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Clinical Scenario: Currently, rest following concussion serves as the keystone of concussion treatment, but substantial evidence to support it is lacking. Recent literature suggests that early physical activity may be beneficial in reducing concussion symptoms which may influence clinical recovery time. Clinical Question: Does early physical activity decrease postconcussion symptoms compared to physical rest following concussion? Summary of Key Findings: A total of 5 articles were included that examined symptom duration changes at multiple time points. All 5 studies utilized follow-up time points compared to initial examination, but there was variance in the specific time points reported. Two studies employed control groups and compared strict or recommended rest to early activity or limited rest. Three studies were observational studies that directly compared baseline measurements to follow-up assessments. Clinical Bottom Line: Current evidence suggests that early physical activity in the acute phase following a concussion may decrease the time needed for symptom resolution compared to immediate rest. Strength of Recommendation: Using Centre for Evidence-Based Medicine 2011 level 3 evidence and higher, the results suggest that early physical activity during the acute phase of a concussion may decrease symptom duration; however, a lack of high-quality studies and inconsistent interventions are limitations to this recommendation.

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Objective The necessity for pre-injury baseline computerized neurocognitive assessments versus comparing post-concussion outcomes to manufacturer-provided normative data is unclear. Manufacturer-provided norms may not be equivalent to institution-specific norms, which poses risks for misclassifying the presence of impairment when comparing individual post-concussion performance to manufacturer-provided norms. The objective of this cohort study was to compare institutionally derived normative data to manufacturer-provided normative values provided by ImPACT® Applications, Incorporated. Method National Collegiate Athletic Association Division 1 university student athletes (n = 952; aged 19.2 ± 1.4 years, 42.5% female) from one university participated in this study by completing pre-injury baseline Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) assessments. Participants were separated into 4 groups based on ImPACT’s age and gender norms: males <18 years old (n = 186), females <18 years old (n = 165), males >19 years old (n = 361) or females >19 years old (n = 240). Comparisons were made between manufacturer-provided norms and institutionally derived normative data for each of ImPACT’s clinical composite scores: Verbal (VEM) and Visual (VIM) Memory, Visual Motor Speed (VMS), and Reaction Time (RT). Outcome scores were compared for all groups using a Chi-squared goodness of fit analysis. Results Institutionally derived normative data indicated above average performance for VEM, VIM, and VMS, and slightly below average performance for RT compared to the manufacturer-provided data (χ2 ≥ 20.867; p < 0.001). Conclusions Differences between manufacturer- and institution-based normative value distributions were observed. This has implications for an increased risk of misclassifying impairment following a concussion in lieu of comparison to baseline assessment and therefore supports the need to utilize baseline testing when feasible, or otherwise compare to institutionally derived norms rather than manufacturer-provided norms.

Purpose This study aimed to determine the effects of superficial cranial cryotherapy on cortical hemodynamics and neurocognitive performance in healthy young adults. Methods Thirty-four healthy individuals (21.3 ± 1.6 yr; 173.8 ± 10.6 cm; 73.3 ± 12.5 kg) participated. Cortical hemodynamic changes over the left prefrontal cortex was assessed using functional near-infrared spectroscopy (fNIRS) throughout the study timeline. All participants were seated in a quiet room and for a 5-min period of cognitive rest before administration of the Stroop Test (CNS Vital Signs) followed by another 5-min period of cognitive rest. Participants were randomized a priori to either the cryotherapy (CryoHelmet™) or control group for 20 min while seated in an isolated quiet room. After the intervention, each group completed a 5-min cognitive rest period, a postintervention Stroop Test, and a final 5-min cognitive rest period. Repeated-measures ANOVA was used to assess cortical hemodynamics (oxygenated hemoglobin, deoxygenated hemoglobin) and Stroop Test outcome scores across time (pre– and post–Stroop Test administration, during intervention, and before and after intervention). Results No significant group–time interactions were observed between groups for oxygenated hemoglobin or deoxygenated hemoglobin (P > 0.05). Cryotherapy participants committed significantly fewer Stroop Test errors than did control participants after intervention (0.7 ± 0.26 vs 1.2 ± 0.23; P = 0.05, η2 p = 0.12). Conclusions Superficial cranial cryotherapy did not significantly influence cortical hemodynamics in this healthy sample. Statistically significant improvements in neurocognitive performance in the intervention group occurred but are negligible in their clinical meaningfulness. Future studies should examine cortical hemodynamic change in pathological populations and determine the clinical utility of superficial cranial cryotherapy.

Context: Limited evidence exists to demonstrate the effect of extrinsic factors, such as footwear worn or the testing environment, on performance of the modified balance error scoring system (mBESS) in the middle school age (10–14 y) population. Therefore, the purpose of our study was to investigate the effect of footwear types and testing environments on performance of the mBESS by middle school athletes. Design: Cross-sectional. Methods: In total, 2667 middle school athletes (55.9% boys and 44.1% girls; age = 12.3 [0.94] y) were administered the mBESS while wearing their self-selected footwear (barefoot, cleats, or shoes) either indoors (basketball court) or outdoors (football field or track). The number of errors committed (range = 0–10) during the double-leg, single-leg, and tandem stances of the mBESS were summed to calculate a total score (range = 0–30). Kruskal–Wallis tests were used to assess for differences among the footwear groups for each mBESS stance and the total score. Mann–Whitney U tests with calculated nonparametric effect sizes (r) were used to assess for differences between the footwear groups and testing environments when appropriate. Results: There were significant differences for the number of committed errors among the footwear groups in the single-leg (P < .001) and tandem (P < .001) stances of the mBESS and mBESS total scores (P < .001). Significantly fewer errors (better) were committed while wearing shoes compared with other footwear in the single-leg and tandem stances of the mBESS (Ps ≤ .032, r = .07–.13). Participants assessed indoors committed significantly fewer errors than those assessed outdoors in each stance of the mBESS (Ps ≤ .022, r = .04–.14). Lower (better) mBESS total scores were observed for participants while wearing shoes (Ps ≤ .002, r = .10–.15) or assessed indoors (P = .001, r = .14). Conclusions: Although our data suggest that the type of footwear worn and the testing environment have a significant effect on mBESS scores of middle school athletes, the magnitudes of these differences are negligible.

Premorbid factors (age, gender, medical history) have been suggested as predictive factors of protracted recovery from concussion in adolescents and adults. Limited evidence exists to evaluate these risk factors for protracted recovery following concussion in children. PURPOSE:To assess the ability of premorbid factors to predict experiencing a protracted recovery following concussion in middle school athletes. METHODS: Our convenience sample consisted of 82 middle school athletes (73.8% boys, 26.2% girls; age=12.6±0.91 years) who were diagnosed with a concussion while participating in school-sponsored sports. Clinical recovery was categorized as expected (0-28 days) or protracted (>28 days) based on the number of days between the date of injury and the date of unrestricted return-to-sport. Independent variables recorded during pre-injury administration of the Child Sport Concussion Assessment Tool 5 th Edition (Child SCAT5) included (1) gender (boy, girl), (2) grade level (6 th , 7 th , and 8 th grade), (3) prior concussion history (0 or 1+ concussions), and (4) prior medical conditions (e.g., diagnosis of dyslexia or ADD/ADHD). Binary logistic regression and Kaplan-Meier curves with log-rank tests were used to predict protracted recovery. RESULTS: Duration of clinical recovery was 16.3±8.88 days (range=0-61 days). The binary logistic regression model was not significant (x 2 (7)=3.37, p=0.85). No demographic or premorbid medical history factors significantly predicted protracted recovery Hazard Ratios: p's≥0.72; Table 1). CONCLUSION: Premorbid factors recorded during pre-injury administration of the Child SCAT5 were not significant predictors of protracted recovery following concussion in middle school athletes. Future investigation of other underrepresented variables in research, such as geographical, environmental, and sociocultural factors, along with Child SCAT5 outcome scores is warranted.