Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild’s 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

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Variations in Time to Recovery from Pediatric Concussion Based on Differing Outcomes of Interest

Neurology ◽

10.1212/01.wnl.0000801828.94648.3d ◽

2021 ◽

Vol 98 (1 Supplement 1) ◽

pp. S10.2-S11

Author(s):

Christina Master ◽

Kristi Metzger ◽

Mr. Daniel Corwin ◽

Catherine McDonald ◽

Melissa Pfeiffer ◽

...

Keyword(s):

Sports Medicine ◽

Clinical Care ◽

Median Number ◽

Self Report ◽

Return To School ◽

Self Assessment ◽

Concussion Management ◽

Pediatric Concussion ◽

Concussion Recovery ◽

Definition Of

ObjectiveTo quantify variability in pediatric concussion recovery across multiple outcomes of interest.BackgroundPediatric concussion studies are hindered by a common significant limitation: lack of agreement on a standard definition of “recovery.” A variety of clinical outcomes of interest utilized across studies, including symptom self-report, neurocognitive testing results, self-reported return to activity, and physician clearance for activity, leads to challenges for both research, as well as clinical concussion management.Design/MethodsWe enrolled concussed youth, ages 11–18 years, from a specialty sports medicine clinic = 28 days of injury. Patients were followed as part of clinical care for concussion for up to 13 weeks. At each visit, participants completed questionnaires and a battery of clinical measures. From these data, we constructed 10 potential definitions of recovery: 3 based on self-reported symptoms (change from pre-injury, no symptoms, below pre-determined thresholds), 2 based on visio-vestibular examination (VVE) deficits (none, = 1), 2 based on physician clearance (for return to school/sport), and 3 based on self-assessment (“back to normal”, return to school/exercise).ResultsOne hundred seventy-four concussed youth were enrolled (median age: 15 years, 54.6% female) with a median time from injury to initial visit of 12 days (IQR: 7, 20). Median number of visits was 2 (range: 1, 5). We observed a wide variation in the proportion of participants recovered across the 10 definitions. Depending on definition, between 4% and 45% were considered recovered within 4 weeks, and between 10% and 80% were considered recovered at the end of follow-up. The VVE-based definition (=1 deficit) consistently had the highest proportion recovered at all time points, while self-reported return to exercise had the lowest proportion.ConclusionsRecovery from concussion is not a single unitary point in time. These results will provide valuable guidance to clinicians in managing concussion and researchers in designing future observational and interventional trials of pediatric concussion.

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Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review

BMJ Open Sport & Exercise Medicine ◽

10.1136/bmjsem-2019-000667 ◽

2020 ◽

Vol 6 (1) ◽

pp. e000667 ◽

Cited By ~ 2

Author(s):

Carol DeMatteo ◽

E Dimitra Bednar ◽

Sarah Randall ◽

Katie Falla

Keyword(s):

Systematic Review ◽

Paediatric Population ◽

Acute Stage ◽

Current Data ◽

Return To School ◽

Original Research ◽

Reference List ◽

Eligibility Criteria ◽

Outcomes For Children ◽

Return To Activity

ObjectiveTo determine the effects of following return to activity (RTA) and return to school (RTS) protocols on clinical outcomes for children with concussion. The 12 subquestions of this review focus on the effectiveness of protocols, guidelines and recommendations, and the evidence supporting content of the protocols including rest, exercise and school accommodations.DesignSystematic review.Data sourcesPubMed, MEDLINE, EMBASE, CINAHL, ERIC and manual reference list check.Eligibility criteria for selecting studiesStudies were included if they evaluated RTA or RTS protocols in children aged 5–18 years with a concussion or if they reported a rigorous study design that provided evidence for the recommendations. Included studies were original research or systematic reviews. Articles were excluded if they did not report on their methodology or included participants with significant neurological comorbidities.ResultsThe literature search retrieved 198 non-duplicate articles and a total of 13 articles were included in this review. Despite the adoption of several RTS and RTA protocols in clinical practice there is little evidence to determine their efficacy in the paediatric population.SummaryThe current data support the recommendation that children in the acute stage postconcussion should undergo 1–2 days physical and cognitive rest as they initiate graduated RTA/RTS protocols. Prolonged rest may increase reported symptoms and time to recovery. Further interventional studies are needed to evaluate the effectiveness of RTA/RTS protocols in youth with concussion.

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