UNIVERSITY OF CALGARY
Physical and Cognitive Activity and Recovery From Sports Related Concussion
by
Justin Terry Lishchynsky
A THESIS
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF SCIENCE
GRADUATE PROGRAM IN KINESIOLOGY
CALGARY, ALBERTA
JULY, 2016
© Justin Terry Lishchynsky 2016
Abstract
Concussions are among the most common injuries in youth sport and can affect an
individual both cognitively and physically, thus proper clinical care is imperative. In this thesis, a
review of physical and cognitive activity and rest following concussion highlights the need for
more research to better define the optimal amounts and types of rest and activity to facilitate
recovery. Comparing Actigraph accelerometry to participant self-report data during concussion
recovery revealed poor agreement and correlation between the two. There was no association
between cognitive activity and recovery from concussion demonstrated in an exploratory
analysis of high and low levels of cognitive activity. More time performing moderate-vigorous
physical activity (>45 minutes daily) was associated with a significantly longer time to return to
baseline symptom scores and being medically cleared to return to play. Future high level studies
evaluating the impact of physical activity on recovery are needed to inform clinical practice.
ii
Preface
The chapters of this thesis include three manuscripts that will be submitted for
publication and all co-authors have granted permission for these manuscripts to be included in
this thesis. Chapter one is an introduction summarizing the prevalence of concussions including
the definition and signs and symptoms of a concussion. Chapter two is a review of the role of
physical and cognitive rest on recovery from concussion, examining the current state of the
literature and highlighting areas that are in need of more research. The co-authors of this
manuscript are Dr. Clodagh Toomey, Dr. Carolyn Emery, Dr. Keith Yeates and Dr. Kathryn
Schneider. My role in this manuscript was leadership in formulating the research questions,
conducting the literature search and critical appraisal, and writing the manuscript.
Chapter three is a manuscript examining physical activity monitoring in youth postconcussion, comparing patient self-reported physical activity and rest levels post-concussion to
activity and rest levels measured using an Actigraph accelerometer. The co-authors of this
manuscript are Dr. Luz Palacios-Derflinger, Dr. Clodagh Toomey, Dr. Carolyn Emery, Dr. Keith
Yeates and Dr. Kathryn Schneider. My contribution to this manuscript was development of the
research question, data collection, data analysis, data cleaning and writing the manuscript.
Chapter four is a manuscript evaluating the association between time spent in moderate
and vigorous physical activity during acute recovery following concussion on time to medical
clearance from a sports-related concussion. The co-authors of this manuscript are Dr. Luz
Palacios-Derflinger, Dr. Clodagh Toomey, Dr. Carolyn Emery, Dr. Keith Yeates and Dr.
Kathryn Schneider My contribution to this paper was to formulate the research questions, data
collection, data analysis, data cleaning and writing of the manuscript.
iii
Chapter five is an exploratory study evaluating the association between cognitive activity
and recovery from sport-related concussion.
iv
Acknowledgements
This thesis would not be possible if not for all the support and mentorship received
during this process. First and foremost, my supervisor Dr. Kathryn Schneider, your support and
expertise is invaluable and your mentorship has taught me so much. Your encouraging and
always positive attitude made working with you a pleasure, so thank you. Thank you to my
committee members Dr. Carolyn Emery, Dr. Keith Yeates and Dr. Clodagh Toomey for all your
help, guidance and expertise with this project.
A special thank you to all the doctors and staff of the University of Calgary Sports
Medicine Centre including Christine Atkins, for all their help with this project and fostering my
love for medicine and the medical profession.
A big thank you to everyone in the Sports Injury Prevention Research Centre, especially
my office mates in the “fishbowl” for answering my constant questions, all the laughs and
making my time in the lab more enjoyable.
I would like to acknowledge and thank the funding that supported this project Alberta
Innovates Health Solutions, Hotchkiss Brain Institute, Canadian Institutes of Health Research,
and the Alberta Children’s Hospital Research Institute.
Last but not least, my family and friends deserve the biggest thanks for all their love and
support and always being there for me, as without them I wouldn’t be where I am today.
v
Dedication
This thesis is dedicated to those most important to me, my family. To my parents Terry
and Debra for teaching me to dream big, the value of hard work and you can accomplish
anything you set your mind to. To my siblings Tanner and Samara for always inspiring and
pushing me to do better. I am truly grateful for all that you’ve done for me and I share this
accomplishment with you.
Love JL
vi
Table of Contents
Abstract ............................................................................................................................... ii
Preface................................................................................................................................ iii
Acknowledgements ..............................................................................................................v
Dedication .......................................................................................................................... vi
Table of Contents .............................................................................................................. vii
List of Tables .......................................................................................................................x
List of Figures and Illustrations ......................................................................................... xi
List of Abbreviations ........................................................................................................ xii
CHAPTER ONE: INTRODUCTION ..................................................................................1
1.1 Problem Statement .....................................................................................................1
1.2 Background ................................................................................................................2
1.2.1 Concussion ........................................................................................................2
1.2.1.1 Definition .................................................................................................2
1.2.1.2 Signs and Symptoms of Acute Concussion .............................................3
1.2.1.3 Management of Acute Concussion ..........................................................4
1.3 Research Rationale ....................................................................................................5
1.4 Research Significance ................................................................................................5
CHAPTER TWO: A REVIEW OF THE ROLE OF PHYSICAL AND COGNITIVE REST
AND ACTIVITY IN RECOVERY FROM CONCUSSION .....................................7
2.1 Introduction ................................................................................................................7
2.2 Pathophysiology of Concussion.................................................................................7
2.3 Bed Rest .....................................................................................................................9
2.4 Cognitive Rest and Activity on Recovery from Concussion ...................................11
2.5 Physical Activity Monitoring...................................................................................12
2.6 Physical Rest and Activity on Recovery from Concussion .....................................14
2.7 Effect of Combined Physical and Cognitive Rest and Activity on Recovery from
Concussion .............................................................................................................17
2.8 Summary ..................................................................................................................20
CHAPTER THREE: PHYSICAL ACTIVITY MONITORING IN YOUTH FOLLOWING A
CONCUSSION .........................................................................................................22
3.1 Introduction ..............................................................................................................22
3.2 Methods ...................................................................................................................24
3.2.1 Statistical Analyses ..........................................................................................25
3.3 Results ......................................................................................................................26
3.4 Discussion ................................................................................................................31
3.4.1 Limitations .......................................................................................................32
3.4.2 Conclusions .....................................................................................................33
CHAPTER FOUR: THE ASSOCIATION BETWEEN MODERATE AND VIGOROUS
PHYSICAL ACTIVITY AND TIME TO MEDICAL CLEARANCE TO RETURN TO
vii
PLAY FOLLOWING SPORT-RELATED CONCUSSION IN YOUTH ICE-HOCKEY
PLAYERS. ................................................................................................................34
4.1 Introduction ..............................................................................................................34
4.2 Methods ...................................................................................................................37
4.2.1 Statistical Analysis ..........................................................................................38
4.3 Results ......................................................................................................................39
4.4 Discussion ................................................................................................................42
4.4.1 Limitations .......................................................................................................44
4.4.2 Conclusion .......................................................................................................46
CHAPTER FIVE: EXPLORATORY ANALYSIS EXAMINING THE ASSOCIATION
BETWEEN COGNITIVE ACTIVITY AND MEDICAL CLEARANCE TO RETURN
TO PLAY. .................................................................................................................47
5.1 Introduction ..............................................................................................................47
5.2 Methods ...................................................................................................................48
5.2.1 Statistical Analysis ..........................................................................................48
5.3 Results ......................................................................................................................49
5.4 Discussion ................................................................................................................50
5.4.1 Limitations .......................................................................................................51
5.4.2 Conclusion .......................................................................................................51
CHAPTER SIX: CONCLUSION ......................................................................................53
6.1 Summary of Findings...............................................................................................53
6.2 Public Health Implications.......................................................................................54
6.3 Recommendations for Future Research ...................................................................55
REFERENCES ..................................................................................................................56
APPENDIX A: INJURY REPORT FORM .......................................................................63
APPENDIX B: CONCUSSION FOLLOW-UP FORM ....................................................65
APPENDIX C: SPORT CONCUSSION ASSESSMENT TOOL – 3RD EDITION ..........72
APPENDIX D: MODIFIED DAILY INTERNATIONAL PHYSICAL ACTIVITY
QUESTIONNAIRE ..................................................................................................76
APPENDIX E: ACTIGRAPH MONITOR LOG ..............................................................78
APPENDIX F: COGNITIVE ACTIVITY SCALE ...........................................................79
APPENDIX G: RETURN TO PLAY PROTOCOL ..........................................................81
APPENDIX H: CONSENT FORM ...................................................................................82
APPENDIX I: DEMOGRAPHICS OF EXCLUDED PARTICPANTS ...........................86
viii
APPENDIX J: MANUSCRIPT APPROVAL FOR USE IN THESIS ..............................88
ix
List of Tables
Table 3.1 Participant demographics .............................................................................................. 27
Table 3.2 Mean difference, Bland Altman limits of agreement (LOA) and Pearson’s r
correlation coefficient for total time by activity intensity over the first three days of
recovery................................................................................................................................. 28
Table 4.1 Participant demographics .............................................................................................. 40
Table 4.2 Outcomes by activity group .......................................................................................... 41
Table 5.1 Participant demographics .............................................................................................. 49
Table 5.2 Outcomes by cognitive activity group .......................................................................... 50
Table 6.1: Demographics of all participants in chapter three, including the participants that
did not complete the MDIPAQ ............................................................................................. 86
Table 6.2: Demographics of all participants in chapter four, including the participants that did
not wear the Actigraph .......................................................................................................... 86
Table 6.3: Demographics of all participants that did not complete the CAS in chapter five ....... 87
x
List of Figures and Illustrations
Figure 3.1 Bland Altman plot of total time spent in sedentary intensity over the first three
days after initial assessment. ................................................................................................. 29
Figure 3.2 Bland Altman plot of total time spent in light intensity over the first three days
after initial assessment. ......................................................................................................... 29
Figure 3.3 Bland Altman plot of total time spent in moderate intensity over the first three
days after initial assessment. ................................................................................................. 30
Figure 3.4 Bland Altman plot of total time spent in vigorous intensity over the first three days
after initial assessment. ......................................................................................................... 30
Figure 4.1 Kaplan-Meier Curve of time to medical clearance to RTP by low and high activity
groups .................................................................................................................................... 42
xi
List Abbreviations
Symbol
Definition
MVPA
RTP
TBI
CISG
mTBI
ATP
AOR
CI
FITT
RPE
MET
BDNF
ImPACT
Moderate and vigorous physical activity
Return to play
Traumatic brain injury
Concussion in sport group
Mild traumatic brain injury
Adenosine triphosphate
Adjusted odds ratio
Confidence interval
Frequency, intensity, time, type
Rating of perceived exertion
Metabolic equivalent
Brain-derived neurotropic factor
Immediate Post-Concussion Assessment and
Cognitive Testing
Balance error scoring system
Standard assessment of concussion
Modified daily international physical activity
questionnaire
International physical activity questionnaire
Limits of agreement
Intraclass correlation coefficients
Sport concussion assessment tool 3rd version
Post-concussion symptom scale
Cognitive activity scale
BESS
SAC
MDIPAQ
IPAQ
LOA
ICC
SCAT-3
PCSS
CAS
xii
Chapter One: Introduction
1.1 Problem Statement
In Canada, approximately 54% of Canadians aged 12 years and older participate in
leisure time physical activity and are considered active or moderately active[1]. Sport, primarily
team and organized sport, is the largest leisure time physical activity in Canada, with 7.3 million
people aged 15 and older participating in some sort of sporting activity[2]. Although sport
participation has many benefits, it also leads to high injury rates that can have a significant
impact on the individual, their family, and the healthcare system[3]. One of the most popular
sports in Canada is ice hockey, with approximately 640,000 players registered in Hockey Canada
in 2014-2015[4]. Ice hockey being one of the most popular sport in Canada, it accounts for 10%
of all sport-related injuries in youth within Canada[3,5]. Concussions have been reported to be
the most common specific injury type in youth ice hockey (ages 9-16 years), accounting for 18%
up to 66% of all injuries[6–8]. A systematic review by Koh et al., (2003) found that overall, ice
hockey demonstrates the highest reported incidence of concussion among the four most popular
team sports (ice hockey, American football, rugby and soccer) for high school, collegiate and
amateur adult males[9]. In a study by Kontos et al., (2016) found that the incidence rate of
concussion in youth ice hockey (ages 12-18 years) in the U.S. was 1.58 concussions per 1000
athlete exposures (games and practices)[10]. In a more recent systematic review and metaanalysis, Pfister et al. (2016) found the top three three sports with the highest concussion
incidence rates were rugby, hockey and American football, with the incidence rate for hockey
being 1.20 (95% CI: 1.00-1.30).[11]
As the reporting of concussion has increased in recent years, a critical need is to continue
to improve the treatment and care of individuals following a concussion, especially in youth who
1
are still growing and developing. Concussions can result in a range of symptoms that may impair
an individual’s ability to perform activities of daily living and may result in time away from
activities such as school, work, and recreation.[12]
The current standard of care for an acute concussion is physical and cognitive rest until
the acute symptoms resolve, then a graded program of exertion prior to medical clearance and
return to play (RTP).[12] Little is known, however, regarding the optimal amount and type of
rest (cognitive and physical rest vs. physical activity) for promoting recovery following a
concussion. Physical activity is defined as “any bodily movements produced by skeletal muscles
that result in energy expenditure.”[13] The current guidelines for prescription of rest following
concussion are based on expert opinion rather than evidence-based due to a lack of high level
evidence. So there is an evident need for more research into the parameters of rest and activity
and its effects on recovery from concussion.
1.2 Background
1.2.1 Concussion
1.2.1.1 Definition
According to the Consensus Statement on Concussion in Sport the 4th International
Conference on Concussion held in Zurich, November 2012, concussion is a brain injury and
subset of traumatic brain injury (TBI). Concussion is defined as: “a complex pathophysiological
process affecting the brain, induced by biomechanical forces.”[12] Concussion typically
incorporates several common characteristics that may be used in identification and diagnosis:
1. “Concussion may be caused either by a direct blow to the head, face, neck or elsewhere
on the body with an ‘impulsive’ force transmitted to the head.
2
2. Concussion typically results in the rapid onset of short-lived impairment of neurological
function that resolves spontaneously. However, in some cases, symptoms and signs may
evolve over a number of minutes to hours.
3. Concussion may result in neuropathological changes, but the acute clinical symptoms
largely reflect a functional disturbance rather than a structural injury and, as such, no
abnormality is typically seen on standard structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss
of consciousness. Resolution of the clinical symptoms typically follows a sequential
course. However, it is important to note that in some cases, symptoms may be
prolonged.”[12]
The Concussion in Sport Group (CISG) acknowledges that the terms mild traumatic brain
injury (mTBI) and concussion are often used interchangeably in the literature. To maintain
consistency with the Consensus Statement on Concussion in Sport, the term concussion will be
used in this thesis.
1.2.1.2 Signs and Symptoms of Acute Concussion
Concussion typically does not result in structural injury or damage to the brain tissue that
is evident on standard neuroimaging, but commonly disrupt the functional capabilities of the
brain.[12] Concussion can impair neurological functioning, resulting in a number of signs that
may include amnesia, orientation problems, and loss of balance/instability.[12]
Concussion can result in clinical findings in a range of domains that can be used in the
acute assessment and diagnosis.[12] According to the 4th International Concussion Consensus
Statement: “the suspected diagnosis of concussion can include one or more of the following
clinical domains:
3
1. Symptoms - somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and/or
emotional symptoms (e.g., lability);
2. Physical signs (e.g., loss of consciousness, amnesia);
3. Behavioural changes (e.g., irritability);
4. Sleep disturbance (e.g., insomnia).
If any one or more of these components are present, a concussion should be suspected and the
appropriate management strategy instituted.”[12] The majority of concussions (80-90%) and
their symptoms resolve in a short time period of 7-10 days.[12] Persistent symptoms lasting
greater than 10 days are generally reported in 10-15% of concussions, with 14-31% of schoolaged children reporting post-concussive symptoms at least three months after a
concussion.[12,14,15]
1.2.1.3 Management of Acute Concussion
The current guidelines for the management of acute concussion are “physical and
cognitive rest until acute symptoms resolve and then a graded program of exertion prior to
medical clearance and return to play (RTP).”[12] It is suggested that an initial period of rest
during the acute symptomatic period following concussion (24-48 hrs) may be beneficial for
recovery.[12] Given the lack of evidence to inform the optimal amount and type of rest for
recovery, a sensible approach to concussion management should include a gradual return to
school and social activities, prior to contact sports, in a manner that does not exacerbate
symptoms.[12] Athletes are expected to proceed progressively through a stepwise return to play
protocol under the guidance of a physician and/or medical professional. The recommended steps
are:
1. Rest
4
2. Light aerobic activity
3. Sport specific exercise
4. Non-contact drills
5. Full contact practice
6. Return to play
Each step should take a minimum of 24 hours before progressing to the next step and if
symptoms occur during the protocol, the patient should return to the last asymptomatic stage
after resting for 24 hours. [12]
1.3 Research Rationale
The guidelines for concussion management are based on expert consensus, and no current
evidence-informed guidelines are available regarding the amount and type of rest that is best for
symptom resolution and recovery. It has been argued that complete bed rest is impractical and
not beneficial for recovery following concussion and sub-symptom threshold exercise may
contribute to earlier symptom resolution and return to play. Therefore, high quality studies
evaluating the optimal amount and type of rest (both cognitive and physical) that is most
conducive to a complete recovery from a concussion are critical. Thus, the purpose of this thesis
is to evaluate the association between physical and cognitive activity on time to concussion
recovery based on physician clearance to return to play and school.
1.4 Research Significance
Concussion is among the most commonly occurring injuries in youth sport, especially in
ice hockey, accounting for 18% up to 66% of all injuries in ice hockey.[6–8] Evidence informed
strategies aimed at minimizing the effects of concussion are imperative to optimize clinical
management. The results from this research project will provide insight into the effects of rest in
5
time to recovery from concussion in youth ice hockey players. Ultimately, the results of this
study will be used to inform optimized clinical management following concussion to help define
the optimal dose and duration of rest and physical activity to facilitate recovery. This research
will also help guide future areas of scientific inquiry by providing data to inform future trials
evaluating the effects of different forms of rest following concussion, which can help inform
clinical care for this injury that creates a significant public health burden for Canadian youth and
their families.
6
Chapter Two: A Review of the Role of Physical and Cognitive Rest and Activity in
Recovery from Concussion
2.1 Introduction
The current management of concussion includes physical and cognitive rest until acute
symptoms resolve, followed by a graded program of exertion before full return to activity.[12]
The guidelines for concussion management are largely based on expert opinion, lacking
empirical evidence and there is a paucity of research evaluating the effects of physical and
cognitive rest on recovery from concussion. The objective of this review is to evaluate the
current literature on the effects of physical and cognitive rest and activity on recovery from
concussion in youth and adults.
2.2 Pathophysiology of Concussion
Concussion typically results from trauma to the brain through acceleration and
deceleration forces that are believed to initiate a complex cascade of neurometabolic and
neurochemical events that may include metabolic, hemodynamic, structural and electrical
changes that may result in altered cerebral functioning.[16,17] Trauma to the brain has been
postulated to result in a disruptive stretching of the neuronal cell membranes and axons resulting
in an ionic flux and indiscriminate release of neurotransmitters.[16–18] The resulting ion and
neurotransmitter imbalances in the brain leads to what is referred to as the neurometabolic
cascade, which has been shown in animal models and has been speculated to be similar in
humans.[16–19]
Animal models demonstrate that brain trauma is followed by an increase in activity of
adenosine triphosphate (ATP)-requiring ionic membrane pumps and thus an increase in glucose
metabolism.[19,20] Acutely following a concussion, the increased activity of ionic membrane
7
pumps causes a depletion of intercellular glucose and ATP stores, which occurs in the setting of
diminished cerebral blood flow, causing a discrepancy between energy supply and demand
resulting in an energy crisis.[17,19] In rat models, this energy crisis begins at the time of injury
and lasts for at least 30 minutes, at which time cerebral metabolism is already at its limits and
any further energy demand caused by a subsequent concussion could cause irreversible neuronal
injury or death.[19,20] Following the acute energy crisis, glucose metabolism and cerebral blood
flow are both reduced, resolving the discrepancy between energy demand and supply.[19]
However, during this period, cerebral blood flow may not be able to respond to a stimulusinduced increase in cerebral glucose metabolism, like increased physical or cognitive activity or
a second concussion, which can then restart the energy crisis. Thus, rest following a concussion
may be beneficial in reducing excessive external stimuli and the risk of a second concussion. A
second concussion could further increase the disparity between energy supply and demand in the
brain increasing the chances of permanent neuronal cell injury and death. Rest in humans may
also help facilitate neurometabolic recovery, but generalizing from animal models to humans is
difficult, as it is not known if the human and animal brain react differently to a concussive injury.
Rest following concussion may not only be beneficial for neurometabolic recovery, but
also in reducing the possibility of an individual experiencing recurrent and successive
concussions. In animal models, a single concussion is associated with behavioural dysfunction
and subcellular alterations that contribute to the existence of a temporal window of brain
vulnerability.[21–23] If a second concussion occurs during this temporal window (3-5 days), it
can lead to exacerbated and more prolonged axonal damage and greater cognitive and
behavioural deficits. [21–23] By analogy, removing a player from sport after sustaining a
8
suspected concussion, will remove the player from the potential risk of a second concussion
occurring during the temporal window of brain vulnerability.
2.3 Bed Rest
Complete bed rest has commonly been prescribed as the primary treatment following
medical issues such as surgical procedures, disorders, and illnesses, dating back to Hippocrates
and the ancient Greeks.[24] The idea of complete bed rest is rooted in medical tradition and
theory based on the idea that illness and injury cause weakness in the body requiring rest until
the illness or injury and the resulting weakness subside.[24] In a review of bed rest as a treatment
by Allen et al., bed rest has commonly been prescribed following myocardial infarction,
psychiatric disorders, and orthopaedic procedures.[24] The authors found that bed rest as a
primary treatment did not significantly improve outcomes and in some disorders, like myocardial
infarction and low back pain, may result in prolonged symptoms and increased risk of further
disease and injury.[24]
According to the Consensus Statement on Concussion in Sport, concussion management
should be based around physical and cognitive rest until the acute symptoms resolve.[12]
Complete bed rest, however, has been described as unrealistic and impractical following
concussion, given that it is virtually impossible for an individual to engage in no physical or
cognitive activity.[25] There is also evidence that exercise and participation in organized sport
has many positive benefits for youth, such as improved physical health, psychological
adaptability, and academic success. Eliminating such activities, especially for long periods of
time, can affect athletes negatively. [25] However, little is known regarding the association
between bed rest and recovery from concussion, and overall the benefits of rest are largely
assumed rather than evidence based.
9
Two studies have evaluated the effects of bed rest and strict rest on post-traumatic
complaints and symptoms and neurocognitive test scores after concussion. The first, by de
Kruijk et al., randomized participants (15-76 years) presenting to an emergency room with a
mTBI to either full bed rest for six days or no rest after injury.[26] The two study groups did not
differ significantly in the reported amounts of outpatient bed rest, and the bed rest group reported
more difficulty complying with the recommendation for rest compared to the no rest group,
although there was no significant difference in adherence between groups. Additionally, no
differences in outcomes of post-traumatic complaints or general heath status were seen at 2
weeks, 3 months, and 6 months. [26] Similar findings were observed in a randomized controlled
trial where participants ages 11-22 years were randomized to either strict rest for 5 days or the
usual care (control) group within 24 hours of sustaining a concussion.[27] Strict rest did not
improve symptoms, neurocognitive, or balance outcomes compared to the control group 3 and 10
days post-injury.[27] However, recommending strict rest did not significantly alter the amount of
physical activity between the two groups measured using self-report activity diaries. Thus, the
two groups actually reported similar levels of physical activity and rest.[27] Both studies used
self-reported daily diaries to measure the amount of bed rest and physical activity, respectively.
Both studies found no significant differences between the intervention and control groups, but
the accuracy with which participants were reporting their activity levels and rest is unknown.
Thus research is needed to detect differences in activity and to validate self-report of patient
physical activity following a concussion. Given the lack of evidence supporting the use of
prolonged bed rest after concussion, more research is needed regarding the type and quantity of
rest that is most beneficial for recovery from concussion.
10
2.4 Cognitive Rest and Activity on Recovery from Concussion
The concept of cognitive rest was introduced at the Second International Conference on
Concussion in Sport in 2004, which recognized cognitive rest as “the need to limit exertion with
activities of daily living and to limit scholastic activities while symptomatic.”[28] Cognitive rest
is not clearly defined, but it can be interpreted as the absence of cognitive activity and is
recommended to include limiting activities that require attention and concentration, such as
reading, text messaging, watching television or movies, playing video games, working online,
and performing schoolwork, as these and other cognitive activities may exacerbate symptoms
and possibly delay recovery.[29–31] Cognitive rest and activity are difficult to measure and
quantify, but are commonly measured using diaries or questionnaires that are subject to biases of
participants reporting more or less cognitive activity to appear more favourable or compliant.
Not only is cognitive rest difficult to measure, it may also be impractical and difficult for patients
to enact. Further research is needed into the optimal amount of cognitive activity or cognitive
load for promoting recovery from concussion.[25,32,33]
Very few studies have examined the effects of cognitive activity and rest alone on
recovery from concussion. In a historical cohort study, Gibson et al.[34] found no association
between the recommendation for cognitive rest and the duration of concussion symptoms
[Adjusted odds ratio (AOR) =0.5; 95% CI=0.18–1.37]. In this study, the recommendation for
cognitive rest was measured retroactively if explicitly mentioned in medical records, and
therefore it is unknown if the participants actually engaged in cognitive rest.[34] This could lead
to a measurement bias of underreporting of cognitive rest, which may explain the lack of
association between cognitive rest and duration of symptoms found by the authors. The study
sample also had a large age range, from 8-26 years, and little is known regarding differences in
11
response to cognitive rest with respect to age.[34] The authors also reported that removing
student athletes from their normal routines increased feelings of anxiety and isolation as
homework increased and they were separated from friends and teammates.[34]
In a cohort study, Brown et al. [30] assessed the effect of cognitive activity on duration of
symptoms after a sports-related concussion. Patients ages 8 – 23 years recorded their cognitive
activity levels using a cognitive activity scale at each follow-up appointment to a Sport
Concussion Clinic within a hospital setting.[30] Cognitive activity was split into quartiles with
patients in the highest quartile of cognitive activity reporting a longer duration of postconcussion symptoms.[30] This is the first use of the cognitive activity scale developed by the
researchers and therefore validity and reliability have not been determined. Although reading
and homework are part of the cognitive activity scale, attendance at school or work was not
recorded, and it is unknown if the increased external stimuli (light and sound) related to being at
work or school could increase post-concussion symptoms, leading to a measurement bias. The
results from Brown et al., that those performing more cognitive activity showed increased
symptom duration, is contradictory to the findings of Gibson et al., that found no association
between the recommendation for cognitive rest and symptom duration. As the literature
examining cognitive rest on recovery from concussion is sparse and inconsistent, more research
is needed to develop reliable and valid measures of cognitive rest that can be used in higher
quality studies to examine the effects of cognitive rest along with physical activity on recovery
from concussion.
2.5 Physical Activity Monitoring
Physical activity and rest can be described as complimentary to each other, because if a
person is not physically active, then they are inactive or resting. Given the importance of
12
physical activity for all aspects of health, extensive research has measured and defined the
optimal amounts of physical activity for overall well-being.[13] Physical activity is defined as
“any bodily movements produced by skeletal muscles that result in energy expenditure.”[13]
Physical rest, however, is not as clearly defined or measured and is commonly associated with
physical inactivity and sedentary behaviour. If physical rest is thought to be the opposite of
physical activity, than it is important to know how physical activity is measured.
Physical activity is commonly described having four dimensions (FITT principle): i)
Frequency – number of sessions or bouts ≥ 10 minutes in length or duration; ii) Intensity – rate
of energy expenditure or the metabolic demand of the activity; iii) Time or duration – amount of
time the activity is performed; and iv) Type or mode – the specific activity performed or in a
physiological type (e.g. aerobic vs. anaerobic).[13] Intensity can be measured and classified in
numerous ways: as a percentage of VO2Max, percentage of heart rate max, ratings of perceived
exertion (RPE), metabolic equivalents (MET), and intensity levels (sedentary, light, moderate,
vigorous).[13] Physical activity intensity can be measured using different methods including
self-report surveys, indirect calorimetry or doubly labeled water method, heart rate monitors, or
motion sensors (e.g., accelerometry).[13] Given the importance of physical rest and physical
activity for recovery from concussion, there is a need to accurately measure physical activity and
rest post-concussion to help determine what amounts of physical activity and rest are most
beneficial for recovery.
Measuring physical activity and rest post-concussion in a manner that will not exacerbate
symptoms and is easily done at home can be challenging. Activity questionnaires and diaries are
easily administered, but may be subject to recall biases. Objective methods such as heart rate
monitors are also subject to limitations. A recent systematic review showed that there is some
13
evidence that cardiac autonomic function is altered with physical activity following concussion,
and it is unknown how reliable and valid measuring heart rate post-concussion is in measuring
physical activity intensity.[35] Accelerometers like the Actigraph monitor have been shown to be
valid and are accepted as a reliable method to objectively measure individual physical activity
using accelerations of the body during movement in a variety of populations.[13] Accelerometers
have the advantage of measuring acceleration in up to three planes (vertical, mediolateral and
anterior-posterior) and continuously capture frequency, duration, and intensity of physical
activity in a time stamped manner, which other methods like questionnaires and diaries cannot
do objectively.[13] Raw accelerometer data records accelerations and decelerations of the body
in counts, which can be expressed in different ways such as counts per second, counts per
minute, or total counts per day.[13] The raw accelerometer counts can then be translated into
units of energy expenditure (METs or kilocalories) or activity intensities based on thresholds
used to differentiate between intensities.[13] Thus accelerometers can measure the amount of
time a person is sedentary or active and may be a useful tool in determining the effect of physical
rest or sedentary time and activity on recovery from concussion.
2.6 Physical Rest and Activity on Recovery from Concussion
Physical activity and exercise have been demonstrated to be beneficial to overall health,
including improving cognition and brain functioning.[36] However, the effect of physical
activity following concussion is largely unknown. The rationale for physical rest after sustaining
a concussion is twofold: one reason is that rest is believed to help restore neurotransmitter and
ion imbalances within the neurons and to prevent further energy discrepancy in the brain. The
second reason is to prevent the possibility of an individual experiencing a second concussion.
Given that physical rest is important for recovery from concussion, but long periods may be
14
impractical and harmful, more research into the optimal amounts and timing of physical activity
and rest is imperative.
Studies using animal models have shown that exercise can improve cognitive
performance and increase proteins, such as brain-derived neurotropic factor (BDNF), that are
important in neural plasticity and repair.[36] Similar effects of exercise have been found in rats
that voluntarily exercise after a concussion, where repair mechanisms and functional recovery
have increased, along with performance in spatial memory and learning tasks, when compared to
sedentary counterparts.[36–38] However, the authors found that the timing of exercise postinjury was an important factor, as the rats that exercised from 0 – 6 days post-injury saw no
increase in BDNF, whereas the rats that exercised 14-20 days post-injury showed a positive
correlation between exercise and BDNF.[36–38] The authors also found that rats that underwent
the acute voluntary exercise (0-6 days post-injury) had more pronounced learning and memory
deficits than unexercised injured rats.[36–38] These studies would suggest that acute exercise
post-concussion can hinder the repair of the brain and cognitive performance, but when exercise
is delayed for two weeks, it can increase BDNF and neural repair and enhance cognitive
functioning.[36–38] These effects have only been shown in animal models, so generalizability to
humans is unclear.
In humans, Leddy et al., [39] examined the effects of a progressive, sub-symptom
threshold exercise training program on patients aged 16-53 years with post-concussion
syndrome. The author’s definition of post-concussion syndrome was symptoms at rest for >=6
weeks but <52 weeks and demonstration of exacerbated symptoms during a graded exercise
treadmill test.[39] Participants went through a baseline period of reporting symptoms for 2-3
weeks, then performing initial incremental treadmill tests at a velocity of 3.3 mph with the
15
treadmill grade increasing to 2.0% after the first minute, then increasing by 1.0% each
subsequent minute until post-concussion symptoms were exacerbated.[39] After the initial
testing, participants exercised for the same duration as their last treadmill test but at an intensity
of 80% of their sub-symptom threshold heart rate, for 5-6 days/week until their symptoms were
no longer exacerbated by the exercise. [39] The authors reported that total daily resting
symptoms, measured using the graded symptom checklist, significantly decreased after the
treatment period compared to the baseline period (baseline: 9.67±8.57, treatment: 5.42±4.54;
paired t-test: p=0.002). [39] All the study participants were able to eventually exercise at or near
their age-predicted heart rate max without symptom exacerbation. [39] Based on these findings,
the authors concluded that controlled exercise is safe to employ in patients with post-concussion
syndrome. The study did however report that symptom reporting was highly variable, both at
baseline and treatment periods, potentially because the study had a small sample size of 12
participants. Therefore it is unknown if similar results would be found with a larger sample.
Additionally, the study design did not include a control group that exercise treatment could be
compared to and it is unknown if exercise alone was responsible for the decrease in symptoms,
as concussion symptoms can resolve over time.[12]
In a study of children who were symptomatic for at least one month following a sportrelated concussion, a program involving submaximal aerobic and coordination exercises
improved post-concussion symptoms and the rate at which players successfully returned to
sport.[40] The aerobic exercise consisted of submaximal (50-60% maximal capacity) training on
either a treadmill or stationary bike for up to 15 minutes.[40] The coordination exercises were
tailored to participants’ main or favorite sport to reintroduce familiar activities in a successful
setting.[40] The study did not include a control group, however, and the treatment was
16
multifactorial, making it difficult to determine if exercise was responsible for the treatment effect
or if it was a combination of the aerobic and coordination exercises or time itself.
In a recent study, physical activity level and symptom duration were not associated
following sport-related concussion.[41] The authors created a physical activity scale based on the
graduated return to play protocol from the Consensus Statement on Concussion in Sport, and
used the post-concussion symptom scale to record patient symptom scores.[41] Physical activity
and symptom scores were measured at the initial physician visit and at each follow-up
appointment, where physical activity was recorded as the average level since the last physician
visit. Across all ages (8-27 years), physical activity level was not independently associated with
symptom duration, but for adolescents (13-18 years), higher levels of physical activity were
associated with shorter symptom duration; however, no data was provided to support either of
these claims.[41] This is the first and only use of the physical activity scale created by Howell et.
al., [41] to date, and thus its reliability and validity for measuring physical activity is unknown.
The authors also found collinearity between physical and cognitive activity and did not include
cognitive activity in their model. Thus, more research is needed into how cognitive and physical
activity together impact time to recovery from concussion.
2.7 Effect of Combined Physical and Cognitive Rest and Activity on Recovery from
Concussion
The consensus statement on concussion in sport states that physical and cognitive rest are
the cornerstone of concussion management.[12] Thus, studies of the effects of both physical and
cognitive rest together on recovery from concussion are important.[42] Few studies have
evaluated the effects of physical and cognitive rest together and the evidence is unclear as to
what amount and type of rest is best for recovery from concussion.
17
In a study of adolescent and collegiate athletes, one week or more of prescribed physical
and cognitive rest improved symptoms and neurocognitive test scores on Immediate PostConcussion Assessment and Cognitive Testing (ImPACT) [F(5,42) = 10.63; p = .001].[43]
However, the study was retrospective, and did not include control or comparison groups, so the
observed improvements may have been due other factors, including spontaneous resolution of
symptoms over time.[43] In addition, adherence to the recommendation of physical and cognitive
rest was not monitored, making it difficult to conclude if rest and what amount of rest was
associated with symptom resolution.[43] In a similar study, one week of physical and cognitive
rest was prescribed for patients with persistent symptoms following concussion.[44] Following
the prescribed rest, symptom reporting improved by 54% overall and by 87% in patients with
elevated post-concussion symptom scores before prescribed rest. [44] Seventy-seven percent of
patients showed statistically reliable improvement on one or more cognitive domain scores and
31% showed reliable improvements on two or more cognitive domains.[44] The study was
limited by a small sample size of 13 participants with the lack of control or comparison groups,
so the study may have been underpowered.
A study by Buckley et al., [45] evaluated the effectiveness of an acute period of physical
and cognitive rest on recovery from concussion. A policy change was implemented at the
University of Delaware in July 2012, such that all student athletes diagnosed with a concussion
were withheld from all academic and physical activities for the remainder of the day at the time
of diagnosis and prescribed physical and cognitive rest for one additional day.[45] The authors
compared symptoms (using the graded symptom checklist), ImPACT, Balance Error Scoring
System (BESS), and Standard Assessment of Concussion (SAC) results in collegiate athletes
diagnosed with a concussion performing “no rest”, before the policy change, with those
18
performing “rest” after the policy change.[45] The rest group was symptomatic significantly
longer than the no-rest group (5.2 ± 2.9 days and 3.9 ± 1.9 days, respectively; t = 2.035, P =
.047), but no significant differences were found between the two groups in time to return to
baseline BESS scores, ImPACT scores, SAC scores, or in time to clinical recovery.[45] The no
rest group was withheld from intercollegiate athletic events and workouts but no restrictions
were placed on activities of daily living or academics.[45] Because the study was done
retrospectively, the amount of cognitive and physical activity that the no rest group performed is
unknown, making it difficult to conclude that the lack of rest alone determined the shorter
duration of symptoms than the rest group. Also, the physical and cognitive rest was only
prescribed for one day, and participants’ activity was not measured for the remainder of their
recovery, so it is unknown what effects physical and cognitive activity after the first day of rest
would have on recovery from concussion.
A retrospective chart review of activity level on symptom status and neurocognitive
function after sports-related concussion showed that participants engaging in moderate levels of
activity demonstrated the best recovery.[46] The authors developed an activity intensity scale
that categorized activity into five categories: 0 - no school or exercise activity, 1 - school activity
only, 2 - school activity and light activity at home (e.g., slow jogging, mowing the lawn), 3 school activity and sports practice, 4 - school activity and participation in a sports game.[46] The
authors found that athletes that engaged in the highest level of activity (level 4) demonstrated the
worst neurocognitive scores (ImPACT).[46] Conversely, the moderate activity group (level 2)
had the best performance out of all the groups on all aspects of the neurocognitive testing.[46]
No statistically significant association was found between symptom duration and activity level,
but the authors reported that clinical trends were observed, with the moderate activity group
19
reporting the fewest number of symptoms.[46] This is one of the few studies showing that
moderate levels of activity are the most beneficial for recovery from concussion, but the study
has several limitations. The activity intensity scale has not been validated, and could be a source
of recall bias, as participants reported their activity levels at each physician appointment,
potentially leading to an underreporting of their actual physical activity in an effort to seem more
compliant with physician recommendations for rest. The study was also a retrospective chart
review, making it difficult to assess temporality and if activity level alone was responsible for the
findings. Nonetheless, the study suggests that there may be an optimal amount of physical and
cognitive activity that is most beneficial for recovery from concussion, and more research is
needed to help determine this optimal physical and cognitive activity.
2.8 Summary
There is a paucity of research evaluating the effects of rest following concussion, and
presently no evidence-infomed guidelines include identification of the ideal amount and type of
rest for promoting symptom resolution and recovery. The majority of studies evaluating the
effects of physical and cognitive rest on recovery from concussion have a wide age range or use
adult (>18 years) participants, making it difficult to know whether similar results would be seen
in youth (<18 years).[26,27,34,39,41,43,45,47] The few studies including youth have not
included control groups, making it impossible to evaluate if rest and/or exercise was responsible
for recovery, as concussive symptoms tend to resolve spontaneously over time.[40,43,46] In the
majority of studies, participants report to a sport medicine clinic or hospital for treatment, which
could lead to a selection bias in that those participants actively seeking out medical attention for
their concussion may be more compliant to physician advice than the rest of the population,
leading to an overestimation of the association between rest or activity and recovery from
20
concussion.[26,27,34,39–41,44,46] In the literature, physical and cognitive rest are not clearly
defined, and previous studies have used self-report or retrospective chart review to measure the
amount of rest or activity performed by participants. Using self-report alone to measure rest or
activity may lead to a measurement bias, in that participants may overestimate the amount of rest
they actually engage in to appear like they are following physician recommendations. This may
lead to an overestimation of the association between rest and recovery, which could be
interpreted as suggesting more rest is beneficial for recovery from concussion, however, this
association is currently unclear. Studies using retrospective chart review do not allow for
objective measures of rest or activity. Thus, research is necessary to i) define physical and
cognitive rest, ii) objectively measure rest and activity, and iii) determine the optimal type and
amount of rest for promoting recovery from concussion.
21
Chapter Three: Physical Activity Monitoring in Youth Following a Concussion
3.1 Introduction
The importance of physical activity for all aspects of health, from physiological to
cognitive functioning, has been extensively researched including measuring and defining optimal
amounts of physical activity for overall well being. [13] Where physical activity is defined as
“any bodily movements produced by skeletal muscles that result in energy expenditure.”[13]
Physical rest conversely, has not been clearly defined and there is still debate as to what physical
rest is and what amounts are beneficial for overall health. There is even less research into the
effects of physical activity and rest on the injured brain, especially after a concussion.
According to the Consensus Statement on Concussion in Sport, the cornerstone of
concussion management is physical and cognitive rest, with an initial period of rest (24-48hr)
during the acute symptomatic phase possibly being beneficial for recovery.[12] These guidelines
for rest following a concussion are largely based on expert opinion and lacking evidence to
inform best practice, therefore it is important to evaluate the effects of rest on recovery from
concussion. The recommendation for the amount of physical rest after concussion is not clearly
defined but can be associated with physical inactivity, sedentary behaviour and bed rest.
Few studies have evaluated the effects of bed rest on recovery from concussion. One
study by de Kruijk et al., randomized participants (15-76 years) presenting to an emergency
room with a mTBI to either full bed rest for six days or no rest after injury.[26] A similar study
randomized participants ages 11-22 years to either strict rest for 5 days or the usual care (control
group within 24 hours of sustaining a concussion).[27] Both studies found similar results,
reporting no significant differences in actual amounts of participant bed rest between
intervention and control group measured using self-report diaries. Strict bed rest did not improve
22
symptoms, neurocognitive or balance outcomes compared to the usual care (controls)
groups.[26,27] Both studies used self-reported activity diaries and it is unknown if these diaries
are accurate measures of rest following concussion. Thus, research evaluating the association
between self-reported and objective measures of rest post concussion is needed.
A paucity of literature is available that examines physical activity post-concussion, with
most studies using self-reported activity. A few studies have retrospectively reviewed
participant’s physical activity post-concussion, either evaluating participants activity levels [46]
or whether a period of rest was observed [43,45]. However, using self-report there may be issues
with recall bias as participants report more or less activity and rest to appear more favourable.
Howell et al., [41] prospectively measured participants physical activity levels using a self-report
scale created from the Consensus guidelines. This scale has not been previously validated and
may result in a reporting bias as participants may underreport the amount of physical activity
they do to appear more compliant with the physician recommendation for rest.[41] There is a
lack of literature measuring physical activity post-concussion and there is a need to evaluate the
most effective methods for measuring activity.
Measurement of physical activity and rest post-concussion in a manner that will not
exacerbate symptoms and can be administered at home, can be challenging. Subjective measures
such as activity questionnaires and diaries can be administered but may be subject to recall and
reporting biases. Objective methods, including heart rate monitors, are subject to limitations. A
recent review reports that cardiac autonomic function may be altered with physical activity
following concussion.[35] Thus, it is unknown how reliable and valid measurement of heart rate
is in estimating physical activity intensity post-concussion.[35] Other methods such as
accelerometers may be more appropriate to measure physical activity and rest post-concussion.
23
Accelerometers are easily worn, often on the wrist or waist. These devices measure accelerations
of the body and continuously capture frequency, duration and intensity of physical activity in a
time stamped manner, which other methods like questionnaires and diaries cannot do
objectively.[13] Accelerometers also have the advantage of converting raw counts into levels of
activity intensities based on previously established count thresholds that can be changed
depending on the population under study.[13]
Additionally, methods that effectively measure the amount of rest a person is getting
following a concussion needs to be accurately quantified so that guidelines can be developed to
define the optimal amounts and type of rest that are the most beneficial for recovery concussion.
Therefore, the purpose of this study is to compare physical activity and rest levels measured via
1) a self-reported questionnaire and 2) a participant worn Actigraph accelerometer to determine
the best and most efficient methods for measuring rest and activity following a concussion.
3.2 Methods
This study is a case series that is part of a cohort study in youth ice hockey players.
Participants presenting to a sport medicine concussion clinic in Calgary, Alberta, Canada
between December 2015 and March 2016 with a concussion that was diagnosed by a sport
medicine physician as per the 4th International Consensus Statement on Concussion in Sport
were included in this study. At the initial post injury appointment, participant demographics of
sex, date of birth, height and weight were obtained. Once written informed consent was granted,
participants were given an Actigraph wGT3X-BT accelerometer (Actigraph LLC, Pensacola, FL,
USA) to be worn over the right anterior superior iliac spine (ASIS) for the first three days after
and including the initial appointment date. Participants were asked to wear the monitor over or
24
underneath their clothes based on comfort, as long as the monitor remained superior to the right
ASIS.
In addition to wearing the monitor, participants were asked to complete a Modified Daily
International Physical Activity Questionnaire (MDIPAQ, Appendix A), which was modified
from the previously validated International Physical Activity Questionnaire (IPAQ).[48] The
IPAQ was previously validated against Computer Science and Application’s Inc. (Shalimar, FL)
accelerometer (CSA model 7164).[48] The MDIPAQ was modified to record participant’s daily
activity prospectively instead of a seven-day retrospective recall like the IPAQ. Even though the
MDIPAQ was developed from the validated IPAQ, this is the first use of the MDIPAQ so the
validity and reliability of this tool has yet to be determined. Participants recorded the amount of
time they spent each of the first three days performing activities in vigorous, moderate, light and
sedentary intensities.
This study was approved by the University of Calgary Conjoint Health Research Ethics
Board (Ethics ID: REB15-2577) and informed written consent to participate was provided by all
participants.
3.2.1 Statistical Analyses
Descriptive statistics were completed, including medians and ranges or frequencies and
proportions as appropriate, for participant baseline characteristics and covariates (including
participants’ level of play, previous history of concussion and initial total and severity of
symptoms). Actigraph raw accelerometer data was converted into activity intensities using cutpoints for sedentary (0-720 counts/min), light (721-3027 counts/min), moderate (30284447counts/min) and vigorous (≥ 4448) intensities using previously validated cut-points in
adolescents by Romanzini et al.[49] Not all participants wore the Actigraph monitor during sleep
25
and the MDIPAQ did not ask about sleep time, therefore sleep time was not included in this
analysis.
Bland-Altman plots with corresponding mean difference and 95% limits of agreement
(LOA) were used to evaluate the agreement between the time spent in each activity intensity
measured by the Actigraph accelerometer compared to the self-reported MDIPAQ. Pearson’s r
correlation coefficients were used to evaluate the correlation between the Actigraph and
MDIPAQ.
3.3 Results
Forty-four participants presented to the sport medicine concussion clinic with a suspected
concussion. Of those, ten participants did not complete the questionnaires and eight participants
did not wear the actigraph monitor after the initial appointment date and were excluded from the
analysis. An additional six participants were not diagnosed with a concussion at the initial
appointment. Therefore twenty participants with a sport-related concussion while playing ice
hockey were included in this study. Participant demographics are summarized in Table 3.1.
The mean difference and 95% limits of agreement between the total minutes recorded by
the Actigraph monitor and reported on the MDIPAQ by intensity is reported in table 3.2. The
mean difference between the two measures ranged from 44.93 minutes (95% LOA: -6.94 - 94.81
minutes) for vigorous intensity, to 714.07 minutes (95% LOA: -977.28 - 2405.43 minutes) for
sedentary intensity over the three days. Bland Altman plots (Figures 3.1-3.4) and 95% limits of
agreement show large intervals and poor agreement between Actigraph recording and participant
self-report on MDIPAQ. Pearson’s r correlation coefficients are also reported in Table 3.2.
Pearson’s r values for all four exercise intensities between the Actigraph accelerometer and
MDIPAQ ranged from 0.09 for moderate intensity to 0.79 for vigorous intensity.
26
Table 3.1 Participant demographics
Characteristic
Result
Sex
16 Male (80%), 4 Female (20%)
Age – years, median (range)
14 (12 – 16)
Height – cm, median
(range)
Weight – kg, median
(range)
Elite (AAA,
AA, A)
Level of
play, n (%)
Non-elite
(Tiers 1-7)
Previous
history of
concussion,
n (%)
166.4 (150.7 – 183.8)
57.4 (40.0 – 93.0)
5 (25%)
15 (75%)
0
13 (65%)
1
4 (20%)
2 or more
3 (15%)
Initial total symptoms /22,
median (range)
Initial symptom severity
/132, median (range)
13 (0 – 21)
26.5 (0 – 71)
27
Table 3.2 Mean difference, Bland Altman limits of agreement (LOA) and Pearson’s r
correlation coefficient for total time by activity intensity over the first three days of
recovery.
Activity
Intensity
Mean Difference
(minutes)
95% LOA
(minutes)
Pearson’s r
Sedentary
714.07
-977.28, 2405.43
0.21
Light
-86.14
-845.19, 672.19
0.09
Moderate
67.66
-12.63, 147.94
0.57
Vigorous
44.93
-6.94, 94.81
0.79
28
-1000
Difference Between Actigraph and MDIPAQ
0
1000
2000
3000
Figure 3.1 Bland Altman plot of total time spent in sedentary intensity over the first three
days after initial assessment.
910.75
2864.67
Mean Time (minutes)
-1000
Difference Between Actigraph and MDIPAQ
-500
0
500
1000
Figure 3.2 Bland Altman plot of total time spent in light intensity over the first three days
after initial assessment.
201.92
903.17
Mean Time (minutes)
29
-50
Difference Between Actigraph and MDIPAQ
0
50
100
150
Figure 3.3 Bland Altman plot of total time spent in moderate intensity over the first three
days after initial assessment.
2.08
185.83
Mean Time (minutes)
Difference Between Actigraph and MDIPAQ
0
20
40
60
80
100
Figure 3.4 Bland Altman plot of total time spent in vigorous intensity over the first three
days after initial assessment.
0
183.83
Mean Time (minutes)
30
3.4 Discussion
Rest followed by a stepwise return play protocol is the foundation of concussion
management, but the amount of rest and activity that is most beneficial for recovery is unknown.
[12] However, before future study can evaluate the effects of rest and activity, it is imperative
that the most accurate measures of rest and activity post-concussion are identified and used. This
study evaluated the agreement and correlation of participant activity post-concussion measured
objectively by Actigraph accelerometer and a self-reported questionnaire.
To our knowledge, this is the first study to compare an accelerometer and self-report rest
and physical activity during recovery following a sport-related concussion. When comparing the
accelerometer to participant self-report, the activity intensities of sedentary, moderate and
vigorous, had positive mean differences indicating that participants underreported their time in
each of those intensities using the self-report. Light activity was the only intensity in which
participants self-reported more time than the accelerometer. This may be due to light activity
being categorized to include activities of daily living and may have been the source of a
reporting bias as participants reported more of their non-sedentary time as light intensity to
appear more compliant with physician instruction to rest and avoid high intensity activity.
Participants also may have not fully understood what sedentary and light activity represents,
making it difficult for them to report the actual amount of time spent doing activities in those
intensities.
Sedentary activity had the largest mean difference at 714.07 minutes indicating
participants underestimated the amount time they spent being sedentary. This may be due to the
previously mentioned lack of understanding of what exactly sedentary behaviour is, especially in
a youth population. Future study should ensure proper understanding of all exercise intensities
31
and evaluate sleep analysis as a component of the self-report measure. Time spent in moderate
and vigorous intensities were also underreported compared to the Actigraph, possibly due to a
reporting bias in which participants underreport the amount of time spent in moderate and
vigorous activity to appear more compliant with physician instruction for rest following a
concussion.
Pearson’s r correlation coefficients were positive for all four intensities, where the time
recorded by the Actigraph increased the MDIPAQ also increased. There was poor correlation
between the Actigraph accelerometer and self-reported MDIPAQ for sedentary and light
intensities. Moderate intensity showed moderate correlation with vigorous intensity showing
good correlation between the two methods. The higher correlations found in moderate and
vigorous intensities may be a result of less time spent in these intensities and a better
understanding of what moderate and vigorous activity are, leading to participants being better
able to self-report the amount of time they spent in those intensities. As the correlation between
the Actigraph and MDIPAQ varies with different activity intensities the more objective
Actigraph may be a more useful measure of activity post-concussion in youth ice hockey players.
3.4.1 Limitations
This study is not without limitations, as this study is a case series that is a part of another
study, it was not powered on the agreement and correlation between the Actigraph and
MDIPAQ. Due to the small sample size, there was large variability in the results and a larger
study may help reduce this variability. Another limitation of this study was that participants did
not record their sleeping time on the self-report measure, whereas the Actigraph was worn during
sleep and recorded sleep time as time spent in sedentary intensity, which may be a reason for the
large mean difference found between the Actigraph and MDIPAQ.
32
Bland-Altman plots and Pearson’s r correlation should be interpreted cautiously as both
have their limitations. Bland-Altman plots are interpreted based on a normal distribution of the
differences between the Actigraph and self-report, which was not the case in this study due to the
small sample size. Pearson’s r only assess a linear relationship between the two variables and
inferences beyond that must be made caustiously.
The generalizability of this study may be limited as it was conducted in youth ice hockey
players presenting to a sport medicine clinic and the results may not be generalizable to other
populations. Future study is therefore needed to evaluate accelerometer and self-report in other
post-concussion populations.
3.4.2 Conclusions
This is the first study to evaluate the agreement and correlation between an Actigraph
accelerometer and a self-reported questionnaire in youth who have been diagnosed with a
concussion. There is poor agreement between the Actigraph and MDIPAQ over the first three
days of recovery for sedentary and light intensities with moderate to good correlation for
moderate and vigorous intensities. Actigraph accelerometry is a more objective measure of
physical activity compared to self-report and may be a more accurate measure. Future studies
evaluating physical activity and rest post-concussion should use accelerometry when possible
over self-reported questionnaires.
33
Chapter Four: The association between moderate and vigorous physical activity and time
to medical clearance to return to play following sport-related concussion in youth icehockey players.
4.1 Introduction
Concussions are a mild traumatic brain injury that can result in a range of symptoms that
may impair an individual’s ability to perform activities of daily living and may result in time
away from activities such as school, work, sport and recreational activities.[12] The current
guidelines for the management of acute concussion according to the Consensus Statement on
Concussion in Sport include physical and cognitive rest until acute symptoms resolve and then a
graded programme of exertion prior to medical clearance and return to play (RTP) and it is
suggested that an initial period of rest (24-48hrs) may be beneficial. Little is known and there is
some debate in the literature as to what the optimal amount and type of rest (cognitive and
physical rest) or physical activity (moderate and vigorous) is most beneficial for recovery
following a concussion.
In the case of a concussion, trauma to the head or body has been postulated to cause
mechanical trauma to the brain through acceleration and deceleration forces that initiate a
complex cascade of neurometabolic and neurochemical events that may include metabolic,
hemodynamic, structural and electrical changes that can result in altered cerebral
functioning.[16,17] In animal rat models it has been shown that to restore ionic and cellular
homeostasis in the brain after concussion there is an increase in activity of adenosine
triphosphate (ATP)-requiring ionic membrane pumps, which occurs in the setting of diminished
cerebral blood flow.[17,19,20] Following a concussion excessive external stimuli and a possible
second concussion could further increase the disparity between energy supply and demand in the
34
brain. Thus rest may be beneficially in reducing the chances of permanent neuronal cell injury
and death.[17,19,20]
Complete bed rest has been described as unrealistic and impractical following
concussion, as it is virtually impossible for an individual to engage in no physical or cognitive
activity.[25] There is substantial evidence that indicates that exercise and participation in
organized sport have positive benefits for youth and eliminating such activity, especially for long
periods, can be expected to have a negative effect increasing symptoms of depression and
anxiety [25] Two studies randomized participants following concussion to full bed rest for six
days vs. no rest [26] and strict rest for five days vs. usual care [50]. Both studies found no
significant differences in the amount of actual rest time between the two groups and thus bed rest
did not improve symptoms or neurocognitive and balance outcomes. These studies found no
significant differences between the control and intervention groups, which may be due to the use
of self-reported activity diaries, with which the accuracy of self-reporting activity following a
concussion is unknown.
In a study of rest following concussion in adolescents and collegiate athletes, one week or
more of prescribed physical and cognitive rest improved symptoms and neurocognitive test
scores on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), however
the study was retrospective and did not include a control group for comparison. [43] Buckley et
al., [45] evaluated the effectiveness of an acute period of physical and cognitive rest on recovery
time following concussion. The authors found conflicting results to Moser et al., that the rest
group was symptomatic significantly longer than the no rest group, although there were no
significant differences in the time to medical clearance between groups.[44] Another study by
Majerske et al., found that student athletes reporting moderate levels of cognitive and physical
35
activity (e.g., school activity , light at home activity, jogging) during the first month after a
concussion was more beneficial for recovery than those reporting no activity (no school or
exercise) or high levels of activity (school activity and participation in sports games).[46]
To effectively evaluate the effects of physical activity on concussion recovery, accurate
measurement tools are imperative. Accelerometry is one such tool that is commonly used to
measure physical activity as it is an easily administered and valid and reliable.[13] The
Actigraph accelerometer has been used in both youth and adult populations and shown to be a
reliable and valid measure when compared to oxygen consumption via VO2 metabolic carts and
other accelerometers.[49,51,52]
Based on the previous literature, excessive rest or complete bed rest and high levels of
activity have not demonstrated to be beneficial for recovery from concussion. There is also little
research on the effects of activity following concussion and there are presently no evidencebased guidelines that identify the ideal combination or amounts of rest and activity for symptom
resolution and recovery after concussion. Therefore, there is a strong need to investigate and
improve methods for measurement of rest and physical activity following a concussion to help
determine the optimal type and amount of rest and physical activity that is most beneficial for
recovery from concussion. The primary purpose of this study was to evaluate the association
between moderate and vigorous physical activity (MVPA) during the first three days following
concussion diagnosis, and time (days) to medical clearance to return to play in youth ice hockey
players. Secondary objectives of this study were to examine the association between MVPA and
time to: i) return to baseline symptom scores, ii) first day of initiation of return to play protocol,
iii) first day of partial restricted return to school and iv) first day of full unrestricted return to
school.
36
4.2 Methods
This study was a cohort study including youth ice hockey players presenting to a sport
medicine clinic who sustained a concussion that was diagnosed by a sport medicine physician.
Prior to injury, participants recorded baseline symptom scores at the beginning of the 2015-2016
ice hockey season, using the Sport Concussion Assessment Tool-3 (SCAT-3) that includes the
Post-Concussion Symptom Scale (PCSS) in which participants recorded their total number of
symptoms from 0 to 22 and the total severity of those symptoms from 0 to 132. After sustaining
a sport related concussion during the hockey season, participants attended an initial physician
appointment where they completed standardized forms (including SCAT-3) and an interview
with a medical professional to record demographics, date and mechanism of injury, and a
medical history including number of previous concussions. Upon diagnosis of a concussion,
participants were approached for participation into this study.
The exposure of time spent in MVPA was measured using a waist worn Actigraph
wGT3X-BT accelerometer (Actigraph LLC, Pensacola, FL, USA), with raw accelerometer data
categorized into activity intensities of sedentary, light, moderate and vigorous using previously
validated cut-points for adolescents by Romanzini et al., [49]. Participants wore the monitor over
the right anterior superior iliac spine either over or under their clothes for comfort, only taking
off the monitor when bathing to prevent water damage and skin irritation. As there is no
previously established cut-point for physical activity, median time was used to dichotomize into
high and low time spent in MVPA.
At the initial and each follow-up appointment participants completed the SCAT-3 and
had a physician assessment. The primary outcome of the date of medical clearance was the date
the participant was cleared by the attending physician to return back to sport. Physicians
37
followed a standardized protocol of medical clearance, where the patient was to be i)
asymptomatic at rest, ii) asymptomatic with exertion and iii) no other reason to withhold
clearance. The outcome of symptom duration was defined as the number of days between the
injury date and the date of return to baseline symptom scores (if available) or return to normal
levels as indicated by the participant and approved by the physician if no baseline was available.
The outcome of number of days to the initiation of the return to play protocol was recorded as
the number of days from the injury date to the date the physician instructed the participant to
begin the protocol. The date of first return to partial and full participation in school was selfreported by the participant to the researchers and the number of days from the injury date was
calculated
This study was approved by the University of Calgary Conjoint Health Research Ethics
Board (Ethics ID: REB15-2577). Informed written consent to participate was provided by all
participants.
4.2.1 Statistical Analysis
The exposure of MVPA was dichotomized into high (≥45 minutes) and low (<45
minutes) activity based on the daily median during the first three days after and including the
initial appointment date. The primary outcome was the number of days from the injury date to
the date medical clearance to return to play. Secondary outcomes were the number of days from
the injury date to the date of i) return to baseline symptom scores ii) initiation of return to play
protocol iii) return to partial/restricted school iv) return to full school participation. Descriptive
statistics reporting medians and ranges or counts and proportions as appropriate was performed
for baseline characteristics and covariates and stratified based on low and high activity groups.
Kaplan-Meier survival analysis with log-rank tests of significance was used to evaluate the effect
38
of high and low MVPA on time to medical clearance and the secondary outcomes. Significance
was set a priori at an alpha of 0.05 for the primary outcome with a Bonferonni correction for the
secondary outcomes (0.05/4 = 0.0125). Due to a small sample size, inferential statistics assessing
the effect of covariates on time to medical clearance could not be done.
4.3 Results
Forty-four participants presented to the sport medicine clinic with a suspected
concussion. Of those, eight participants did not wear the actigraph monitor after the initial
appointment date and were excluded. An additional 6 participants were not diagnosed with a
concussion at the initial appointment and were not recruited into the study. Therefore, a total of
thirty participants were included in the current study, with participant demographics presented in
Table 4.1.
All participants who sustained a sport-related concussion during the 2015-2016 hockey
season, presenting to the clinic in a median of 4 days ranging from 2 – 20 days after the injury
date. Using the PCSS from the SCAT-3, the median number of total symptoms participants
reported at their initial appointment was 11.5 symptoms out of 22, ranging from 0 – 21, with a
median symptom severity score of 20 out of 132 (range: 0 – 71).
The median time in moderate and vigorous physical activity over the first three days
following and including the initial appointment date for all participants was 44.8 minutes (4.0 –
109.0 minutes). The number of days from the injury date to each outcome for the high and low
activity groups are presented in table 4.2, except for the number of days to return to partial
school. Only eight participants (26.7%) returned to partial school (1/2 days) at a median of 4
days (range: 1 – 8 days) before returning to full school participation. Four participants (13.3%)
did not miss any days of school and returned to full school participation the day after their injury.
39
Survival analysis log-rank tests comparing the low and high activity groups for each
outcome are presented in Table 4.2. The high activity group took significantly more time to be
medically cleared to return to play (chi2=5.27, p=0.022, alpha=0.05) compared to the low
activity group (Figure 4.1). The only secondary outcome that was significant was the low activity
group returned to baseline symptom scores significantly sooner (chi2=6.37, p=0.017,
alpha=0.125) than the high activity group.
Table 4.1 Participant demographics
Characteristic
Sex
Age – years, median (range)
Height – cm, median
(range)
Weight – kg, median
(range)
Elite (AAA,
AA, A)
Level of
play, n (%)
Non-elite
(Tiers 1-7)
Previous
0
history of
1
concussion,
2 or more
n (%)
Initial total symptoms /22,
median (range)
Initial symptom severity
/132, median (range)
Number of days to initial
appointment
Time spent in sedentary
(total minutes)
Time spent in light (total
minutes)
Low Activity Group
11 male, 4 female
14 (13 -17)
High Activity Group
14 male, 1 female
14 (12 – 17)
166.1 (153.2 – 185.2)
166.2 (139.4 – 180.3)
56.6 (43.2 – 74.5)
53.2 (28.5 – 93.0)
6 (40.0%)
3 (20.0%)
9 (60.0%)
12 (80.0%)
9 (60.0%)
8 (53.3)
4 (26.7%)
4 (26.7)
2 (13.3%)
3 (20.0)
13 (0 – 21)
10 (0 – 20)
21 (0 – 71)
16 (0 – 56)
4 (2 – 6)
4 (2 – 20)
1266.33 (745.0 – 1418.17)
1166.0 (982.33 – 1270.83)
83.50 (17.83 – 147.67)
131.5 (59.67 – 225.5)
40
Table 4.2 Outcomes by activity group
Outcome
Low Activity
(MVPA <45
minutes)
High Activity
(MVPA ≥45
minutes)
Log-rank test
chi2
p-value
Number of days to
medical clearance to
15 (10 – 30)
19 (12 – 55)
5.27
0.022*
return to play (median,
range)
Number of days to
return to baseline
14 (5 – 25)
19 (4 – 52)
6.37
0.0116**
symptom scores
(median, range)
Number of days to
initiation of return to
11 (4 – 25)
12 (4 – 40)
1.76
0.185
play protocol (median,
range)
Number of days to
partial return to school
4.5 (2 – 8)
2.5 (1 – 4)
1.79
0.181
(median, range)
Number of days to full
return to school
9 (0 – 15)
3 (0 – 27)
1.17
0.280
(median, range)
* Significant difference (significance p<0.05) in survivor function between low and high activity
groups
** Significant difference (significance p<0.0125) in survivor function between low and high
activity groups
41
.75
.5
.25
0
Proportion Medically Cleared
1
Figure 4.1 Kaplan-Meier Curve of time to medical clearance to RTP by low and high
activity groups
0
10
20
30
Number of Days
40
50
Number Remaining
Low Activity 15
High Activity 15
15
15
5
7
0
3
0
2
1
5
95% CI
95% CI
Low Activity (<45 min)
High Activity (≥45 min)
4.4 Discussion
There is a paucity of research evaluating the effects of exercise and on recovery from
sport-related concussion. This is one of the first studies, to our knowledge, to objectively
evaluate high and low levels of physical activity during recovery on time to medical clearance to
return to play. All participants in this study performed at least some MVPA over the first three
days, despite physician instruction to initially rest following the concussion. This supports the
idea that complete bed rest is unrealistic and impractical to perform. Therefore, instead of
completely eliminating activity initially post-concussion, efforts should be made into limiting the
amount of higher intensity activities.
The results from this study suggest that more time in MVPA during the first three days
after initial assessment is significantly associated with a greater time to medical clearance to
42
return to play and return to baseline symptom scores. These findings are different than the results
of Howell et al., who reported that in adolescents, higher levels of physical activity and lower
initial symptoms after concussion are associated with a shorter duration of symptoms.[41] This
may however be due higher physical activity being associated with a less severe injury, as they
are less symptomatic becoming more active and asymptomatic sooner. Howell et al., also used a
self-reported activity questionnaire, recording participants activity levels during the entire
duration of their recovery, which may be a source of reporting bias leading to different results
than this study.[41]
The results from this study of less time in MVPA over the first three days after initial
assessment suggest that an initial period of rest may be beneficial for recovery.As complete rest
is impractical, limiting the amount of MVPA during recovery may be beneficial for concussion
recovery. This is also supported by the findings of Majerske et al., that found clinical trends in
participants performing moderate (school activity and light at home activity) levels of activity
reporting the fewest number of symptoms post-concussion.[46]
All participants reached each outcome in a logical order by returning to full school
participation first, followed by starting the return to play protocol, then returning to baseline
symptom scores before being medically cleared. The low activity group reached medical
clearance and returned to baseline symptom scores in fewer days than the high activity group,
where the high activity returned to school sooner. The high activity group was less symptomatic
initially possibly leading to an earlier return to school. However, returning to school earlier may
have prolonged symptoms resulting in a longer time to return to baseline symptoms and to
medically clearance. However, more research evaluating physical activity throughout the entire
43
duration of recovery is needed including the effect of cognitive activity in conjunction with
physical activity on concussion recovery.
4.4.1 Limitations
This is the first study of its kind and contributes to the concussion literature, but is not
without its limitations. Due to the small sample size, we were unable to evaluate the effect of
covariates on the time to medical clearance, as more previous concussions and a greater number
and severity of initial symptoms are speculated to be associated with a longer recovery. The
small sample size and inability to account for other factors (i.e. cognitive activity) does not allow
for the conclusion that a higher MVPA level alone contributed to a longer time to medical
clearance. There is no known clinical significance of selecting the median of 45 minutes a day of
MVPA as the cut-point for high and low cognitive activity. However, as the data was not
normally distributed the median was selected to avoid biases of the mean from skewness of the
data. Also as this is the first study of it’s kind the median amount of MVPA a day was selected
as a starting point that can be used for future research. A limitation of this study was only
looking at the effects of MVPA on recovery and not including rest, although the two are
complimentary to each, were if you’re not active you are resting or sedentary. Examining rest on
recovery from concussion is important as it is unknown how much rest in conjunction with
MVPA is most beneficial for recovery, and is an area of future research.
A selection bias may be present as all participants reported to the sports medicine clinic
and therefore may perceive their injury as more serious than the general population. This may be
reflected in the median days to medical clearance of all participants in this study being 17 days
(range: 10 – 55), which is longer than the consensus statement that the majority (80-90%) of
concussions resolving in 7 – 10 days.[12] Participants reported to the clinic at a median of 4 days
44
(range: 2 – 20 days) after their concussion and therefore it was unable to know what type and
how much activity participants were doing immediately after their concussion. It can be
speculated based on the results of this study, that if participants were more active immediately
after their concussion, this could lead to a longer recovery.
Participants self-reported the date they first returned to full school as participants were
only withheld or had restrictions (1/2 days) from school attendance if participants reported
increased symptoms with school or cognitive activity. The date of return to school may then be
influenced by the date of the injury, as if the injury occurred during a school break the first date
of return to school cannot be till after the break. This would then lead to an over estimation of the
amount of time to return to school, but this was not significantly different between the high and
low activity groups, as this was the case for only a few participants.
There may have been a Hawthorne effect as participants wore the accelerometer over
their waist, thus knowing that their activity was being observed and measured. Participants
knowing that they are being studied may have then changed their behaviour and activity to
appear more compliant with the physician’s instruction to rest. This would lead to an
underestimation of the true activity performed by participants. Another potential confounder is
the time to presentation to the sports medicine centre with a suspected concussion as it is
unknown what activity participants were doing immediately after the injury and how this would
affect recovery. Total initial symptoms and symptom severity score may also be possible
confounders as it is speculated that a greater total number and severity of symptoms would
decrease initial physical activity levels and may lead to a longer recovery time. A greater number
of previous concussions is also hypothesized to confound the effect of physical activity on
45
concussion recovery, as a greater number of concussions may take a longer time to be medically
cleared to return to play. Future study should include evaluation of these covariates.
4.4.2 Conclusion
Youth ice hockey players that spend participate in MVPA during more than 45 minutes
total in the first three days after initial assessment take longer to return to baseline symptom
scores and to be medically cleared to return to play than players participating in less than 45
minutes MVPA. As it is impractical for youth ice hockey players to completely rest after a
concussion, limiting the amount of time in MVPA initially may be beneficial for returning to
play sooner.
46
Chapter Five: Exploratory analysis examining the association between cognitive activity
and medical clearance to return to play.
5.1 Introduction
A concussion is a brain injury that may result from trauma to the head or body that can
result in altered cerebral functioning.[12,16,19] A concussion can result in cognitive symptoms
that may impair an individuals cognitive abilities.[12] Therefore the concept of cognitive rest
was introduced at the Second International Conference on Concussion in Sport in 2004, which
recognized the need to limit exertion with activities of daily living and to limit scholastic
activities while symptomatic. [28] Furthermore, cognitive rest may include limiting activities
such as reading, text messaging, watching television or movies, playing video games, working
online, and performing schoolwork.[29,31,47]
Cognitive rest and activity are difficult to measure and there are very few studies
evaluating its effects on recovery from concussion. Gibson et al., retrospectively evaluated the
effect of the recommendation for cognitive rest on concussion symptoms.[34] The authors found
that there was no association between the recommendation for cognitive rest and the duration of
post-concussion symptoms.[34] However, only the recommendation for cognitive rest was
measured so it is unknown what amounts of cognitive rest if any, the participants performed,
which could be a reason for the no association found.[34]
Another study by Brown et al. found that participants in the highest quartile of cognitive
activity, using a developed cognitive activity scale, reported a longer duration of post-concussion
symptoms. However, this was the first and only use of the cognitive activity scale and
psychometric properties of this scale have yet to be determined. As there is conflicting and
lacking research into the effects of cognitive activity and rest on recovery post-concussion, the
47
primary purpose of the current study was to evaluate the association between cognitive activity
and time to medical clearance to return to play. The secondary outcomes of this study were to
evaluate cognitive activity on time to i) return to baseline symptom scores ii) initiation of the
return to play protocol iii) first day of restricted return to school and iv) first day of full return to
school.
5.2 Methods
This study is a case series that is part of a prospective cohort in youth ice hockey players.
Participants presenting to a sport medicine clinic with a concussion that was diagnosed by a sport
medicine physician were included in this study. Participant’s cognitive activity during the first
three days after and including the initial appointment date was measured using a Cognitive
Activity Scale (CAS) developed by Brown et al.[47] Participants rated their daily cognitive
activity on a scale from 0 to 4 where 0 is complete cognitive rest with the most stimulating
activities being watching television or listening to music, and 4 being full cognitive activity. The
primary objective of this exploratory analysis was to evaluate the association between cognitive
activity level and the time to medical clearance to return to play. The secondary outcomes were
the effect of cognitive activity on time to i) return to baseline symptom scores, ii) initiation of the
return to play protocol and iii) date of first return to full school participation.
5.2.1 Statistical Analysis
The median level of cognitive activity over the first three days after initial assessment
was dichotomized into high (levels 3 and 4) and low (levels 0, 1 and 2) cognitive levels. The low
cognitive activity group includes moderate, minimal and complete cognitive rest, where the high
cognitive group includes significant and full cognitive activity. Kaplan-Meier analysis with log
rank tests of significance were used to evaluate the effect of high and low cognitive activity on
48
time to medical clearance and the secondary objectives. Significance was set a priori at an alpha
of 0.05 for the primary outcome and a Bonferroni correction was used for the secondary
outcomes (alpha 0.05/4 = 0.0125).
5.3 Results
Twenty-four out of the thirty participants completed the CAS with 16 participants
reporting low levels of cognitive activity over the first three days, compared to 8 participants
reporting high levels of cognitive activity. Log-rank tests of significance revealed there was no
difference between the low and high cognitive activity groups in the number of days to medical
clearance (chi2=0.23, p=0.64), number of days to return to baseline symptom scores (chi2=0.17,
p=0.68), number of days to the initiation of the return to play protocol (chi2=0.04, p=0.85) and
number of days to return to full school (chi2=0.42, p=0.52).
Table 5.1 Participant demographics
Characteristic
Sex
Age – years, median (range)
Height – cm, median
(range)
Weight – kg, median
(range)
Elite (AAA,
AA, A)
Level of
play, n (%)
Non-elite
(Tiers 1-7)
Previous
0
history of
1
concussion,
2 or more
n (%)
Initial total symptoms /22,
median (range)
Initial symptom severity
/132, median (range)
Low Cognitive Activity
Group
14 male (87.5%),
2 female (12.5%)
14 (13 -17)
High Cognitive Activity
Group
6 male (75.0%),
2 female (25.0%)
14.5 (12 – 15)
165.9 (139.4 – 183.8)
169.0 (150.7 – 180.3)
55.4 (28.5 – 93.0)
56.6 (40.0 – 74.3)
13 (81.3%)
5 (62.5%)
3 (18.8%)
3 (37.5%)
9 (56.3%)
5 (62.5%)
4 (25.0%)
1 (12.5%)
3 (18.8%)
2 (25.0%)
13.5 (6 – 21)
11.5 (0 – 17)
34 (8 – 71)
20 (0 – 46)
49
Table 5.2 Outcomes by cognitive activity group
Outcome
Number of days to
medical clearance to
return to play (median,
range)
Number of days to
return to baseline
symptom scores
(median, range)
Number of days to
initiation of return to
play protocol (median,
range)
Number of days to
partial return to school
(median, range)
Number of days to full
return to school
(median, range)
Low Cognitive
Activity
High Cognitive
Activity
20.5 (11 – 38)
Log-rank test
chi2
p-value
14 (10 – 52)
0.23
0.635
19 (9 – 38)
13.5 (4 – 52)
0.17
0.679
11.5 (9 – 27)
12 (4 – 40)
0.04
0.847
4.5 (2 – 8)
4 (4 – 4)
0.22
0.637
9 (2 – 27)
5.5 (0 – 13)
0.42
0.519
5.4 Discussion
Research on the effects of cognitive activity alone on recovery from concussion is sparse
and limited. This study evaluated the association of high and low levels of cognitive activity
during the first three days after initial assessment on the time to medical clearance to return to
play. This study found that low and high cognitive activity had no significant effect on the time
to medical clearance to return to play or any of the secondary outcomes.
These results coincide with the findings of Gibson et al. that found no association
between the recommendation for cognitive rest and the duration of concussion symptoms.[34]
The study by Brown et al. that developed the CAS, found that participants in the highest quartile
of cognitive activity reported a longer duration of cognitive symptoms.[47] Dissimilar results
50
were found in this study when using the same scale, however due to small sample size cognitive
activity was dichotomized instead of analysing cognitive activity in quartiles such as in Brown et
al.[47]
Cognitive activity is difficult to measure and this is only the second known use of the
CAS post-concussion. Therefore, the validity and reliability of the CAS is unknown so the
results of this study should be interpreted cautiously. As cognitive activity is difficult to measure
and quantify it is unknown how well the CAS was able to actually capture and measure the
cognitive activity participants performed. This may have led to an underestimation of the amount
of cognitive activity performed leading to a nondifferential misclassification bias, which would
result in no association between cognitive activity and time to medical clearance. Future study
evaluating other methods including the CAS on recovery from concussion is desperately needed.
5.4.1 Limitations
The sample size in this study did not allow for analysis of the effect that covariates and
cognitive activity may have on the time to medical clearance. As cognitive activity was
dichotomized into high and low levels the effect of specific cognitive levels on recovery is
unknown and is an area for future research. The use of a self-reported cognitive scale may be
subject to a reporting bias in that participants report lower levels of cognitive activity to appear
more compliant with physician instruction for cognitive rest and restriction post-concussion.
5.4.2 Conclusion
There is no significant difference in the time to medical clearance between youth
reporting high versus low cognitive activity during the first three days after initial assessment of
sport-related concussion. Cognitive activity level also had no significant effect on the time to
return to baseline symptom scores, initiation of return to play protocol or the first day of return to
51
school. Given the lack of association between cognitive activity and recovery from concussion
that was identified in this study, cognitive activity did not have any effect on concussion
recovery, however more study is needed.
52
Chapter Six: Conclusion
6.1 Summary of Findings
There is a paucity of research evaluating the effects of rest and exercise on recovery from
concussion, especially in youth sport participants. Animal models have identified a
neurometabolic cascade after concussion that may result in altered cerebral functioning, therefore
physical and cognitive rest may then be beneficial for neurometabolic recovery.[16–20] It can
be speculated that similar effects would be found in humans, however the recommendation for
complete rest following a concussion has been shown to have no effect on recovery and has been
described as unrealistic and impractical to perform.[25–27] Therefore the research in this thesis
assists to address some of the gaps in the literature around the optimal amount and types of rest
and activity that are most beneficial for recovery from concussion.
Before evaluating the effects of rest and activity on recovery from concussion, it is
important to select an accurate measure of activity and rest. Evaluating the agreement and
correlation between the self-reported MDIPAQ and the waist worn Actigraph accelerometer
during the first three days after initial concussion assessment, revealed large mean differences
with wide 95% limits of agreement for all activity intensities of sedentary, light, moderate and
vigorous. Participants underreported the amount of time spent in sedentary, moderate and
vigorous intensities, while over reporting the mount of light intensity time. Intraclass correlations
coefficients revealed poor correlation between the Actigraph and MDIPAQ with wide 95%
confidence intervals. Based on these results, an objective measure of physical activity, such as
accelerometry, should be used when possible for studying physical activity post-concussion.
Therefore, Actigraph accelerometry was used to evaluate the association between time
spent in MVPA and time to medical clearance to return to play. High levels (≥45 minutes a day)
53
of MVPA during the first three days after initial assessment is associated with a longer time to
return to baseline symptom scores (chi2=6.37; p=0.012) and longer time to be medically cleared
to return to play (chi2=5.27; p=0.02), compared to low levels of MVPA (<45 minutes a day).
However, the high activity group returned to partial and full school before the low activity group.
The high activity group was less symptomatic initially possibly leading to an earlier return to
school. Although, returning to school sooner may have prolonged symptoms resulting in a longer
time to return to baseline symptoms and to medically clearance. An exploratory analysis of the
association of cognitive activity level on the time to medically clearance revealed no significant
differences between high and low cognitive activity. Cognitive activity level during the first
three days after initial assessment was not statistically associated with any concussion recovery
outcome. The overall results from this thesis suggest that limiting the amount of MVPA during
the first three days after initial assessment may be beneficial for recovery from concussion.
6.2 Public Health Implications
Concussions pose a significant problem in youth ice hockey, having the highest incidence
of concussion among the four most popular team sports (ice hockey, American football, rugby
and soccer), with 18% up to 66% of all injuries in youth ice hockey being concussive injuries.[6–
9] Concussions can result in a range of symptoms that may impair an individual’s ability to
perform activities of daily living and may result in time away from activities such as school,
work, and recreation.[42] As concussions can cause short and long health problems, proper
management and care is imperative.
The findings from this study indicate that lower amounts of MVPA during the initial
period of recovery from concussion may be beneficial. The results from this research provide
insights into the effects of exercise on concussion recovery and help optimize the clinical
54
management of to concussion to better facilitate recovery. The results from these studies will
inform future study to better understand the effects of rest and activity following concussion.
6.3 Recommendations for Future Research
This research is a building block for future study into the optimal amounts and types of
activity and rest that are most beneficial for concussion recovery. Future study should employ
the use of a large sample size so that the effect of covariates like previous history of concussion
and initial symptoms on concussion recovery can be evaluated. Future study should also examine
all levels of physical and cognitive activity throughout the entire duration of recovery including
immediately after the injury, to better understand how physical and cognitive activity levels
change as a person recovers. Ideally, in future studies participants should begin wearing the
Actigraph accelerometer immediately after they are removed from play for a suspected
concussion, so that activity levels can be monitored as soon as possible after the injury. Sleep
analysis including duration and quality of sleep should also be evaluated, as sleep and rest may
have an effect the duration of an individual’s recovery from concussion. Future research should
employ the use of randomized controlled trials to help identify cause and effect relationships
between physical and cognitive activity levels and recovery from concussion, as well as control
for potential confounders, both known and unknown. Ultimately, this study will inform future
research to better define the optimal dose, duration and timing of physical activity and rest to
best facilitate and optimize the clinical care of sport-related concussions.
55
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Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injury
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Barlow KM, Crawford S, Stevenson A, et al. Epidemiology of postconcussion syndrome
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Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent
Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA
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Barkhoudarian G, Hovda DA, Giza CC, et al. The Molecular Pathophysiology of
Concussive Brain Injury. Clin Sports Med 2011;30:33–48. doi:10.1016
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Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery
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Shrey DW, Griesbach GS, Giza CC. The pathophysiology of concussions in youth. Phys
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Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train
2001;36:228–35.http://www.ncbi.nlm.nih.gov/pubmed/12937489
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Yoshino A, Hovda DA, Kawamata T, et al. Dynamic changes in local cerebral glucose
utilization following cerebral conclusion in rats: evidence of a hyper- and subsequent
hypometabolic state. Brain Res 1991;561:106–
19.http://www.ncbi.nlm.nih.gov/pubmed/1797338
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Vagnozzi R, Tavazzi B, Signoretti S, et al. Temporal window of metabolic brain
vulnerability to concussions: mitochondrial-related impairment--part I. Neurosurgery
2007;61:379. doi:10.1227/01.NEU.0000280002.41696.D8 [doi]
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Tavazzi B, Vagnozzi R, Signoretti S, et al. Temporal window of metabolic brain
vulnerability to concussions: oxidative and nitrosative stresses--part II. Neurosurgery
2007;61:390–5; discussion 395–6.http://www.ncbi.nlm.nih.gov/pubmed/17806141
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Laurer HL, Bareyre FM, Lee VM, et al. Mild head injury increasing the brain’s
vulnerability to a second concussive impact. J Neurosurg 2001;95:859–70.
doi:10.3171/jns.2001.95.5.0859
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Allen C, Glasziou P, Mar C Del. Bed rest: a potentially harmful treatment needing more
careful evaluation. Lancet 1999;354:1229–33. doi:10.1016/S0140-6736(98)10063-6
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Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence
and perspective amidst the alarms. Clin J Sport Med 2012;22:383–4.
doi:10.1097/JSM.0b013e31826396fc
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de Kruijk JR, Leffers P, Meerhoff S, et al. Effectiveness of bed rest after mild traumatic
brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg
Psychiatry 2002;73:167–72.http://www.ncbi.nlm.nih.gov/pubmed/12122176
27
Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of Strict Rest After Acute
Concussion: A Randomized Controlled Trial. Pediatrics Published Online First: 5 January
2015. doi:peds.2014-0966 [pii]
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McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the
2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med
2005;39:196–204. doi:10.1136/bjsm.2005.018614
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McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport
- the Third International Conference on Concussion in Sport held in Zurich, November
2008. Physician Sportsmed 2009;37:141–
59.http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=
med5&AN=20048521
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Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of
post-concussion symptoms. Pediatrics 2014;133:e299–304. doi:10.1542/peds.2013-2125
[doi]
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Meehan WP. Medical therapies for concussion. Clin Sports Med 2011;30:115–24, ix.
doi:10.1016/j.csm.2010.08.003
32
Eastman A, Chang DG. Return to Learn: A review of cognitive rest versus rehabilitation
after sports concussion. NeuroRehabilitation 2015;37:235–44. doi:10.3233/NRE-151256
33
Silverberg ND, Iverson GL. Is Rest After Concussion ‘The Best Medicine?’ J Head
Trauma Rehabil 2013;28:250–9. doi:10.1097/HTR.0b013e31825ad658
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34
Gibson S, Nigrovic LE, O’Brien M, et al. The effect of recommending cognitive rest on
recovery from sport-related concussion. Brain Inj 2013;27:839–42.
doi:10.3109/02699052.2013.775494
35
Blake TA, McKay CD, Meeuwisse WH, et al. The impact of concussion on cardiac
autonomic function: A systematic review. Brain Inj 2016;30:132–45.
doi:10.3109/02699052.2015.1093659
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Griesbach GS. Exercise after traumatic brain injury: is it a double-edged sword? PM R
2011;3:S64–72. doi:10.1016/j.pmrj.2011.02.008
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Griesbach GS, Hovda DA, Molteni R, et al. Voluntary exercise following traumatic brain
injury: brain-derived neurotrophic factor upregulation and recovery of function.
Neuroscience 2004;125:129–39. doi:10.1016/j.neuroscience.2004.01.030
38
Griesbach GS, Gomez-Pinilla F, Hovda DA. The upregulation of plasticity-related
proteins following TBI is disrupted with acute voluntary exercise. Brain Res
2004;1016:154–62. doi:10.1016/j.brainres.2004.04.079
39
Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold
exercise training for refractory post-concussion syndrome. Clin J Sport Med 2010;20:21–
7. doi:10.1097/JSM.0b013e3181c6c22c
40
Gagnon I, Galli C, Friedman D, et al. Active rehabilitation for children who are slow to
recover following sport-related concussion. Brain Inj 2009;23:956–64.
doi:10.3109/02699050903373477
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Howell DR, Mannix RC, Quinn B, et al. Physical Activity Level and Symptom Duration
Are Not Associated After Concussion. Am J Sports Med Published Online First: 2
February 2016. doi:10.1177/0363546515625045
60
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McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport:
the 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl
Train 2013;48:554–75. doi:10.4085/1062-6050-48.4.05 [doi]
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Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical
rest for treatment of sports-related concussion. J Pediatr 2012;161:922–6.
doi:10.1016/j.jpeds.2012.04.012
44
Moser RS, Schatz P, Glenn M, et al. Examining prescribed rest as treatment for
adolescents who are slow to recover from concussion. Brain Inj 2015;29:58–63.
doi:10.3109/02699052.2014.964771
45
Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not
Improve Concussion Recovery Time. J Head Trauma Rehabil Published Online First: 24
July 2015. doi:10.1097/HTR.0000000000000165
46
Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity
levels, symptoms, and neurocognitive performance. J Athl Train 2008;43:265–74.
doi:10.4085/1062-6050-43.3.265
47
Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of
post-concussion symptoms. Pediatrics 2014;133:e299–304. doi:10.1542/peds.2013-2125
48
Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire:
12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381–95.
doi:10.1249/01.MSS.0000078924.61453.FB
49
Romanzini M, Petroski EL, Ohara D, et al. Calibration of ActiGraph GT3X, Actical and
RT3 accelerometers in adolescents. Eur J Sport Sci 2014;14:91–9.
doi:10.1080/17461391.2012.732614
61
50
Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion:
a randomized controlled trial. Pediatrics 2015;135:213–23. doi:10.1542/peds.2014-0966
51
Evenson KR, Catellier DJ, Gill K, et al. Calibration of two objective measures of physical
activity for children. J Sports Sci 2008;26:1557–65. doi:10.1080/02640410802334196
52
Hänggi JM, Phillips LRS, Rowlands A V. Validation of the GT3X ActiGraph in children
and comparison with the GT1M ActiGraph. J Sci Med Sport 2013;16:40–4.
doi:10.1016/j.jsams.2012.05.012
62
APPENDIX A: INJURY REPORT FORM
63
ONLY complete this section once the athlete has fully returned to play AND has completed all injury related care
18. Date of full medical clearance for return to: Normal daily activities (MM/DD/YY): _____/____/_____
Non-contact sports (full participation) (MM/DD/YY): ______/____/_____
Collision/contact sports (full participation) (MM/DD/YY): ______/____/_____
19. Who provided clearance to return to play? !Physician !Therapist !Coach !Parent !Self !Other: _____________________
20. Total time parent/guardian missed work as a direct result of the player’s injury: ______days + ______hours !Not working
21. Parent/guardian’s occupation:___________________________ !Not working
22. Was an ambulance called? !No !Yes - If yes, did the player ride to the hospital in the ambulance? !No !Yes
23. Was the player admitted to the hospital (other than an emergency department visit)? !No !Yes
If yes, primary reason for hospitalization:________________________ # nights in the hospital:______________
If yes, did the player have surgery in the hospital? !No !Yes - Name or describe the surgery:___________________________________
24. Did the player see any health care professional(s) for assessment/treatment of this injury? ❑No
!On-site first aid
!EMT/Paramedic
!Family Physician/GP
!ER Physician
!Sport Med. Physician
Total # visits:_____
Total # visits:_____
Total # visits:_____
Total # visits:_____
Total # visits:_____
!Paediatrician
!Surgeon
!Radiologist
!Chiropractor
!Physiotherapist
Total # visits:_____
Total # visits:_____
Total # visits:_____
Total # visits:_____
Total # visits:_____
❑Yes (check all that apply):
!Athletic Therapist
!Massage Therapist
!Dentist
!Other:____________
___________________
Total # visits:_____
Total # visits:_____
Total # visits:_____
Total # visits:_____
25. Did the player have any tests or receive any other treatment for this injury? !No !Yes
If yes, check all that apply:
!MRI
!X-ray
!CT scan
!Bone
scan
# of times:_____ Body part:_____________
# of times:_____ Body part:_____________
# of times:_____ Body part:_____________
# of times:_____ Body part:_____________
!Cast
!Brace
!Splint
!Taping
!Crutches
!Other:__
# of casts:______ Body part:_____________ Type:_____________
# of braces:_____ Body part:_____________ Type:_____________
# of splints:_____ Body part:_____________ Type:_____________
# of tape rolls:___ Body part:_____________ Type:_____________
______________________________________________________
26. Did the player take any medications for this injury?
!No !Yes
If yes, name:______________________________________________ type (eg, oral, injected):___________________________________
duration (days):________________ frequency (eg, # doses/day):__________________________ dosage (eg, 200mg):______________________________
If the player sees a physician, therapist, or other practitioner, have this healthcare provider complete the following section (unless a
fee is involved). Upon completion, return to your Team Designate or study personnel.
HOCKEY STUDY 2013-2018
Player’s Name:
Medical practitioner’s name:___________________________
Occupation: !Sport Med. Physician !Family Physician/GP !ER Physician
!Athletic Therapist
!Physiotherapist
!Other:_____________________________________________
Date (MM/DD/YY): _____/_____/_____
Diagnosis/clinical impression (check both if needed):
!Concussion !Other:_______________________
Treatment plan: !Rest until asymptomatic !Begin RTP steps !Return to full participation
!Other:
Conditions of clearance: !Asymptomatic !Complete RTP steps
!Other:
ONCE PLAYER IS CLEARED TO RETURN TO UNRESTRICTED COMPETITION:
Office use only
Date of clearance (MM/DD/YY): _____/_____/_____
IID:______________
UCDC:___________
V.2
64
APPENDIX B: CONCUSSION FOLLOW-UP FORM
65
Name:
SSID#:
☐ INITIAL APPOINTMENT
☐ PHYSICIAN FOLLOW-UP #_________
☐ RETURN TO PLAY
Assessment date:
Injury date:
Injury ID#
Stage of Return to Play Protocol at present:
Comments:
☐1. Rest
☐4. Non-contact practice
☐2. Aerobic exercise
☐5. Full contact
☐3. Sport specific
☐6. Full RTP/Game play
exercises
Please complete the following section for INITIAL APPOINTMENT:
Height:
cm
Weight:
kg
Have you changed any of your equipment (since last testing)? ☐Yes ☐No
If yes, what? ☐Mouthguard ☐Helmet ☐
Other:_____________________________
(please describe body part)
Mechanism of Injury:
☐Direct blow to head circle: right, left, front, back
☐Fell and hit head on ice circle: Fell back, forward, side
☐Hit head on… circle: boards, glass
☐Combination
☐Other:________________________________________________
STATION CHECKLIST
Station
Baseline
order
Order
Completed?
ImPACT
SCAT3
DVA (Computer)
Dynamic balance
meas.
Cervical measures
Clinical vestibular
meas.
PRISM
VOMS
KD
Saliva
MRI
For patient/parent to complete (at each test session)
Please describe the stage of rest that your child is currently at:
66
Tester name
¨ Complete rest: No cognitive, no physical exercise
¨ Partial rest:
• Cognitive: Estimate number of hours in the day you are performing a cognitive
activity and describe the activity
§ Hours:__________/day;
Activity:_________________________________________
• Physical: Describe any physical activity in your day (i.e., walk to school):
____________________________________________________________________________
____________________________________________________________________________
__________________________________
• Is there an increase in symptoms with cognitive or physical activity? ☐Yes ☐
No
•
What triggers your
symptoms?_______________________________________________________________________
•
Have you returned to school?
¨ Yes – Date of first day of full return to school:
____________________________________________________________________
¨ Partial - Please describe; including date of first day of return to partial school:
_____________________________________________________________________
¨ No
¨ Return to school protocol (if
developed):______________________________________________________
¨ What factors are limiting you from returning to school?
1. ______________________________________________________________
_________________
2. ______________________________________________________________
_________________
3. ______________________________________________________________
_________________
4. ______________________________________________________________
_________________
If exacerbate symptoms? ☐Yes ☐No
•
•
Have you returned to work?
¨ Not applicable
¨ Yes
¨ Partial - Please
describe:___________________________________________________________________
__
¨ No
¨ Return to work plan (if
developed):___________________________________________________________
¨ Occupation:
____________________________________________________________________________
____
¨ What factors are limiting you from returning to work?
1. ______________________________________________________________
_________________
67
•
2. ______________________________________________________________
_________________
3. ______________________________________________________________
_________________
4. ______________________________________________________________
_________________
If you have returned to work, do you have symptoms after? ☐Yes ☐No
Have you had physiotherapy or other treatment? ☐Yes ☐No
If yes: Type of treatment:_____________________________________________________ Number of
times:_____________
Saliva
Sample #
Time of day (24h)
Date taken
(MMM/DD/YY)
Time since injury
(hours)
Assessor’s initials:
SCAT3
Test domain
Number of Symptoms (3a)
Symptom Severity Score (3a)
Number of Symptoms (3b)
Symptom Severity Score of 60
(3b)
Number of Symptoms (4)
Symptom Severity Score (4)
Glasses?
Static VA
Dynamic VA:
85°/sec
Dynamic VA:
120°/sec
Score
/22
/132
/20
/60
/20
/60
Test domain
Orientation
Immediate memory
Delayed recall
Score
/5
/15
/5
BESS (total errors)
Tandem gait (seconds)
Coordination
Assessor’s initials:
COMPUTERIZED DYNAMIC VISUAL ACUITY (DVA)
☐ Yes
☐ No
Perception
time
Left______________ Right ________________
Left______________ Right ________________
Assessor’s initials:
CLINICAL VESTIBULAR MEASURES
Extraocular motion? ☐ Normal
Describe:___________________________________
68
/1
☐ Abnormal
Visual symptoms? ☐ Yes
NPRS-Dizziness
/10
☐ No
Head thrust
Right: ☐ Positive
☐ Negative
Left: ☐ Positive
☐ Negative
Clinical dynamic visual acuity
Baseline
Clinical
Difference:
VA:
DVA:
Assessor’s initials:
CERVICAL MEASURES
NPRS-Neck pain
/10
NPRS-Headache
/10
Cervical Range of motion
Cervical flexor endurance
Pain? ☐Yes ☐ No
sec
Cervical flexionrotation test
Right
☐ Positive ☐ Negative
Pain? ☐Yes ☐ No
Left
☐ Positive ☐ Negative
Pain? ☐Yes ☐ No
Cervical rotationside flexion test
(Measured in lbs.)
Right
Head perturbation
test
1:
lbs
1:
3:
lbs
Left side
Right
side
/3
2:
lbs
Right anterior
/3
Right posterior
/3
Anterior
/3
Left anterior
/3
Posterior
/3
Left posterior
/3
TOTAL
/24
Left
lbs
2:
lbs
3:
lbs
Assessor’s initials:
VESTIBULAR/OCULAR-MOTOR SCREENING (VOMS)
Vestibular/Ocular
Motor Test:
Not
Tested
Headache
0-10
Dizziness
0-10
BASELINE
SYMPTOMS:
69
Nausea
0-10
Fogginess
0-10
Comments
/3
Smooth Pursuits
Saccades –
Horizontal
Saccades –
Vertical
Convergence
(Near Point) (cm)
1: _________ 2:
___________
3: _________
VOR – Horizontal
VOR – Vertical
Visual Motion
Sensitivity Test
Assessor’s initials:
DYNAMIC BALANCE MEASURES
Functional gait assessment
Score
1
Gait level surface
/3
Walking while talking
test
Normal
2
Changes in gait speed
/3
Simple
sec
3
Gait with horizontal head turns
/3
Complex
sec
4
Gait with vertical head turns
/3
5
Gait and pivot turn
/3
6
Step over obstacle
/3
70
Time
sec
Letter:
Word
sec
# of words:
7
/3
8
Gait with narrow base of
support
Gait with eyes closed
9
Ambulating backwards
/3
10
Steps
/3
Total
/30
11
Tandem gait with head motion
/3
12
Tandem gait backwards
/3
13
/3
15
Walking - rapid horizontal head
turns
Walking - rapid vertical head
turns
Walking backward – horizontal
16
Walking backward – vertical
/3
Assessor’s initials:
TOTAL
/18
Grand Total
14
/3
Appeared to give good effort?
☐ Yes
☐ No
NOTES:
/3
/3
King-Devick Test
Time
Errors
Comments:
Assessor’s initials:
ADDITIONAL CLINICAL NOTES
Assessor’s initials:
71
/48
APPENDIX C: SPORT CONCUSSION ASSESSMENT TOOL – 3RD EDITION
Downloaded from http://bjsm.bmj.com/ on March 19, 2015 - Published by group.bmj.com
SCAT3
™
Sport Concussion Assessment Tool – 3rd edition
For use by medical professionals only
name
Date / Time of Injury:
Date of Assessment:
What is the SCAT3?1
the SCAt3 is a standardized tool for evaluating injured athletes for concussion
and can be used in athletes aged from 13 years and older. it supersedes the original SCAt and the SCAt2 published in 2005 and 2009, respectively 2. For younger
persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed
for use by medical professionals. If you are not qualifi ed, please use the Sport Concussion recognition tool1. preseason baseline testing with the SCAt3 can be
helpful for interpreting post-injury test scores.
Specifi c instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SCAt3, please read through these instructions carefully. this
tool may be freely copied in its current form for distribution to individuals, teams,
groups and organizations. Any revision or any reproduction in a digital form requires approval by the Concussion in Sport Group.
NOTE: the diagnosis of a concussion is a clinical judgment, ideally made by a
medical professional. the SCAt3 should not be used solely to make, or exclude,
the diagnosis of concussion in the absence of clinical judgement. An athlete may
have a concussion even if their SCAt3 is “normal”.
What is a concussion?
A concussion is a disturbance in brain function caused by a direct or indirect force
to the head. It results in a variety of non-specifi c signs and / or symptoms (some examples listed below) and most often does not involve loss of consciousness.
Concussion should be suspected in the presence of any one or more of the
following:
-
examiner:
1 glasgow coma scale (gCS)
Best eye response (e)
no eye opening
1
eye opening in response to pain
2
eye opening to speech
3
eyes opening spontaneously
4
Best verbal response (v)
no verbal response
1
incomprehensible sounds
2
inappropriate words
3
Confused
4
oriented
5
Best motor response (m)
no motor response
1
extension to pain
2
Abnormal fl exion to pain 3
Flexion / Withdrawal to pain 4
localizes to pain
5
obeys commands
6
glasgow Coma score (e + v + m)
Symptoms (e.g., headache), or
Physical signs (e.g., unsteadiness), or
Impaired brain function (e.g. confusion) or
Abnormal behaviour (e.g., change in personality). of 15
GCS should be recorded for all athletes in case of subsequent deterioration.
2 maddocks Score3
Sideline ASSeSSmenT
“I am going to ask you a few questions, please listen carefully and give your best effort.”
Modifi ed Maddocks questions (1 point for each correct answer)
indications for emergency management
noTe: A hit to the head can sometimes be associated with a more serious brain
injury. Any of the following warrants consideration of activating emergency procedures and urgent transportation to the nearest hospital:
-
Glasgow Coma score less than 15
Deteriorating mental status
potential spinal injury
progressive, worsening symptoms or new neurologic signs
What venue are we at today? 0
1
Which half is it now?
0
1
Who scored last in this match?
0
1
What team did you play last week / game?
0
1
Did your team win the last game?
0
1
maddocks score
of 5
Maddocks score is validated for sideline diagnosis of concussion only and is not used for serial testing.
Potential signs of concussion?
if any of the following signs are observed after a direct or indirect blow to the
head, the athlete should stop participation, be evaluated by a medical professional and should not be permitted to return to sport the same day if a
concussion is suspected.
Y
n
Balance or motor incoordination (stumbles, slow / laboured movements, etc.)?
Y
n
Disorientation or confusion (inability to respond appropriately to questions)?
Y
n
loss of memory:
Y
n
Blank or vacant look:
Y
n
Visible facial injury in combination with any of the above:
Y
n
Any loss of consciousness?
notes: mechanism of injury (“tell me what happened”?):
“if so, how long?“
“if so, how long?“
“Before or after the injury?"
Any athlete with a suspected concussion should be removed
From PlAy, medically assessed, monitored for deterioration
(i.e., should not be left alone) and should not drive a motor vehicle
until cleared to do so by a medical professional. no athlete diagnosed with concussion should be returned to sports participation
on the day of injury.
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BACkground
CogniTive & PhySiCAl evAluATion
4 Cognitive assessment
Date:
name:
examiner:
Standardized Assessment of Concussion (SAC) 4
Sport / team / school:
Date / time of injury:
Age:
Gender:
m
F
orientation (1 point for each correct answer)
What month is it? 0
1
What is the date today? 0
1
How many concussions do you think you have had in the past?
What is the day of the week? 0
1
When was the most recent concussion?
What year is it? 0
1
How long was your recovery from the most recent concussion?
What time is it right now? (within 1 hour)
0
1
Years of education completed:
Dominant hand:
right
left
neither
Have you ever been hospitalized or had medical imaging done for
a head injury?
Y
n
orientation score
Have you ever been diagnosed with headaches or migraines?
Y
n
immediate memory
Do you have a learning disability, dyslexia, ADD / ADHD?
Y
n
Have you ever been diagnosed with depression, anxiety
or other psychiatric disorder?
Y
n
Has anyone in your family ever been diagnosed with
any of these problems?
Y
n
Are you on any medications? if yes, please list:
Y
n
List
of 5
Trial 1
Trial 2
Trial 3
Alternative word list
elbow
0
1
0
1
0
1
candle
baby
finger
apple
0
1
0
1
0
1
paper
monkey
penny
carpet
0
1
0
1
0
1
sugar
perfume
blanket
saddle
0
1
0
1
0
1
sandwich
sunset
lemon
bubble
0
1
0
1
0
1
wagon
iron
insect
Total
SCAT3 to be done in resting state. Best done 10 or more minutes post excercise.
SymPTom evAluATion
Concentration: digits Backward
List
3 how do you feel?
“You should score yourself on the following symptoms, based on how you feel now”.
none
mild
of 15
immediate memory score total
moderate
severe
Trial 1
Alternative digit list
4-9-3
0
1
6-2-9
5-2-6
4-1-5
3-8-1-4
0
1
3-2-7-9
1-7-9-5
4-9-6-8
6-2-9-7-1
0
1
1-5-2-8-6
3-8-5-2-7
6-1-8-4-3
7-1-8-4-6-2
0
1
5-3-9-1-4-8
8-3-1-9-6-4
7-2-4-8-5-6
Headache
0
1
2
3
4
5
6
“pressure in head”
0
1
2
3
4
5
6
neck pain
0
1
2
3
4
5
6
nausea or vomiting
0
1
2
3
4
5
6
Dizziness
0
1
2
3
4
5
6
Blurred vision
0
1
2
3
4
5
6
Balance problems
0
1
2
3
4
5
6
Sensitivity to light
0
1
2
3
4
5
6
Sensitivity to noise
0
1
2
3
4
5
6
Feeling slowed down
0
1
2
3
4
5
6
Feeling like “in a fog“
0
1
2
3
4
5
6
“Don’t feel right”
0
1
2
3
4
5
6
Difficulty concentrating
0
1
2
3
4
5
6
Difficulty remembering
0
1
2
3
4
5
6
Fatigue or low energy
0
1
2
3
4
5
6
Confusion
0
1
2
3
4
5
6
Drowsiness
0
1
2
3
4
5
6
trouble falling asleep
0
1
2
3
4
5
6
Modified Balance Error Scoring System (BESS) testing5
more emotional
0
1
2
3
4
5
6
Which foot was tested (i.e. which is the non-dominant foot)
irritability
0
1
2
3
4
5
6
Testing surface (hard floor, field, etc.)
Sadness
0
1
2
3
4
5
6
Condition
nervous or Anxious
0
1
2
3
4
5
6
Double leg stance:
Total of 4
Concentration: month in reverse order (1 pt. for entire sequence correct)
range of motion
tenderness
6 Balance examination
Do one or both of the following tests.
Footwear (shoes, barefoot, braces, tape, etc.)
left
right
errors
Single leg stance (non-dominant foot):
errors
tandem stance (non-dominant foot at back):
errors
And / or
Y
n
Tandem gait6,7
Do the symptoms get worse with mental activity?
Y
n
time (best of 4 trials):
self rated
self rated and clinician monitored
clinician interview
self rated with parent input
overall rating: if you know the athlete well prior to the injury, how different is
the athlete acting compared to his / her usual self? Please circle one response:
N/A
Scoring on the SCAT3 should not be used as a stand-alone method
to diagnose concussion, measure recovery or make decisions about
an athlete’s readiness to return to competition after concussion.
Since signs and symptoms may evolve over time, it is important to
consider repeat evaluation in the acute assessment of concussion.
seconds
7 Coordination examination
upper limb coordination
Which arm was tested:
unsure
upper and lower limb sensation & strength
Findings:
Do the symptoms get worse with physical activity?
260
of 5
5 neck examination:
Symptom severity score (Maximum possible 132)
very different
1
Concentration score
Total number of symptoms (Maximum possible 22)
no different
0
Dec-nov-oct-Sept-Aug-Jul-Jun-may-Apr-mar-Feb-Jan
Coordination score
left
right
of 1
8 SAC delayed recall4
delayed recall score
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Balance testing – types of errors
inSTruCTionS
Words in Italics throughout the SCAt3 are the instructions given to the athlete by
the tester.
Symptom Scale
“You should score yourself on the following symptoms, based on how you feel now”.
to be completed by the athlete. in situations where the symptom scale is being
completed after exercise, it should still be done in a resting state, at least 10 minutes
post exercise.
For total number of symptoms, maximum possible is 22.
For Symptom severity score, add all scores in table, maximum possible is 22 x 6 = 132.
SAC 4
immediate memory
“I am going to test your memory. I will read you a list of words and when I am done, repeat
back as many words as you can remember, in any order.”
1. Hands lifted off iliac crest
2. opening eyes
3. Step, stumble, or fall
4. moving hip into > 30 degrees abduction
5. lifting forefoot or heel
6. remaining out of test position > 5 sec
each of the 20-second trials is scored by counting the errors, or deviations from
the proper stance, accumulated by the athlete. the examiner will begin counting
errors only after the individual has assumed the proper start position. The modified
BeSS is calculated by adding one error point for each error during the three
20-second tests. The maximum total number of errors for any single condition is 10. if a athlete commits multiple errors simultaneously, only one error is
recorded but the athlete should quickly return to the testing position, and counting
should resume once subject is set. Subjects that are unable to maintain the testing
procedure for a minimum of five seconds at the start are assigned the highest
possible score, ten, for that testing condition.
Trials 2 & 3:
oPTion: For further assessment, the same 3 stances can be performed on a surface
of medium density foam (e.g., approximately 50 cm x 40 cm x 6 cm). “I am going to repeat the same list again. Repeat back as many words as you can remember in
any order, even if you said the word before.“
Tandem gait6,7
Complete all 3 trials regardless of score on trial 1 & 2. Read the words at a rate of one per second.
Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform
the athlete that delayed recall will be tested.
Concentration
digits backward
“I am going to read you a string of numbers and when I am done, you repeat them back to
me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you
would say 9-1-7.”
Participants are instructed to stand with their feet together behind a starting line (the test is
best done with footwear removed). Then, they walk in a forward direction as quickly and as
accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot
heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they
cross the end of the 3m line, they turn 180 degrees and return to the starting point using the
same gait. A total of 4 trials are done and the best time is retained. Athletes should complete
the test in 14 seconds. Athletes fail the test if they step off the line, have a separation between
their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is
not recorded and the trial repeated, if appropriate.
If correct, go to next string length. If incorrect, read trial 2. One point possible for each string
length. Stop after incorrect on both trials. The digits should be read at the rate of one per second.
Coordination examination
months in reverse order
upper limb coordination
Finger-to-nose (FTN) task: “Now tell me the months of the year in reverse order. Start with the last month and go
backward. So you’ll say December, November … Go ahead”
1 pt. for entire sequence correct
delayed recall
the delayed recall should be performed after completion of the Balance and Coordination examination.
“Do you remember that list of words I read a few times earlier? Tell me as many words from the
list as you can remember in any order.“
Score 1 pt. for each correct response
“I am going to test your coordination now. Please sit comfortably on the chair with your eyes
open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow
and fingers extended), pointing in front of you. When I give a start signal, I would like you to
perform five successive finger to nose repetitions using your index finger to touch the tip of
the nose, and then return to the starting position, as quickly and as accurately as possible.”
Scoring: 5 correct repetitions in < 4 seconds = 1
Note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow
or do not perform five repetitions. Failure should be scored as 0.
references & Footnotes
Balance examination
Modified Balance Error Scoring System (BESS) testing 5
This balance testing is based on a modified version of the Balance Error Scoring System (BESS)5. A stopwatch or watch with a second hand is required for this testing.
“I am now going to test your balance. Please take your shoes off, roll up your pant legs above
ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three
twenty second tests with different stances.“
(a) double leg stance:
“The first stance is standing with your feet together with your hands on your hips and with
your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be
counting the number of times you move out of this position. I will start timing when you are
set and have closed your eyes.“
(b) Single leg stance:
“If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now
stand on your non-dominant foot. The dominant leg should be held in approximately 30 degrees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability
for 20 seconds with your hands on your hips and your eyes closed. I will be counting the
number of times you move out of this position. If you stumble out of this position, open your
eyes and return to the start position and continue balancing. I will start timing when you are
set and have closed your eyes.“
(c) Tandem stance:
“Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly
distributed across both feet. Again, you should try to maintain stability for 20 seconds with
your hands on your hips and your eyes closed. I will be counting the number of times you
move out of this position. If you stumble out of this position, open your eyes and return to
the start position and continue balancing. I will start timing when you are set and have closed
your eyes.”
1. this tool has been developed by a group of international experts at the 4th international Consensus meeting on Concussion in Sport held in Zurich, Switzerland
in november 2012. the full details of the conference outcomes and the authors of
the tool are published in the BJSm injury prevention and Health protection, 2013,
Volume 47, issue 5. the outcome paper will also be simultaneously co-published in
other leading biomedical journals with the copyright held by the Concussion in Sport
Group, to allow unrestricted distribution, providing no alterations are made.
2. mcCrory p et al., Consensus Statement on Concussion in Sport – the 3rd international Conference on Concussion in Sport held in Zurich, november 2008. British
Journal of Sports medicine 2009; 43: i76-89.
3. maddocks, Dl; Dicker, GD; Saling, mm. the assessment of orientation following
concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32 – 3.
4. mcCrea m. Standardized mental status testing of acute concussion. Clinical Journal of Sport medicine. 2001; 11: 176 – 181.
5. Guskiewicz Km. Assessment of postural stability following sport-related concussion. Current Sports medicine reports. 2003; 2: 24 – 30.
6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-tooke, G. & mcCrory, p.
normative values for 16-37 year old subjects for three clinical measures of motor
performance used in the assessment of sports concussions. Journal of Science and
Medicine in Sport. 2010; 13(2): 196 – 201.
7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., olsson, m., Yden. t. & marshall,
S.W. The effect of footwear and sports-surface on dynamic neurological screening in sport-related concussion. Journal of Science and medicine in Sport. 2010;
13(4): 382 – 386
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AThleTe inFormATion
Scoring Summary:
Any athlete suspected of having a concussion should be removed
from play, and then seek medical evaluation.
test Domain
Score
Date:
Signs to watch for
number of Symptoms of 22
Problems could arise over the first 24 – 48 hours. The athlete should not be left alone and must go to a hospital at once if they:
Symptom Severity Score of 132
-
Have a headache that gets worse
Are very drowsy or can’t be awakened
Can’t recognize people or places
Have repeated vomiting
Behave unusually or seem confused; are very irritable
Have seizures (arms and legs jerk uncontrollably)
Have weak or numb arms or legs
Are unsteady on their feet; have slurred speech
Date:
Date:
orientation of 5
immediate memory of 15
Concentration of 5
Delayed recall of 5
SAC Total
BESS (total errors)
Tandem Gait (seconds)
Coordination of 1
remember, it is better to be safe.
Consult your doctor after a suspected concussion.
return to play
Athletes should not be returned to play the same day of injury.
When returning athletes to play, they should be medically cleared and then follow
a stepwise supervised program, with stages of progression.
notes:
For example:
rehabilitation stage
Functional exercise at each stage
of rehabilitation
objective of each stage
no activity
physical and cognitive rest
recovery
light aerobic exercise
Walking, swimming or stationary cycling keeping intensity, 70 % maximum predicted
heart rate. no resistance training
increase heart rate
Sport-specific exercise
Skating drills in ice hockey, running drills in
soccer. no head impact activities
Add movement
non-contact
training drills
progression to more complex training drills,
eg passing drills in football and ice hockey.
may start progressive resistance training
exercise, coordination, and
cognitive load
Full contact practice
Following medical clearance participate in
normal training activities
Restore confidence and assess functional skills by coaching staff
return to play
normal game play
There should be at least 24 hours (or longer) for each stage and if symptoms recur the athlete should rest until they resolve once again and then resume the program
at the previous asymptomatic stage. resistance training should only be added in the
later stages.
if the athlete is symptomatic for more than 10 days, then consultation by a medical
practitioner who is expert in the management of concussion, is recommended.
medical clearance should be given before return to play.
ConCuSSion injury AdviCe
patient’s name
(To be given to the person monitoring the concussed athlete)
Date / time of injury this patient has received an injury to the head. A careful medical examination has
been carried out and no sign of any serious complications has been found. recovery
time is variable across individuals and the patient will need monitoring for a further
period by a responsible adult. Your treating physician will provide guidance as to
this timeframe.
Date / time of medical review treating physician
if you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please contact your doctor or
the nearest hospital emergency department immediately.
other important points:
- Rest (physically and mentally), including training or playing sports until symptoms resolve and you are medically cleared
- no alcohol
- no prescription or non-prescription drugs without medical supervision.
Specifically:
· no sleeping tablets
· Do not use aspirin, anti-inflammatory medication or sedating pain killers
- Do not drive until medically cleared
- Do not train or play sport until medically cleared
Contact details or stamp
Clinic phone number
262
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© 2013 Concussion in Sport Group
APPENDIX D: MODIFIED DAILY INTERNATIONAL PHYSICAL ACTIVITY
QUESTIONNAIRE
Modified Daily International Physical Activity Questionnaire
We are interested in finding out about the kinds of physical activities that people do as part of
their everyday lives. The questions will ask you about the time you spent being physically active
in the last 24 hours. Please think about the activities you do at school, at home, to get from place
to place, and in your spare time for fun, exercise or sport.
Think about all the vigorous activities that you did in the last 24 hours. Vigorous physical
activities refer to activities that take hard physical effort and make you breathe much harder than
normal. Think only about those physical activities that you did for at least 10 minutes at a time.
1. Based on the last 24 hours, how much time did you spend doing vigorous physical
activity on activities like running, fast bicycling, playing games or sports like hockey or
basketball?
Date
Hours &
Minutes
per day
E.g.
Jan.
1/2016
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
1 hr &
10 min
Think about all the moderate activities that you did in the last 24 hours. Moderate activities
refer to activities that take moderate physical effort and make you breathe somewhat harder than
normal. Think only about those physical activities that you did for at least 10 minutes at a time.
2. Based on the last 24 hours, how much time did you spend doing moderate physical
activity on activities like bicycling, rollerblading or skateboarding at a regular pace, light
swimming, or playing sports like golf?
Date
E.g.
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Jan.
1/2016 _______ _______ _______ _______ _______ _______ _______
__
__
__
__
__
__
__
Hours &
1 hr &
Minutes
10 min
per day
Think about all the light activities that you did in the last 24 hours. Light activities refer to
activities that take little physical effort and make you breathe normal rate. Think only about
those physical activities that you did for at least 10 minutes at a time.
76
3. Based on the last 24 hours, how much time did you spend doing light physical activity
on activities like light walking from place to place, shower/bathing, making to eat and
doing dishes?
Date
Hours &
Minutes
per day
E.g.
Jan.
1/2016
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
1 hr &
10 min
The last question is about the time you spent being sedentary based on the last 24 hours.
Sedentary activities refer to activities that require little to no movement.
4. Based on the last 24 hours, how much time did you spend being sedentary, like time
spent sitting at home and at school, visiting with friends and reading or lying watching
television or playing video games?
Date
Hours &
Minutes
per day
E.g.
Jan.
1/2016
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
_______
__
1 hr &
10 min
This is the end of the questionnaire, thank you for participating.
77
APPENDIX E: ACTIGRAPH MONITOR LOG
MonitorLog
Inthetablebelow,writedownthedatesandtimesonwhichyoutakeoffthemonitor.Note
thetimes,including“a.m.”or“p.m.”,thatyouputitonandtakeitoffduringeachday.Also
notethereasonyoutookitoff.Belowisasampleentry:
Date
Day
TimeOff
TimeOn
Reason
th
e.g.January6 Wednesday
7:30AM
7:45AM
Shower
2016
MonitorOff(complete):
Date
Day
TimeOff
OFFICE USE ONLY
Actigraph ID_________________
Start Date and Time:______________
Participant ID:_______________
Valid
78
APPENDIX F: COGNITIVE ACTIVITY SCALE
SSID:_______________________
Name:_______________________
Date:_______________________
Form #:_______________________
Cognitive Activity Scale
0
Complete Cognitive Rest
No reading, homework, text
messaging, video game playing,
online activity, crossword puzzles,
or similar activities. The most
stimulating activities at this level
would be watching television,
watching movies, or listening to
music.
1
Minimal Cognitive Activity
No reading, homework, crossword
puzzles, or similar activities. Less
than 5 text messages per day, less
than 20 min per day combined of
online activity and video games.
2
Moderate Cognitive Activity
Reading less than 10 pages per
day, less than 20 text messages
per day, and doing less than 1 h
combined of homework, online
activity, and video games per day.
3
Significant Cognitive Activity
Reading less, doing less
homework, working less online,
text messaging less, and doing
crossword or other activities than
you would normally do, but more
than listed in level 2.
4
Full Cognitive Activity
You have not limited cognitive
activity at all
Please use the following instructions: “Cognitive activities are those activities which require you to think
harder than usual. Homework, reading, playing video games, text messaging, doing crossword puzzles,
playing trivia games and working online are all forms of cognitive activity. Using the scale above, please
record your average cognitive activity from 0 – 4 on the table below for each day of the week. Please
include the date for each day of the week.
79
Date
Score
E.g.
Jan.
1/2016
2
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
_______
_______
_______
_______
_______
_______
_______
80
APPENDIX G: RETURN TO PLAY PROTOCOL
Return to Play Protocol
ß Stepwise symptom-limited program, with stages of progression
Step 1: rest (cognitive and exertional) until 100% asymptomatic (or feeling 100%
normal) for a minimum of 2 days
Step 2: stationary cycle for 15 minutes with heart rate between 130 and 155 BMP
Step 3: sport specific on-ice drills without puck (helmet, skates, gloves, and stick
only) - goal-line to red-line, back to blue-line, forward to far blue-line, back
to red-line, forward to far end of ice – half speed), if asymptomatic skate
all 5 circles alternating directions (crossovers, half speed) – total on-ice
drills not to exceed 20 minutes.
Step 4: full speed practice – non-contact drills only
Step 5: full contact practice after medical clearance (may require f/u assessment
with study physician prior to clearance for this step if no athletic therapist
is present/available to monitor during this stage)
Step 6: clear to return to unrestricted participation
ß Each step requires 24 hours period. If athlete experiences exertional
symptoms during any one of these steps, he/she must return to step 1
of the protocol for a minimum of 2 days.
81
APPENDIX H: CONSENT FORM
KINESIOLOGY
SPORT MEDICINE CENTRE
ConsentForm
TITLE:Theassociationbetweenphysicalandcognitiverestonrecoveryfromsports
relatedconcussion.
INVESTIGATORS:
PrincipalInvestigators:,Dr.KathrynSchneider,UniversityofCalgary.
Co-Investigator:Dr.CarolynEmery,Dr.KeithYeates,Dr.ClodaghToomey,Justin
Lishchynsky,Master’sStudent,UniversityofCalgary.
ContactPhoneNumber:JustinLishchynsky(403)220-4267
Thisconsentformisonlypartoftheprocessofinformedconsent.Itshouldgiveyou
thebasicideaofwhattheresearchisaboutandwhatyourparticipationwillinvolve.
Ifyouwouldlikemoredetailaboutsomethingmentionedhere,orinformationnot
includedhere,pleaseask.Takethetimetoreadthiscarefullyandtounderstandany
accompanyinginformation.Youwillreceiveacopyofthisform.
BACKGROUND
Concussionsareabraininjurythatiscausedbyeitheradirectblowtothehead,
neckorelsewhereonthebodywiththeforcebeingtransferredtothehead.
Concussionstypicallyresultinarangeofsymptomsfromheadaches,nausea,
dizziness/balanceproblems,slowedreactiontimeandmemoryproblems.Following
aconcussionthecurrentmanagementprotocolisphysicalandmental/cognitive
restisprescribeduntilacutesymptomsresolve.Thenagradedandstepwise
programofexertionisprescribeduntilthepatientismedicallyclearedtoreturnto
play.Itiscurrentlyunknownwhattheoptimalamountandtypeofrestisfor
recoveryfromconcussion.
EthicsID:REB15-2577
StudyTitle:Theassociationbetweenphysicalandcognitiverestonrecoveryfromconcussionin
youthicehockey
PI:Dr.KathrynSchneider
Versionnumber/date:Version2;October29,2015
Page1of4
82
WHATISTHEPURPOSEOFTHESTUDY?
Thepurposeofthisstudyistolookattheeffectsofrestandactivityonthelengthof
timeittakestogetbacktoactivity,sportandschoolfollowingaconcussion.Another
purposeofthestudyistoevaluatethevalidityofpatientreportedactivityandrest
levelswhilesymptomatic,comparedtoactualphysicalactivityandrestmeasured
byanActigraphactivitymonitor,andcompareparentandparticipantreported
activityandrestlevels.
WHATWOULDIHAVETODO?
Ifyouagreetoparticipateinthestudyyouwillcontinuetobeseenbythestudy
sportmedicinephysicianasapartofthenormalstandardofcare.Thephysicianwill
performanumberoftestsincludingsymptomrecording,balanceandmentaltests,
alltohelpdiagnoseandprescribeappropriatetreatmentforyou.Youwillfollowthe
physician’sprescribedtreatmentandhaveweeklyfollowupappointmentsuntilyou
aremedicallyclearedtoreturntosport.
Duringyourparticipationinthestudy,youwillbegivenanActigraphactivity
monitor,whichistobewornaroundthewaistovertopoftherighthipbone.This
monitoristobewornfortheentiredurationyouareintheactivitystudy,only
takingoffthemonitortoshower/bath.Youwillrecordwhenyoutakeoffandput
backonthemonitor.Themonitorwillcollectinformationaboutyourmovements
whileyouarewearingthemonitor.Themonitorwillnotcauseanyharmtoyouor
giveanyinformationtoyou.Onlytheresearcherswillbeabletoaccessthe
informationcollectedbythemonitor,butyouwillbegivenasummaryoftheresults
attheendofthestudyuponrequest.
Youwillrecordyourtheirdailyphysicalandcognitiveactivityusingtheprovided
questionnaires.Youwillalsofilloutanactivityquestionnairebasedonthelast7
daysateachdoctor’sappointment.Thesequestionnaireswillbefilledoutuntilyou
aremedicallyclearedtoreturntoplayatwhichtimeyourparticipationinthestudy
willbedone.
WHATARETHERISKS?
Therearenoknownriskstoyourparticipationinthestudy,asyouwillbeclosely
monitoredbythesportsmedicinephysicianandreceivethestandardcareand
treatmentforyourconcussion.
ARETHEREANYBENEFITSTOMYPARTICIPATION?
Ifyouagreetoparticipateinthisstudytheremayormaynotbeadirectmedical
benefit.Yoursymptomsfromtheconcussionmayimprove
EthicsID:REB15-2577
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duringthestudybutthereisnoguaranteethatthisresearchwillhelpyou.The
informationwegetfromthisstudymayhelpustoprovidebettertreatmentsinthe
futureforpatientswithconcussions.Thisinformationmayalsohelpdecreasethe
timelostfromsport,schoolandworkduetoaconcussion.
DOIHAVETOPARTICIPATE?
Participationisvoluntaryandnotparticipatingwillinnowayaffectyourcare.If
youagreetoparticipate,werequireyoutosignandreturnthisformtothe
researchers.Twocopiesoftheformareprovided.Pleasekeeponeforyour
records.Pleasehaveanotherpersonwitnessyoursignatureonthecopythatyou
returntous.Yoursignatureonthisformindicatesthatyouhaveunderstoodtoyour
satisfactiontheinformationregardingyourparticipatinginthisresearchproject.In
nowaydoesthiswaiveyourlegalrightsnorreleasetheinvestigators,sponsorsor
involvedinstitutionsfromtheirlegalandprofessionalresponsibilities.Youarefree
towithdrawfromthestudyatanytimebycontactingthestudy
coordinator/researchers.Continuedparticipationshouldbeasinformedasyour
initialconsent,soyoushouldfeelfreetoaskforclarificationornewinformation
throughoutyourparticipation.Youwillbeinformedifthereisnewinformation
availablethroughthisstudyperiod.
WILLIBEPAIDFORPARTICIPATING,ORDOIHAVETOPAYFORANYTHING?
Therewillbenofinancialrewardtoorcoststoyouasaparticipantinthisstudy.
Theinvestigatorswillcoverthecostsforparkingatclinicvisits.
WILLMYRECORDSBEKEPTPRIVATE?
Alloftheinformationcollectedfromthestudywillremainstrictlyconfidential.Only
theinvestigatorsresponsibleforthisstudy,theresearchassistantswhowillbe
doingdataentryandtheUniversityofCalgary,ConjointHealthResearchEthics
Boardwillhaveaccesstothisinformation.Confidentialitywillbeprotectedby
usingonlystudyidentificationnumberinthedatabase.Anyresultsofthestudy,
whicharereported,willinnowayidentifystudyparticipants.
IFISUFFERARESEARCH-RELATEDINJURY,WILLIBECOMPENSATED?
Intheeventthatyousufferaninjuryasaresultofparticipatinginthisresearch,no
compensationwillbeprovidedtoyoubytheUniversityofCalgary,AlbertaHealth
ServicesortheResearchers.Youstillhaveallyourlegalrights.Nothingsaidinthis
consentformaltersyourrighttoseekdamages.
EthicsID:REB15-2577
StudyTitle:Theassociationbetweenphysicalandcognitiverestonrecoveryfromconcussionin
youthicehockey
PI:Dr.KathrynSchneider
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SIGNATURES
Yoursignatureonthisformindicatesthatyouhaveunderstoodtoyoursatisfaction
theinformationregardingyourparticipationintheresearchprojectandagreeto
participationasasubject.Innowaydoesthiswaiveyourlegalrightsnorreleasethe
investigators,orinvolvedinstitutionsfromtheirlegalandprofessional
responsibilities.Youarefreetowithdrawfromthestudyatanytimewithout
jeopardizingyourhealthcare.Ifyouhavefurtherquestionsconcerningmatters
relatedtothisresearch,pleasecontact:
JustinLishchynsky,Master’sStudent(403)220-4267
Ifyouhaveanyquestionsconcerningyourrightsasapossibleparticipantinthis
research,orresearchingeneral,pleasecontacttheChairoftheConjointHealth
ResearchEthicsBoard,UniversityofCalgaryat(403)220-7990”.
Name(print)
SignatureandDate
___________________________________________
___________________________________________
Investigator/Delegate’sName
SignatureandDate
Witness’Name
SignatureandDate
Theinvestigatororamemberoftheresearchteamwill,asappropriate,explainto
youtheresearchandyourinvolvement.Theywillseekyourongoingcooperation
throughoutthestudy.
TheUniversityofCalgaryConjointHealthResearchEthicsBoardhasapprovedthis
researchstudy.Asignedcopyofthisconsentformhasbeengiventoyoutokeepfor
yourrecordsandreference.
EthicsID:REB15-2577
StudyTitle:Theassociationbetweenphysicalandcognitiverestonrecoveryfromconcussionin
youthicehockey
PI:Dr.KathrynSchneider
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APPENDIX I: DEMOGRAPHICS OF EXCLUDED PARTICPANTS
Table 6.1: Demographics of all participants in chapter three, including the participants
that did not complete the MDIPAQ
Characteristic
Included participants
Excluded participants
Sex
16 Male (80%), 4 Female
(20%)
9 Male (90%), 1 Female (10%)
Age – years, median (range)
14 (12 – 16)
14 (12 – 17)
Height – cm, median (range)
166.4 (150.7 – 183.8)
164.6 (139.4 – 185.2)
Weight – kg, median (range)
57.4 (40.0 – 93.0)
51.8 (28.5 – 74.5)
5 (25.0%)
6 (60.0%)
15 (75.0%)
4 (40.0%)
0
13 (65.0%)
4 (40.0%)
1
4 (20.0%)
4 (40.0%)
2 or more
3 (15.0%)
2 (20.0%)
13 (0 – 21)
7.5 (0 – 19)
26.5 (0 – 71)
10 (0 – 56)
Level of play, n
(%)
Previous history
of concussion, n
(%)
Elite (AAA,
AA, A)
Non-elite
(Tiers 1-7)
Initial total symptoms /22,
median (range)
Initial symptom severity /132,
median (range)
Table 6.2: Demographics of all participants in chapter four, including the participants that
did not wear the Actigraph
Characteristic
Included Participants
Excluded Participants
Sex, n (%)
25 male (83.3%)
5 Female (16.7%)
8 male (100%)
14 (12 – 17)
166.2 (139.4 – 185.2)
54.6 (28.5 – 93.0)
14.5 (12-18)
168.8 (145.4 – 184.9)
57.2 (33.4 – 83.9)
Age – years, median (range)
Height – cm, median (range)
Weight – kg, median (range)
Elite (AAA,
AA, A)
Level of play, n (%)
Non-elite
(Tiers 1-7)
21 (70.0%)
9 (30.0%)
86
1 (12.5%)
7 (87.5%)
Previous history of
concussion, n (%)
0
17 (56.7%)
1
8 (26.7%)
0
2 or more
5 (16.7%)
0
11.5 (0 – 21)
5 (0 – 17)
20 (0 – 71)
5.5 (0 – 21)
Initial total symptoms /22, median
(range)
Initial symptom severity /132, median
(range)
8 (100%)
Table 6.3: Demographics of all participants that did not complete the CAS in chapter five
Characteristic
Included participants
Excluded participants
Sex
20 Male (83.3%), 4 Female
(16.7%)
5 Male (83.3%), 1 Female (16.7%)
14 (12 – 17)
13.4 (12 – 17)
166.2 (139.4 – 183.8)
166.3 (153.2 – 185.2)
56.3 (28.5 – 93.0)
51.8 (43.2 – 74.5)
18 (75.0%)
3 (50.0%)
6 (25.0%)
3 (50.0%)
0
14 (58.3%)
3 (50.0%)
1
5 (20.8%)
3 (50.0%)
2 or more
5 (20.8%)
0 (0%)
13 (0 – 21)
6 (1 – 11)
6 (1 – 11)
8 (1 – 20)
Age – years, median
(range)
Height – cm, median
(range)
Weight – kg, median
(range)
Elite
(AAA,
AA, A)
Level of
play, n (%) Non-elite
(Tiers 17)
Previous
history of
concussion,
n (%)
Initial total symptoms
/22, median (range)
Initial symptom severity
/132, median (range)
87
APPENDIX J: MANUSCRIPT APPROVAL FOR USE IN THESIS
HiJustin,
Igiveyou,JustinLishchynsky,permissiontousethemanuscriptsinyourthesis,whichis
entitled,"PhysicalandCognitiveActivityandRecoveryFromSportsRelatedConcussions.”
Best,
KeithYeates
KeithOwenYeates
I,ClodaghToomey,grantpermissiontoJustinLishchynskytousethemanuscriptsinhis
thesistitled"PhysicalandCognitiveActivityandRecoveryFromSportsRelated
Concussions”.
Regards,
Clodagh
--
ClodaghToomey
DearJustin,
Igiveyou,JustinLishchynsky,permissiontousethemanuscriptsinyourthesis,whichis
entitled,"PhysicalandCognitiveActivityandRecoveryFromSportsRelatedConcussions.”
Sincerely,
Kathryn
KathrynSchneiderPT,PhD
DearJustin,
Igiveyou,JustinLishchynsky,permissiontousethemanuscriptsinyourthesis,whichis
entitled,"PhysicalandCognitiveActivityandRecoveryFromSportsRelatedConcussions.”
Sincerely,
CarolynEmery
CarolynAEmery
88
HiJustin,
Igiveyou,JustinLishchynsky,permissiontousethemanuscriptsinyourthesis,whichis
entitled,"PhysicalandCognitiveActivityandRecoveryFromSportsRelatedConcussions.”
Luz
LuzPalacios-Derflingher
89