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Exercise intolerance is an objective biomarker of the physiological dysfunction after sport-related concussion (SRC). Several trials have established the safety and clinical efficacy of subsymptom threshold aerobic exercise prescribed within 1 week of injury as treatment for SRC. Clinicians, however, may not be comfortable prescribing aerobic exercise after SRC. This article presents 3 methods of exercise prescription for patients with SRC. The first requires a graded exertion test plus a home-based exercise program requiring a heart rate (HR) monitor. The second requires a graded exertion test but no HR monitor for home-based exercise. The third requires solely an HR monitor to safely progress through the home-based exercise prescription. Patients are encouraged to keep a symptom and exercise diary and return for re-evaluation every 1 to 2 weeks. Delayed recovery should prompt the clinician to evaluate for other potential symptom generators (eg, cervical, vestibular, oculomotor, mood, or migraine disorders). [ABSTRACT FROM AUTHOR]

The author talks about why a change from a concussion assessment that is symptom-based to a structured physical examination is needed. Topics include an introduction on how the editorial came to be, a discussion of the research's focus on concussion and mTB1 physiological aspects, and the advantages of an emergency department (ED) physical examination. Also mentioned are the American College of Emergency Medicine and the Acute Concussion Evaluation (ACE).

Objective: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls. Participants: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male). Methods: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury). Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p <.001) but did not differ in meeting standard OH criteria (3% vs 5%, p =.32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, p =.65). Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH. [ABSTRACT FROM AUTHOR]

Objective: Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury. Design: Prospective cohort study. Setting: Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019. Patients: One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion). Independent Variables: Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness). Main Outcome Measures: Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS. Results: Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340). Conclusions: We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery. [ABSTRACT FROM AUTHOR]

Concussion affects the autonomic nervous system and its control of cerebral blood flow, which may be why uncontrolled activity can exacerbate symptoms after concussion. Traditionally, patients have been advised to restrict physical and cognitive activity until all symptoms resolve. However, recent research suggests that prolonged rest beyond the first couple of days after a concussion might hinder rather than aid recovery. Humans do not respond well to removal from their social and physical environments, and sustained rest adversely affects the physiology of concussion and can lead to physical deconditioning and reactive depression. Some animal data show that early forced exercise is detrimental to recovery after concussion, but other animal data show that voluntary exercise is not detrimental to recovery. We developed the Buffalo Concussion Treadmill Test to systematically evaluate exercise tolerance in persons with prolonged symptoms after concussion (ie, more than 4-6 weeks, which is called postconcussion syndrome [PCS]). Using a predetermined stopping criterion (symptom-exacerbation threshold), akin to voluntary exercise in animals, the Buffalo Concussion Treadmill Test is the only functional test known to safely and reliably reveal exercise intolerance in humans with PCS. The test data are used to develop individualized subthreshold exercise treatment programs to restore the physiology to normal and enhance recovery. Return of normal exercise tolerance can then be used to establish physiological recovery from concussion. New research suggests that absolute rest beyond the first few days after concussion may be detrimental to concussion recovery. However, further research is required to determine the appropriate mode, duration, intensity, and frequency of exercise during the acute recovery phase of a concussion prior to making specific exercise recommendations. For patients with PCS, subsymptom threshold exercise improves activity tolerance and is an appropriate treatment option for this patient population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Affective symptoms, specifically, anxiety, are often overlooked after sport-related concussion (SRC), and may contribute to prolonged recovery. OBJECTIVE: To examine the impact of anxiety during clinical recovery among adolescents (13–18y) enrolled in a randomized trial of aerobic exercise for SRC. METHODS: Patients at three sites were randomized into aerobic exercise or stretching arms, and enrolled in the 4-week intervention. The relationship between PROMIS Anxiety score at initial visit and time to symptom resolution was evaluated with survival analysis. The relationship between weekly PROMIS Anxiety score and Post-concussion Symptom Inventory (PCSI) score was evaluated with Linear Mixed Models. Analyses adjusted for study arm and baseline covariates. RESULTS: Among 54 adolescents (median age = 15.8y, initial visit PCSI score = 32, pre-injury PROMIS Anxiety score = 2), median time to symptom resolution was 10 days (25th-75th percentiles: 6-24) in the Low-PROMIS Anxiety group and 12 days (25th-75th percentiles: 5-21) in the High-PROMIS Anxiety group (p = 0.62). Each additional unit of PROMIS Anxiety score corresponded to a 1.52-unit higher PCSI total score (p < 0.01). Neither effect varied by aerobic exercise/stretching group. CONCLUSION: Higher initial PROMIS Anxiety score was not significantly associated with delayed symptom resolution. However, over time, PROMIS Anxiety score was significantly associated with elevated PCSI score, regardless of exercise/stretching group. [ABSTRACT FROM AUTHOR]

The article focuses on the goal attainment ratings of therapists and clients of Lakeshore Psychiatric Hospital in Toronto, Ontario. The investigation on goal attainment scaling had been introduced to the treatment program in a form of goal-oriented record system requiring the records of results including the changes on client's behavior. Goal attainment ratings by client have shown to be correlated to overall community adjustments including client's satisfaction, length of stay, community adjustments and goal specific adjustments.

There is no single gold standard test to diagnose sport-related concussion (SRC). Concussion-related exercise intolerance, that is, inability to exercise to the individual's appropriate level due to exacerbation of concussion-like symptoms, is a frequent finding in athletes early after SRC that has not been systematically evaluated as a diagnostic test of SRC. We performed a systematic review and proportional meta-analysis of studies that evaluated graded exertion testing in athletes after SRC. We also included studies of exertion testing in healthy athletic participants without SRC to assess specificity. Pubmed and Embase were searched in January 2022 for articles published since 2000. Eligible studies included those that performed graded exercise tolerance tests in symptomatic concussed participants (> 90% of subjects had an SRC, seen within 14 days of injury), at the time of clinical recovery from SRC, in healthy athletes, or both. Study quality was assessed using the Newcastle-Ottawa Scale. Twelve articles met inclusion criteria, most of which were of poor methodological quality. The pooled estimate of incidence of exercise intolerance in participants with SRC equated to an estimated sensitivity of 94.4% (95% confidence interval [CI]: 90.8, 97.2). The pooled estimate of incidence of exercise intolerance in participants without SRC equated to an estimated specificity of 94.6% (95% CI: 91.1, 97.3). The results suggest that exercise intolerance measured on systematic testing within 2 weeks of SRC may have excellent sensitivity for helping to rule in the diagnosis of SRC and excellent specificity for helping to rule out SRC. A prospective validation study to determine the sensitivity and specificity of exercise intolerance on graded exertion testing for diagnosing SRC after head injury as the source of symptoms is warranted. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS. Design: Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program. Setting: Three university-associated sports medicine clinical programs. Participants: Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury. Independent Variable: King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test. Main Outcome Measure: Persistent post-concussive symptoms. Results: Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS. Conclusions: Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction. [ABSTRACT FROM AUTHOR]

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups. Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults. All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings. Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Investigate the reliability of concussion symptoms captured through ecological momentary assessment (EMA) and compare time with recovery based on 3 definitions of symptomatic recovery and the date of clinical clearance to begin the return-to-play (RTP) process. Design: We used a mobile app with EMA to monitor concussion symptoms as part of a multicenter randomized controlled trial. Setting: Three sports medicine practices. Participants: Patients between 13 and 18 years old with sport-related concussion were prompted to complete the Post-Concussion Symptom Inventory daily over 4 weeks. Interventions: None. Main Outcome Measures: We compared the elapsed days to reaching the 4 outcomes using scatterplots and Kaplan–Meier curves. Results: Among 118 participants, symptoms reported into the app had excellent agreement with symptoms reported at a clinical visit on the same day (intraclass correlation coefficient = 0.97). Most (>50%) participants reached "specific symptom return to preinjury levels," "overall symptom return to preinjury levels," and "current symptom resolution" based on EMA symptom reports between several days and 1 week before achieving "clinical clearance to RTP" determined at a clinical visit, which had 100% sensitivity, but between 56.3% and 78.1% specificity, relative to the app-measured symptom outcomes. Conclusions: Time until symptom recovery varies based on the chosen definition of symptomatic recovery but is a more precise correlate with clinical clearance to begin the RTP process when defining symptom recovery as a return to a preinjury baseline level of symptomatology. Real-time symptom monitoring may be beneficial clinically, allowing providers to assess patients' recovery status and make more timely and remote treatment recommendations. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. This article presents the telehealth version of the Buffalo Concussion Physical Examination (BCPE) (Tele-BCPE). It is a brief, focused telehealth PE for use in the outpatient setting by sports medicine physicians, pediatricians, neurologists, and primary care physicians. It is derived from the BCPE and includes general considerations for providers performing telehealth services and instructions for adapting traditional clinical tests for virtual use. The Tele-BCPE includes an orthostatic intolerance screen, examination of the cranial nerves, and tests of the oculomotor, vestibular, and cervical systems. It is meant to be used at initial and follow-up outpatient visits for patients acutely after concussion and in those with prolonged symptoms. This telehealth PE, when combined with other assessments, can help provide direct treatment to patients at any stage after concussion and reduce barriers to healthcare access posed by the COVID-19 pandemic and for patients living in rural or underserved areas. [ABSTRACT FROM AUTHOR]

Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies. [ABSTRACT FROM AUTHOR]

Objective: To describe the derivation of a brief but pertinent physical examination (PE) for adolescents who have sustained sportrelated concussion (SRC). Design: Prospective cohort. Setting: University concussion management clinic. Participants: Acutely concussed (AC, n = 52, 15.5 ± 1.4 years, 4.4 ± 2 days since injury, 26.2 ± 38 days to recovery, 71% males) and healthy control (HC) adolescents (n = 30, 15.8 ± 1.4 years, 73% males). Intervention: Acutely concussed had a PE on visit 1 and were retested at visit 2 (13.6 ± 1 day after visit 1). Acutely concussed were further characterized as normal recovery (NR, n = 41, 15.5 ± 1.5 years, recovery time 13.0 ± 7 days) and delayed recovery (DR, n = 11, 15.5 ± 1.2 years, recovery time 75.4 ± 63 days). Main Outcome Measure: Physical examination findings, including cervical, vestibular, and oculomotor systems. Results: Visit 1 abnormal PE signs were significantly greater in AC versus HC (2.79 ± 2.13 vs 0.07 ± 0.37, P < 0.0001) but not in NR versus DR (2.61 ± 2.2 vs 3.45 ± 1.8, P = 0.246). Visit 2 abnormal PE signs differentiated NR versus DR (0.17 ± 0.7 vs 2.45 ± 2.1, P<0.0001). Conclusions: A brief focused PE can help to diagnose SRC, establish recovery, and may have prognostic value. [ABSTRACT FROM AUTHOR]

This article presents a brief, focused physical examination [PE, the Buffalo Concussion Physical Examination (BCPE)] for sport-related concussion (SRC) to be considered for use in the outpatient setting by sports medicine physicians, pediatricians, and primary-care physicians. This companion paper describes how to perform the PE, which was derived in a separate study presented in this journal. It is envisioned for use at the initial and follow-up outpatient visits both for acute concussions and in patients with prolonged symptoms. A pertinent PE, combined with other assessments, can help identify specific treatment targets in those with persistent symptoms after SRC. The BCPE includes orthostatic vital signs and examinations of the cranial nerves, oculomotor/ophthalmologic, cervical, and vestibular systems. Supplementary tests, including testing for exercise tolerance and neurocognitive function, may be performed if indicated. It is recommended that a PE be performed at the initial visit and every 1 to 2 weeks after SRC. On return of symptoms, cognition, and the PE to baseline, as well as normalization of any supplementary tests, patients can begin a return to play program. [ABSTRACT FROM AUTHOR]

The King-Devick (KD) test is a rapid number-reading test that has emerging use in the assessment of sport-related concussion (SRC). Previous research suggested that healthy individuals and patients with acute concussions who had shorter recovery times (<3 weeks) demonstrated a learning effect on the KD test after mild to moderate exertion, whereas patients with longer recovery times did not. To assess if the absence of postexertional improvement on the KD test within 10 days of concussive head injury was associated with a longer duration of recovery. Prospective cohort study. University concussion-management clinics. Male and female adolescent athletes (n = 99, aged 13–18 years) presenting within 10 days of SRC. The KD test was administered before and after the Buffalo Concussion Treadmill Test (BCTT). Days from injury to recovery, with recovery defined as being asymptomatic, confirmed by the assessment of a physician who was blinded to the treatment group, and the return of normal exercise tolerance on the BCTT were recorded. Participants with postexertional slowing (PES group, n = 33) had a longer duration of recovery (17 days versus 13.5 days, P =.033) than participants without PES (no-PES group, n = 66). At any clinic visit, PES was also associated with a relative risk of 2.36 (95% confidence interval = 1.55, 3.61; P <.001) of not recovering within the following week. The current study validates our prior work showing that acutely concussed adolescents who did not display the typical learning effect on the KD test after the BCTT took longer to recover from SRC than those who exhibited the typical learning effect. [ABSTRACT FROM AUTHOR]

Abstract Objective This study investigated the diagnostic and prognostic value of the King-Devick (K-D) test in conjunction with treadmill testing in adolescents after sport-related concussion (SRC) in an outpatient concussion management clinic without baseline measures. Design Prospective cohort. Methods The K-D test was administered pre- and post-exercise on a graded treadmill test to acutely concussed (AC, <10 days from injury, n = 46, 15.4 ± 2.1 years) participants for 2 clinic visits (1 week apart) and to matched controls (MC, n = 30, 15.8 ± 1.4 years) for 2 visits (1 week apart). Initial K-D test times were compared between MC and AC. Changes in times from pre- to post- exercise during a treadmill test were compared for MC and AC and from Visit 1 to Visit 2. Smooth pursuits and repetitive saccades were compared with initial visit K-D test performance. Results Comparison of pre-exercise K-D test times at Visit 1 distinguished MC from AC (46.1 ± 9.2 s vs. 53.7 ± 13.0 s, p =.007). Comparison of pre- and post-exercise K-D test times revealed significant improvements for MC (46.1 ± 9.2 s vs. 43.1 ± 8.5 s, p <.001) and AC who recovered by Visit 2 (Fast Recovery Group [FRG], n = 23, 50.4 ± 10.0 s vs. 47.3 ± 9.8 s, p =.002). No significant difference was seen in pre- and post-exercise K-D test times on Visit 1 for AC who took longer than 2 weeks to recover (Slow Recovery Group [SRG], n = 23, 57.0 ± 15.0 s vs. 56.0 ± 16.3 s, p =.478). At Visit 1, AC had more abnormal smooth pursuits than MC (17% vs. 3%, non-significant, p =.064). AC, however, had significantly more abnormal repetitive saccades than MC (37% vs. 3%, p =.001) and AC with abnormal repetitive saccades took significantly longer to complete the Visit 1 pre-exercise K-D test than AC with normal repetitive saccades (58.6 ± 16.0 s vs 50.8 ± 10.2 s, p =.049). Conclusion The study supports utility of the K-D test as part of outpatient concussion assessment. Lack of improvement in K-D test performance after an exercise test may be an indicator of delayed recovery from SRC. Highlights • Comparison of K-D test scores distinguishes healthy controls from acutely concussed adolescents in a clinical setting. • Lack of improvement on K-D test scores after an exercise protocol indicates delayed recovery from concussion. • Concussed patients with abnormal eye movements took longer on initial K-D tests compared to patients without abnormalities. [ABSTRACT FROM AUTHOR]

Objective: To evaluate (1) systematic assessment of exercise tolerance in adolescents shortly after sport-related concussion (SRC) and (2) the prognostic utility of such assessment. Design: Prospective randomized controlled trial. Setting: University and community sports medicine centers. Participants: Adolescents with SRC (1-9 days from injury). Sixty-five were randomized and 54 completed the study (mean age 15 years, 4 days after injury). Interventions: Buffalo Concussion Treadmill Test (BCTT, = 5 27) or not (controls, n = 27) on visit day #1. Heart rate threshold (HRt) at symptom exacerbation represented level of exercise tolerance. Participants reported symptoms daily for 14 days and then had follow-up BCTT (n = 54). Recovery was defined as returning to normal level of symptoms and exercise tolerance, verified by independent physician examination. Main Outcome Measures: Days to recovery and typical (≤21 days) versus prolonged recovery (>21 days). Mixed effects linear models and linear regression techniques examined symptom reports and time to recovery. Linear regression assessed the association of HRt with recovery time. Results: Days to recovery (P = 0.7060) and typical versus prolonged recovery (P = 0.1195) were not significantly different between groups. Symptom severity scores decreased in both groups over 14 days (P,0.0001), were similar (P=0.2984), and did not significantly increase the day after the BCTT (P = 0.1960). Lower HRt on visit day #1 was strongly associated with prolonged recovery time (P = 0.0032). Conclusions: Systematic evaluation of exercise tolerance using the BCTT within 1 week after SRC did not affect recovery. The degree of early exercise intolerance after SRC was important for prognosis. This has implications for school academic and team preparation. [ABSTRACT FROM AUTHOR]

The primary objective of this study was to determine factors in the clinic setting associated with concussion-related problems in the school setting. A total of 91 student athletes, 13 to 19 years old, completed the SCAT2 and computerized testing during their initial visit to the clinic. During a follow-up telephone interview, one-third reported problems with return to school. The presence of problems reported in school was associated with severity of concussion as represented by recovery time and the overall number of symptoms at the first clinic visit. Gender, age, and previous concussions were not associated with school problems. Athletes with computerized test scores below the ninth percentile were more likely to report school problems. The current study offers some descriptive information for clinicians and ideas for future research related to adolescent athletes with concussion and problems with return to the classroom. [ABSTRACT FROM AUTHOR]

BACKGROUND: Youth ice hockey injury rates and mechanisms have been described by various classification systems. Intentional versus unintentional contact was used to classify mechanisms of injuries. All injuries (n=247) in one youth hockey programme over a 5-year period were recorded and included in the analysis. PURPOSE: To evaluate youth ice hockey injuries and compare programmes that allow body checking versus programmes that do not allow body checking. A primary goal was to determine whether programmes that allow body checking have increased injury rates from intentional body contact. Another goal was to describe the rates of injury across ages, levels of competitive play and during games versus practices. METHODS: Rates of injury were compared for three levels of competition (house, select and representative) for approximately 3000 boys aged 4–18 years over a 5-year period. This represents 13 292 player years. Data were collected prospectively in this cohort study. All injuries were reported prospectively by a designated team official and verified by a physician. The log injury rate (per 1000 player hours) was modelled via Poisson regression with log player hours used as an offset. Rate ratio was used to explain the covariate-adjusted injury rate for each of three groups (all injuries, intentional injuries, unintentional injuries). RESULTS: Unintentional contacts accounted for 66.0% of overall injuries (95% CI 60.0 to 72.0), compared with 34.0% from intentional contacts (p<0.001;Z=5.25). Serious injuries (fractures, dislocations, concussions) resulted more often from unintentional collisions (p=0.04). Players in more competitive leagues that allow body checking had a greater incidence of total injuries than less competitive leagues. CONCLUSIONS: Most injuries in the youth hockey programme studied were the result of unintentional contact, and were generally more severe. These findings were not expected given previously published research. [ABSTRACT FROM AUTHOR]

Abstract: Persons with traumatic brain injury (TBI) often have difficulty recognizing emotion in others. This is likely due to difficulties in interpreting non-verbal cues of affect. Although deficits in interpreting facial cues of affect are being widely explored, interpretation of vocal cues of affect has received much less attention. Accurate interpretation of vocal affect cues is important, particularly when facial cues are absent or ambiguous. These cues also contribute to more accurate identification of emotion. The neural substrates of facial and vocal affect recognition appear to be shared, further contributing to improved bimodal processing. This article discusses the importance of vocal affect cues in interpreting emotion. Expression of vocal affect in persons with TBI is also briefly discussed since difficulty in controlling and manipulating vocal cues of emotion when speaking may also contribute to poor social outcomes. A review of the literature in acoustic parameters that contribute to identification and expression of emotions is followed by a discussion on the integration of visual and auditory cues in bimodal processing and the relationship between facial and vocal affect in persons with TBI. Learning Outcomes: Readers will be able to: 1) Identify the parameters primarily used to describe the acoustic characteristics of vocal affect; 2) Describe the acoustic parameters typically associated with Anger, Fear, Happiness and Sadness; 3) Describe the difficulties experienced by persons with TBI in the perception and integration of facial and vocal cues of affect. [Copyright &y& Elsevier]

Background and Objectives: We determined inter-modality (in-person vs telemedicine examination) and inter-rater agreement for telemedicine assessments (2 different examiners) using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a standardized concussion examination designed for remote use., Methods: Patients referred for an initial evaluation for concussion were invited to participate. Participants had a brief initial assessment by the treating neurologist. After a patient granted informed consent to participate in the study, the treating neurologist obtained a concussion-related history before leaving the examination room. Using the Tele-BCPE, 2 virtual examinations in no specific sequence were then performed from nearby rooms by the treating neurologist and another neurologist. After the 2 telemedicine examinations, the treating physician returned to the examination room to perform the in-person examination. Intraclass correlation coefficients (ICC) determined inter-modality validity (in-person vs remote examination by the same examiner) and inter-rater reliability (between remote examinations done by 2 examiners) of overall scores of the Tele-BCPE within the comparison datasets. Cohen's kappa, κ, measured levels of agreement of dichotomous ratings (abnormality present vs absent) on individual components of the Tele-BCPE to determine inter-modality and inter-rater agreement., Results: For total scores of the Tele-BCPE, both inter-modality agreement (ICC = 0.95 [95% CI 0.86-0.98, p < 0.001]) and inter-rater agreement (ICC = 0.88 [95% CI 0.71-0.95, p < 0.001]) were reliable (ICC >0.70). There was at least substantial inter-modality agreement (κ ≥ 0.61) for 25 of 29 examination elements. For inter-rater agreement (2 telemedicine examinations), there was at least substantial agreement for 8 of 29 examination elements., Discussion: Our study demonstrates that the Tele-BCPE yielded consistent clinical results, whether conducted in-person or virtually by the same examiner, or when performed virtually by 2 different examiners. The Tele-BCPE is a valid indicator of neurologic examination findings as determined by an in-person concussion assessment. The Tele-BCPE may also be performed with excellent levels of reliability by neurologists with different training and backgrounds in the virtual setting. These findings suggest that a combination of in-person and telemedicine modalities, or involvement of 2 telemedicine examiners for the same patient, can provide consistent concussion assessments across the continuum of care., Competing Interests: M.N. Haider received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for BlinkTBI and personal compensation in the range of $500-$4,999 for serving as a statistician with Oculogica; the institution of M.N. Haider received research support from NIH; J.J. Leddy received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Neuronasal, received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Quadrant Biosciences, and received stock or an ownership interest from Highmark Innovations, 360 Concussion Care, and Noggin Health; the institution of J.J. Leddy has received research support from NIH, research support from DoD, and research support from AMSSM; L.J. Balcer is Editor-in-Chief of the Journal of Neuro-Ophthalmology; N.A. Busis has received personal compensation for serving as an editorial advisory board member for Neurology Today and for serving as a speaker for the American Academy of Neurology and as the AAN's primary advisor to the American Medical Association's CPT Editorial Panel. The other authors report no disclosures relevant to the manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp., (© 2024 American Academy of Neurology.)

Objective: Approximately 20% of students with sport-related concussion (SRC) report new symptoms of anxiety and depression which may be associated with delayed recovery and increased risk for developing a mood disorder. Early prescribed aerobic exercise facilitates recovery in athletes with concussion-related exercise intolerance. We studied the effect of aerobic exercise treatment on new mood symptoms early after SRC., Design: Exploratory secondary analysis of 2 randomized controlled trials (RCT)., Setting: Sports medicine clinics associated with UB (Buffalo, NY), CHOP (Philadelphia, PA), and Boston Children's Hospital (Boston, MA)., Participants: Male and female adolescents (aged 13-18 years) diagnosed with SRC (2-10 days since injury)., Interventions: Participants were randomized to individualized targeted heart rate aerobic exercise (n = 102) or to a placebo intervention designed to mimic relative rest (n = 96)., Main Outcome Measures: Incidence of Persisting Post-Concussive Symptoms (PPCS, symptoms ≥28 days)., Results: First RCT recruited from 2016 to 2018 and the second from 2018 to 2020. Of 198 adolescents, 156 (79%) reported a low burden (mean 1.2 ± 1.65/24) while 42 (21%) reported a high burden (mean 9.74 ± 3.70/24) of emotional symptoms before randomization. Intervention hazard ratio for developing PPCS for low burden was 0.767 (95% CI, 0.546-1.079; P = 0.128; β = 0.085) and for high burden was 0.290 (95% CI, 0.123-0.683; P = 0.005; β = 0.732)., Conclusions: High burden of mood symptoms early after injury increases risk for PPCS, but the sports medicine model of providing early targeted aerobic exercise treatment reduces it. Nonsports medicine clinicians who treat patients with a high burden of new mood symptoms after concussion should consider prescribing aerobic exercise treatment to reduce the risk of PPCS and a mood disorder., Competing Interests: The authors do not declare any relevant conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the feasibility of an exercise tolerance assessment and intervention added to the Progressive Return to Activity Clinical Recommendations (PRA-CR) in acutely concussed service members (SMs)., Methods: This non-randomized, pilot trial was performed at one center. SMs in the experimental group (ERG) performed the Buffalo Concussion March-in-place Test (BCMT) at every clinic visit and were prescribed at least 20 minutes/day of targeted exercise in addition to PRA-CR. Data for the control group (SCG) were extracted from the same clinic immediately prior to ERG. SMs in both groups were assessed by the same clinician to determine return-to-duty., Results: BCMT identified concussion-related exercise intolerance in 100% ( n  = 14) at screening visit (mean 3.4 days after injury) and in 0% ( n  = 7) who had recovered. No adverse effects were associated with BCMT. The estimated recovery time for ERG who performed the exercise intervention ( n  = 12) was 17.0 (12.8, 21.2) days and for SCG ( n  = 15) was 23.7 (19.9, 27.5) days ( p  = 0.039)., Conclusion: Assessment of exercise tolerance was feasible and could be incorporated into the PRA-CR. Future definitive, randomized controlled trials should be performed to assess the effectiveness of exercise reset program for SMs after concussion.