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Active Recovery for Children Slow to Recover from Sport Related Concussion

Active Recovery for Children Slow to Recover from Sport Related Concussion

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02/11/2013

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Brain Injury
, November 2009; 23(12): 956–964
Active rehabilitation for children who are slow to recover followingsport-related concussion
ISABELLE GAGNON
1,2
, CARLO GALLI
1
, DEBBIE FRIEDMAN
1
, LISA GRILLI
1
, &GRANT L. IVERSON
3
1
 Montreal Children’s Hospital, Montreal, Canada,
2
 McGill University, Montreal, Canada, and 
3
University of British Columbia and British Columbia Mental Health & Addiction Services, Vancouver, Canada
(Received 25 February 2009; revised 29 August 2009; accepted 27 September 2009)
Abstract
Primary objective
: To present an innovative approach to the management of children who are slow to recover after a sport-related concussion.
Research design
: The article describes the underlying principles and the development of specific interventions for a newrehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures.
 Methods and procedures
: Development of the intervention was done using multiple perspectives including that of theliterature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric andadolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. Theintervention was implemented and evaluated with a sample of 16 children and adolescents.
 Main outcomes and results
: The presented cases suggest that involvement in controlled and closely monitored rehabilitation inthe post-acute period may promote recovery in children and adolescents who present with atypical recovery following aconcussion. All 16 of the children and adolescents who participated in the programme experienced a relatively rapidrecovery and returned to their normal lifestyles and sport participation.
Conclusions
: A gradual, closely-supervised active rehabilitation programme in the post-acute period (i.e. after 1 monthpost-injury) appears promising to improve the care provided to children who are slow to recover.
Keywords:
Concussion, mild traumatic brain injury, paediatric, rehabilitation, sports
Introduction
Sport-related concussions (i.e. mild traumatic braininjuries (MTBI)) occur fairly commonly, particularlyin football, soccer, rugby and hockey [1–3]. Themajority of the literature to date suggests thatathletes recover quickly from concussions, withsome recovering in 1–2 days and most recoveringwithin 7–10 days [4, 5]. There is concern, however,that concussions in children might be different [6]and might be associated with slower recovery.Professionals providing services to children andadolescents after a concussion have long recognizedthe need for coordinated care for this clienteleand, particularly, the need for individualizedinterdisciplinary management of the paediatric ath-lete who sustains a concussion [7–10]. More focusedand specific research with children has been recom-mended [11, 12].Agreement statements developed by governmentalorganizations [13], professional associations [10, 14]and research groups [11] set forth the recommen-dation that athletes, including children, should beasymptomatic at rest prior to engaging in physicalexertion. Without question, these agreement state-ments are designed to protect the health and welfareof the athlete, reduce the likelihood of the athleteexperiencing a set-back in the recovery process andminimize the chances that the athlete will be
Correspondence: Isabelle Gagnon, Montreal Children’s Hospital-McGill University Health Center, Trauma Programs, C-833, 2300 Tupper, Montreal,Canada, H3H 1P3. Tel: 514-412-4400 x23422. Fax: 514-412-4398. E-mail: isabelle.gagnon8@mcgill.caISSN 0269–9052 print/ISSN 1362–301X online
ß
2009 Informa Healthcare Ltd.DOI: 10.3109/02699050903373477
 
returned to sport prematurely and experience anoverlapping injury. The recommendation that ath-letes avoid exercise until completely asymptomatic atrest works well for most injured athletes, most of thetime. However, when athletes are very slow torecover, there is a risk that their symptoms anddeficits (cognitive, motor) will (1) become chronicand (2) be caused in whole or part by factors thatmight not be directly related to the neurobiology of the original concussion. Moreover, from a practicalperspective, it is very difficult to ensure that mildlysymptomatic children will not engage in physicalexertion (e.g. vigorous playing and running).Therefore, children and adolescents with persistentsymptoms represent a unique challenge to healthcareproviders.Over the past 2 years, clinicians at the MontrealChildren’s Hospital Trauma Programs have beendeveloping an individualized approach with paedia-tric athletes who sustain concussions and are slowto recover. The
Montreal Children’s Hospital Rehabilitation After Concussion
(MCH-RAC) pro-gramme consists of gradual, closely monitored phys-ical conditioning, general coordination exercises,visualization, as well as education and motivationactivities. These are performed in the presence of persistent symptoms in order to contribute to theirresolution as well as to improve children’s generalphysical condition and mood. The programme isindividualized and is designed to last until completesymptomresolutionatrest.Atthattime,childrenandadolescents are eligible toresume the standard returnto activity protocols, part of the Montreal Children’sHospital MTBI/Return to Sports Program. Othergroups, working with an adult population, have alsodescribed similar approaches in the domain of reha-bilitation post-concussion with both athletes andnon-athletes [15, 16].The purpose of this paper is to present aninnovative approach to the rehabilitation of childrenwho are slow to recover after a sport-relatedconcussion. The article describes the principlesunderlying the MCH-RAC as well as its interventionmodalities. A series of cases concerning the impact of this rehabilitation strategy on the resolution of post-concussion symptoms as well as children’s perspec-tive on their experience with the intervention willalso be discussed.
Development of the intervention andunderlying principles
Designing successful interventions requires theunderstanding of challenges facing the targetedpopulation as well as elements on which one canhope to have an impact. Three broad principles wereused to guide the design of the MCH-RAC: (1) thenon-specificity of post-concussion symptoms, (2) themulti-dimensional impacts of injury on athletes and(3) the effects of exercise as an interventionmodality.First, post-concussion-like symptoms are non-specific [17–19]. They can be associated with avariety of things, such as school-related stress,relationship stress, mild depression, anxiety condi-tions, Attention-Deficit Hyperactivity Disorder(ADHD) and sleep disturbances. Therefore, thelonger the athlete is symptomatic the more likely,statistically, that some of the symptoms will becaused or maintained (at least in part) by factorsother than the neurobiology of the concussion.Secondly, athletes can have adverse psychologicalreactions to being injured and to being kept out of sports [20–24]. These psychological reactionsinclude denial, mild depression, anxiety, worry,anger, diminished vigour, loneliness, worthlessness,impatience and general overall negativity [25].According to models of psychological reaction tosport injury, these reactions are mediated in part bypersonal and situational factors, but also on cogni-tive appraisal of the situation [24]. These psycho-logical reactions can underlie what appear to bepost-concussion symptoms, especially when thesymptoms persist for several weeks. Moreover,improvement in the psychological condition of thephysically injured athlete (not concussed athlete) isassociated with perceived progress in rehabilitation[26, 27].Thirdly, there is evidence that exercise has positiveeffects on mental health and that it could be used asa treatment for depression in adults [28]. There isalso evidence that depressed mood after a concus-sion could reflect pathophysiology consistent witha limbic-frontal model of depression [29, 30].Therefore, it is possible that exercise could have abeneficial effect on symptoms in children if theirsymptoms are related to depressed mood or mentalhealth issues. Furthermore, there is evidence in theanimal literature that exercise is good for the brainand promotes neuroplasticity, even after fluid-percussion induced MTBI in rats [31, 32].However, there appears to be a temporal windowin which exercise does
not 
promote neuroplasticityand the literature suggests that exercise could,theoretically, slow down recovery if done too soonafter injury [33]. In fact, the molecular markers aresuppressed if the injured rat is allowed to engage involuntary exercise during the first week post-injurybut not in the post-acute phase (3–4 weeks post-injury). Most children and adolescents do notreceive follow-up interventions beyond the initialmanagement period, even though their deficits(balance, response time, cognitive) may last up to
Rehabilitation after concussion
957
 
3 months [34–36]. Furthermore, for the group of individuals who fail to return to pre-injury statusafter the expected initial recovery period, treatmentrecommendations usually are broad, do not suggestspecific evidence-based interventions and are notvery helpful to the professionals who have todetermine the best way to address the needs of these children.Starting from these principles, a systematic searchoftheEnglishandFrenchliteratureonpaediatricandadolescent MTBI as well as on exercise-inducedchangestoneurological functionperformedusingthefollowing six databases: MEDLINE (1980–2008),CINHAL (1982–2008), ERIC (1980–2008),PsychINFO (1980–2008) and SportsDiscus (1980– 2008). This review led to the theoretical rationale forthe components of the programme set out in Table I.
The MCH-RAC
The Montreal Children’s Hospital (MCH) is atertiary care paediatric teaching Hospital affiliatedwith McGill University in Montreal, Canada. It isone of two designated paediatric Trauma centres inthe Province of Quebec, Canada. The MCHTrauma mandate consists of five different pro-grammes (Trauma, Neurotrauma, MTBI/Return toSports, Burns and Injury Prevention). The manage-ment of children who sustain a concussion within theinstitution is a comprehensive multilevel programmeinvolved with children who require admission to thehospital and for those who are cared for directly inthe Emergency Department (ED) or on an out-patient basis when referred from community part-ners (paediatricians, family doctors, schools andsports teams).The physician in the MCH-ED uses a standar-dized form to assess children presenting withconcussion. This form was designed to ensure thatall injury variables useful for diagnostic and prog-nostication purposes are collected systematically.The form also contains clear criteria for referral tofurther services, namely the MCH NeurotraumaProgramme, following discharge from the ED, usu-ally after a few hours of assessment/observation.Before leaving the ED, children receive standardeducation and documentation regarding the natureof the injury, reassurance and instructions for returnto school and physical activities, as well as contactinformation should they need further information.For those children referred to the NeurotraumaProgramme (see Table II), follow-up phone callsensure individualized education/information andreturn to activities instructions.The MTBI/Return to Sports Clinic is part of the MCH Trauma Programs and was created toprovide children and adolescents with the opportu-nity to follow a closely monitored, stepwise pro-gramme to ensure that their return to sport andschool is a positive and safe one. Children seen in thecontextofthisclinicareatleast7yearsoldandbelongto one of two categories: elite athletes (defined aspracticing more than 8 hours of competitive levelsports per week) and children who are slow torecover, defined here as presenting with symptomsor impairments lasting more than 4 weeks (Figure 1).The latter slow to recover group is the focus of thispaper.
Intervention
The MCH-RAC programme is therefore an inter-vention for children and adolescents who do not
Table I. Theoretical rational for the Montreal Children’sHospital Rehabilitation After Concussion (MCH-RAC)Programme.I.
Aerobic Activity
Increase brain-derived neurotrophic factor (BDNF)SynaptogenesisIncreased cardiovascular activityAltered cerebral vascular function and brain perfusionIncreased endorphin releaseImproved brain autoregulationImprove overall fitness levelReduce fatigue/improve energy levelsReduce stress, worry and anxietyImprove moodImprove cognitionImprove self-efficacy and performanceII.
Coordination/Skill Practice
(Enjoyed Activity)Increased endorphin releaseImprove moodIII.
Visualization of Positive and Successful Activities Related toPreferred Physical Activity
Reassurance and increased confidence relating to ability topractice sportActivated brain regions linked to motor activitiesImprove self-efficacy and performanceIV.
Education and Motivation
Education and reassurance leads to empowerment andimproved copingIncreased confidence in services providedTable II. Criteria for referral to the Montreal Children’s HospitalNeurotrauma Programme.Prolonged loss of consciousness (
>
1 minute) at time of injuryConcussive convulsionsSkull fracturePatients given Miami-J collar to rule out neck injuriesPersistent symptoms with no improvement lasting
>
1 weekPersistent deficits or cognitive impairmentsMultiple concussions (
>
2 in the same year) or occurring with lessimpact forcesElite athletes (practice
>
8 hours/week competitive sport)Delayed Emergency Department visit with confirmed skullfracture
958
I. Gagnon et al.

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