Objective To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic. Study design This was a retrospective, exploratory cohort study of 247 patients age 5-18 years old with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact chi-square tests, logistic regression, quantile regression, and Kaplan Meier survival curves. Results The median time until returning to school part-time was 12 days (interquartile range (IQR) 6-21); until returning to school full-time without accommodations was 35 days (IQR 11-105); until becoming symptom-free was 64 days (IQR 18-119); and until being fully cleared to return to sports was 75 days (IQR 30-153). 73% of all patients were symptomatic for >4 weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion. Conclusion Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.

A high prevalence of vision diagnoses (accommodative, binocular convergence, and saccadic eye movement disorders) was found in this sample of adolescents with concussion, with some manifesting more than one vision diagnosis. These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses.

CME Educational Objectives 1. Prescribe physical and cognitive rest for pediatric and adolescent concussion. 2. Implement a gradual “return-to-learn” plan for student-athletes after concussion. 3. Communicate specific school-based accommodations to facilitate a gradual reintegration to full school activities. The concept of “return-to-play” after concussion is familiar to pediatricians who routinely care for injured student-athletes. Premature return-to-play of a student-athlete who is still injured from a concussion may result in more severe and potentially long-lasting deficits. 1

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Objective To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits, and to describe the correlation of these deficits with neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion. Methods This was a retrospective cohort study of patients age 5–18 years old with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from 7/1/2010–12/31/2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed. Results 247 patients were chosen from 3740 eligible visits for detailed review and abstraction. 81% showed a vestibular abnormality on initial clinical exam. Those patients with vestibular signs on initial exam took a significantly longer time to return to school (median 59 days vs. 6 days, p=0.001) or to be fully cleared (median 106 days vs. 29 days, p=0.001). They additionally scored more poorly on initial computerized neurocognitive testing, and took longer for neurocognitive deficits to recover. Those patients with three or more prior concussions had a higher prevalence of vestibular deficits and took longer for those deficits to resolve. Conclusion Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.

Vision and vestibular problems predict prolonged concussion recovery in children. A history of motion sickness may be an important premorbid factor. Public insurance status may represent problems with disparities in access to concussion care. Vision assessments in concussion must include smooth pursuits, saccades, near point of convergence (NPC), and accommodative amplitude (AA). A comprehensive, multidomain assessment is essential to predict prolonged recovery time and enable active intervention with specific school accommodations and targeted rehabilitation.

Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.

When scheduling youth sporting events, potential activity volume and intensity over any 48-hour period, recovery time between all training and competition bouts, and potential between-day sleep time (≥ 7 hours) should be considered to optimize safety. An overscheduling injury can be defined as an injury related to excessive planned physical activity without adequate time for rest and recovery, including between training sessions/competitions and consecutive days.