology Clinic., Participants: Thirty-four patients (13-18 years of age) with persistent PCSs., Main Outcome Measures: All patients underwent at least 1 tilt table test. The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden. Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted., Results: Twenty-four of the 34 (70.6%) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14). Patients with POTS had higher PCS-I scores than normal patients (P < 0.001) and higher ratings of light-headedness than both normal patients (P = 0.015) and syncope patients (P = 0.04). Twelve POTS patients underwent repeat tilt table testing, and 9 of 12 (75%) no longer met POTS diagnostic criteria. All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo., Conclusions: Our study demonstrates a high rate of tilt table abnormalities among youth with persistent PCSs. Several patients with POTS had normalization of tilt table testing when PCSs improved. These findings warrant further research of autonomic dysfunction related to concussion., Clinical Relevance: Our study is the first to prospectively characterize autonomic dysfunction in patients with persistent PCSs using HUT testing and to show that the tilt test abnormalities normalize in some patients as PCSs improve.

Background: Concussion guidelines recommend physical and cognitive rest until all postconcussion symptoms resolve, in part because of potential health risks, including catastrophic injury related to a second impact. However, when postconcussion symptoms persist for weeks or months, these risks are poorly characterized., Hypothesis: Physicians' perceived health risks and management strategies for patients with persistent postconcussion symptoms will vary., Study Design: Cross-sectional study., Level of Evidence: Level 3., Methods: A survey of the physician members of the American College of Sports Medicine assessed the perceived health risks related to advancing activity, the indications for neuroimaging, and the referral patterns for patients with persistent postconcussion symptoms., Results: A total of 572 physicians completed the survey (response rate, 27.2%). The majority of physicians recommended physical rest (97.4%) and cognitive rest (93.8%) within the first week of injury. Perceived health risks related to advancing activity in the symptomatic patient differed at 2 weeks versus 3 months after injury (P < 0.001 for all comparisons). Respondents from the United States were more likely to list second impact syndrome as a potential health risk at 2 weeks compared with respondents from other countries (P = 0.04). The majority (56%) responded that the risk of second impact syndrome remains until all symptoms resolve. When postconcussion symptoms persist beyond 1 month, 61.9% of physicians responded that neuroimaging is indicated. Approximately 60% of respondents had access to a multidisciplinary concussion clinic within 60 miles of their practice., Conclusion: When postconcussion symptoms persist, the perceived health risks, management practices, and access to multidisciplinary care vary among physicians., (© 2015 The Author(s).)

Background/aim: A standard definition of Post-concussion Syndrome (PCS) does not exist. The objective was to determine consensus regarding the definition of PCS among physician members of the American College of Sports Medicine (ACSM)., Methods: Physician members of the ACSM were sent an electronic survey to determine opinions regarding the PCS diagnosis., Results: Five hundred and ninety-seven physicians completed the survey. When asked the minimum duration of symptoms required to diagnose PCS, respondents answered: <2 weeks (26.6%), 2 weeks to 1 month (20.4%), 1-3 months (33%) and >3 months (11.1%). Physicians who see ≥10% concussion patients in their practise, as well as physicians whose concussion population consists of >50% paediatric patients, were more likely to require >1 month of symptoms (p < 0.001). When asked the minimum number of symptoms required to diagnose PCS, responses varied: one symptom (55.9%), two symptoms (17.6%), three symptoms (14.6%) and four or more symptoms (3.2%). Respondents from the US were more likely than non-US respondents to require only one symptom for the PCS diagnosis (p = 0.01)., Conclusions: There is a lack of consensus regarding the definition of PCS among physician members of the ACSM. A standard definition would improve consistency in concussion research and in clinical practise.

Background/objective: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. Methods: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10–19 years, who presented to a sports concussion clinic within 30 days of injury. Results: The majority of CT scans (n= 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n= 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (allp< 0.001). Prior concussion (p= 0.002) and continued participation in activity after injury (p= 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p= 0.024, hazard ratio = 1.2) or MRI (p< 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. Conclusion: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield. [ABSTRACT FROM AUTHOR]