Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.

Context: State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination. Objective: To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality. Design: Qualitative document analysis. Setting: High school athletics. Participants: In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018–2019 academic year. Main Outcome Measures: Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test. Results: There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5–22.5] versus 6 [3–10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

Background: Concussion baseline assessments are often administered during the pre-season of sports. Current recommendations suggest that baseline assessments may be useful in aiding and interpreting post-injury evaluations but are not necessary. However, it has become common practice for athletic trainers (ATs) to administer and implement baseline assessments in athletes. Hypothesis/Purpose: The purpose was to determine K-12 ATs’ current concussion baseline assessment practice patterns. Methods: A Qualtrics survey was designed and implemented to 443 ATs (193 males, 244 females, 5 prefer not to answer, n=1 missing). Most respondents had earned a master’s degree (n=288, 65.0%), and were employed full-time (n=381,86.4%). Respondents were solicited over email to complete the survey which consisted of multipart, multiple-choice, and open-ended questions. Responses are reported as frequencies and percentages. Chi-square analysis was run to determine group (years of experience) and baseline practice patterns, p<0.05. Results: Seventy-five percent of respondents (n=330) reported administering baseline concussion assessments, with 37 (8.4%) reporting they do not administer baseline assessments but plan to in the future. The top five most reported assessment tools used were ImPACT (n=245, 55.3%), SCAT 5 (n=59, 13.3%), CNS Vital signs (n=25, 5.6%), BESS (n=25, 5.6%), and VOMS (n=22, 5.0%). The majority of respondents reported standard of care (n=226, 51%), provide better care (n=202, 45.6%%), school/organization policy (n=197,44.5%), to help diagnose concussion (n=139, 31.4%), concussion education (n=117, 26.4%), and liability (n=101, 22.8%), as the top reasons for using concussion baseline assessments. No differences were found between ATs with less than 10 years of experience, 11-20 years of experience, or 21+ years of experience in having formal training on administration of baseline assessments ( p=.164), or having received formal training on interpretation of baseline assessments ( p=.104). However, differences were noted by years of experience for reviewing baseline assessments for validity 2= 8.68, p=.013, and for those who restrict testing when individuals are sleep deprived 2=10.06 p=0.039. The majority reported receiving formal training to administer (n=209, 66.8%) and to interpret (n=178, 56.9%) neurocognitive baseline assessment. The majority of respondents report feeling extremely comfortable (n=214, 69%) and extremely competent (n=205, 65.9) in administering neurocognitive assessments, and moderately comfortable (n=117, 38.2%) and moderately competent (n=137, 45.1%) in test interpretation. Conclusion: The majority of ATs reported administering baseline concussion assessments and felt comfortable and competent in the administration and interpretation of assessments in adolescent athletes. Most ATs reported standard of care and providing better care as reasons for implementing assessments.

Objective The purpose of this study was to understand if the vestibular-ocular reflex is related to scores from a computerized neurocognitive exam. Method Data was obtained via IRB-approved retrospective chart review. 109 youth athletes (median age 13; 73.3% male) participated in a pre-season baseline assessment consisting of the gaze stabilization test (GST; a measure of vestibular-ocular reflex function) and the ImPACT computerized neurocognitive test (CNT). ImPACT composite scores and GST velocities in the leftward and rightward directions were evaluated. A spearman correlation was utilized to determine the relationship between variables (GST and CNT). Results No significant relationship existed between rightward and leftward velocities and any ImPACT composite (highest value; r = 0.20, p &gt; 0.05 for Right GST and Impulse Control). Conclusions There was no relationship between a measure of the vestibular-ocular reflex and CNT. Thus, the tests measure two distinct abilities that can be affected by sport-related concussion. Results indicate the importance of understanding pre- and post-injury function for both cognitive and vision function to guide clinical decision making.

Focused Clinical Question: In a high school, college, and professional athletic population, does individualized baseline tests increase the diagnostic accuracy (e.g., sensitivity and specificity) of identifying cognitive impairments when utilizing neurocognitive testing compared to normative data? Clinical Bottom Line: There was insufficient evidence to definitively suggest the use of individualized baseline data over the use of normative data during a postinjury assessment.