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Brain Injury, November 2009; 23(12): 956–964

Active rehabilitation for children who are slow to recover following


sport-related concussion

ISABELLE GAGNON1,2, CARLO GALLI1, DEBBIE FRIEDMAN1, LISA GRILLI1, &


GRANT L. IVERSON3
1
Montreal Children’s Hospital, Montreal, Canada, 2McGill University, Montreal, Canada, and 3University of
British Columbia and British Columbia Mental Health & Addiction Services, Vancouver, Canada

(Received 25 February 2009; revised 29 August 2009; accepted 27 September 2009)

Abstract
Primary objective: To present an innovative approach to the management of children who are slow to recover after a sport-
related concussion.
Research design: The article describes the underlying principles and the development of specific interventions for a new
rehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures.
Methods and procedures: Development of the intervention was done using multiple perspectives including that of the
literature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric and
adolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. The
intervention was implemented and evaluated with a sample of 16 children and adolescents.
Main outcomes and results: The presented cases suggest that involvement in controlled and closely monitored rehabilitation in
the post-acute period may promote recovery in children and adolescents who present with atypical recovery following a
concussion. All 16 of the children and adolescents who participated in the programme experienced a relatively rapid
recovery and returned to their normal lifestyles and sport participation.
Conclusions: A gradual, closely-supervised active rehabilitation programme in the post-acute period (i.e. after 1 month
post-injury) appears promising to improve the care provided to children who are slow to recover.

Keywords: Concussion, mild traumatic brain injury, paediatric, rehabilitation, sports

Introduction interdisciplinary management of the paediatric ath-


lete who sustains a concussion [7–10]. More focused
Sport-related concussions (i.e. mild traumatic brain
and specific research with children has been recom-
injuries (MTBI)) occur fairly commonly, particularly
mended [11, 12].
in football, soccer, rugby and hockey [1–3]. The
Agreement statements developed by governmental
majority of the literature to date suggests that
organizations [13], professional associations [10, 14]
athletes recover quickly from concussions, with
some recovering in 1–2 days and most recovering and research groups [11] set forth the recommen-
within 7–10 days [4, 5]. There is concern, however, dation that athletes, including children, should be
that concussions in children might be different [6] asymptomatic at rest prior to engaging in physical
and might be associated with slower recovery. exertion. Without question, these agreement state-
Professionals providing services to children and ments are designed to protect the health and welfare
adolescents after a concussion have long recognized of the athlete, reduce the likelihood of the athlete
the need for coordinated care for this clientele experiencing a set-back in the recovery process and
and, particularly, the need for individualized minimize the chances that the athlete will be

Correspondence: Isabelle Gagnon, Montreal Children’s Hospital-McGill University Health Center, Trauma Programs, C-833, 2300 Tupper, Montreal,
Canada, H3H 1P3. Tel: 514-412-4400 x23422. Fax: 514-412-4398. E-mail: isabelle.gagnon8@mcgill.ca
ISSN 0269–9052 print/ISSN 1362–301X online ! 2009 Informa Healthcare Ltd.
DOI: 10.3109/02699050903373477
Rehabilitation after concussion 957

returned to sport prematurely and experience an used to guide the design of the MCH-RAC: (1) the
overlapping injury. The recommendation that ath- non-specificity of post-concussion symptoms, (2) the
letes avoid exercise until completely asymptomatic at multi-dimensional impacts of injury on athletes and
rest works well for most injured athletes, most of the (3) the effects of exercise as an intervention
time. However, when athletes are very slow to modality.
recover, there is a risk that their symptoms and First, post-concussion-like symptoms are non-
deficits (cognitive, motor) will (1) become chronic specific [17–19]. They can be associated with a
and (2) be caused in whole or part by factors that variety of things, such as school-related stress,
might not be directly related to the neurobiology of relationship stress, mild depression, anxiety condi-
the original concussion. Moreover, from a practical tions, Attention-Deficit Hyperactivity Disorder
perspective, it is very difficult to ensure that mildly (ADHD) and sleep disturbances. Therefore, the
symptomatic children will not engage in physical longer the athlete is symptomatic the more likely,
exertion (e.g. vigorous playing and running). statistically, that some of the symptoms will be
Therefore, children and adolescents with persistent caused or maintained (at least in part) by factors
symptoms represent a unique challenge to healthcare other than the neurobiology of the concussion.
providers. Secondly, athletes can have adverse psychological
Over the past 2 years, clinicians at the Montreal reactions to being injured and to being kept out of
Children’s Hospital Trauma Programs have been sports [20–24]. These psychological reactions
developing an individualized approach with paedia- include denial, mild depression, anxiety, worry,
tric athletes who sustain concussions and are slow anger, diminished vigour, loneliness, worthlessness,
to recover. The Montreal Children’s Hospital impatience and general overall negativity [25].
Rehabilitation After Concussion (MCH-RAC) pro- According to models of psychological reaction to
gramme consists of gradual, closely monitored phys- sport injury, these reactions are mediated in part by
ical conditioning, general coordination exercises, personal and situational factors, but also on cogni-
visualization, as well as education and motivation tive appraisal of the situation [24]. These psycho-
activities. These are performed in the presence of logical reactions can underlie what appear to be
persistent symptoms in order to contribute to their post-concussion symptoms, especially when the
resolution as well as to improve children’s general symptoms persist for several weeks. Moreover,
physical condition and mood. The programme is improvement in the psychological condition of the
individualized and is designed to last until complete physically injured athlete (not concussed athlete) is
symptom resolution at rest. At that time, children and associated with perceived progress in rehabilitation
adolescents are eligible to resume the standard return [26, 27].
to activity protocols, part of the Montreal Children’s Thirdly, there is evidence that exercise has positive
Hospital MTBI/Return to Sports Program. Other effects on mental health and that it could be used as
groups, working with an adult population, have also a treatment for depression in adults [28]. There is
described similar approaches in the domain of reha- also evidence that depressed mood after a concus-
bilitation post-concussion with both athletes and sion could reflect pathophysiology consistent with
non-athletes [15, 16]. a limbic-frontal model of depression [29, 30].
The purpose of this paper is to present an Therefore, it is possible that exercise could have a
innovative approach to the rehabilitation of children beneficial effect on symptoms in children if their
who are slow to recover after a sport-related symptoms are related to depressed mood or mental
concussion. The article describes the principles health issues. Furthermore, there is evidence in the
underlying the MCH-RAC as well as its intervention animal literature that exercise is good for the brain
modalities. A series of cases concerning the impact of and promotes neuroplasticity, even after fluid-
this rehabilitation strategy on the resolution of post- percussion induced MTBI in rats [31, 32].
concussion symptoms as well as children’s perspec- However, there appears to be a temporal window
tive on their experience with the intervention will in which exercise does not promote neuroplasticity
also be discussed. and the literature suggests that exercise could,
theoretically, slow down recovery if done too soon
after injury [33]. In fact, the molecular markers are
suppressed if the injured rat is allowed to engage in
Development of the intervention and
voluntary exercise during the first week post-injury
underlying principles
but not in the post-acute phase (3–4 weeks post-
Designing successful interventions requires the injury). Most children and adolescents do not
understanding of challenges facing the targeted receive follow-up interventions beyond the initial
population as well as elements on which one can management period, even though their deficits
hope to have an impact. Three broad principles were (balance, response time, cognitive) may last up to
958 I. Gagnon et al.

Table I. Theoretical rational for the Montreal Children’s Table II. Criteria for referral to the Montreal Children’s Hospital
Hospital Rehabilitation After Concussion (MCH-RAC) Neurotrauma Programme.
Programme.
Prolonged loss of consciousness (>1 minute) at time of injury
I. Aerobic Activity Concussive convulsions
Increase brain-derived neurotrophic factor (BDNF) Skull fracture
Synaptogenesis Patients given Miami-J collar to rule out neck injuries
Increased cardiovascular activity Persistent symptoms with no improvement lasting >1 week
Altered cerebral vascular function and brain perfusion Persistent deficits or cognitive impairments
Increased endorphin release Multiple concussions (>2 in the same year) or occurring with less
Improved brain autoregulation impact forces
Improve overall fitness level Elite athletes (practice >8 hours/week competitive sport)
Reduce fatigue/improve energy levels Delayed Emergency Department visit with confirmed skull
Reduce stress, worry and anxiety fracture
Improve mood
Improve cognition
Improve self-efficacy and performance involved with children who require admission to the
II. Coordination/Skill Practice (Enjoyed Activity) hospital and for those who are cared for directly in
Increased endorphin release
the Emergency Department (ED) or on an out-
Improve mood
III. Visualization of Positive and Successful Activities Related to patient basis when referred from community part-
Preferred Physical Activity ners (paediatricians, family doctors, schools and
Reassurance and increased confidence relating to ability to sports teams).
practice sport The physician in the MCH-ED uses a standar-
Activated brain regions linked to motor activities
dized form to assess children presenting with
Improve self-efficacy and performance
IV. Education and Motivation concussion. This form was designed to ensure that
Education and reassurance leads to empowerment and all injury variables useful for diagnostic and prog-
improved coping nostication purposes are collected systematically.
Increased confidence in services provided The form also contains clear criteria for referral to
further services, namely the MCH Neurotrauma
3 months [34–36]. Furthermore, for the group of Programme, following discharge from the ED, usu-
individuals who fail to return to pre-injury status ally after a few hours of assessment/observation.
after the expected initial recovery period, treatment Before leaving the ED, children receive standard
recommendations usually are broad, do not suggest education and documentation regarding the nature
specific evidence-based interventions and are not of the injury, reassurance and instructions for return
very helpful to the professionals who have to to school and physical activities, as well as contact
determine the best way to address the needs of information should they need further information.
these children. For those children referred to the Neurotrauma
Starting from these principles, a systematic search Programme (see Table II), follow-up phone calls
of the English and French literature on paediatric and ensure individualized education/information and
adolescent MTBI as well as on exercise-induced return to activities instructions.
changes to neurological function performed using the The MTBI/Return to Sports Clinic is part of
following six databases: MEDLINE (1980–2008), the MCH Trauma Programs and was created to
CINHAL (1982–2008), ERIC (1980–2008), provide children and adolescents with the opportu-
PsychINFO (1980–2008) and SportsDiscus (1980– nity to follow a closely monitored, stepwise pro-
2008). This review led to the theoretical rationale for gramme to ensure that their return to sport and
the components of the programme set out in Table I. school is a positive and safe one. Children seen in the
context of this clinic are at least 7 years old and belong
to one of two categories: elite athletes (defined as
The MCH-RAC practicing more than 8 hours of competitive level
sports per week) and children who are slow to
The Montreal Children’s Hospital (MCH) is a recover, defined here as presenting with symptoms
tertiary care paediatric teaching Hospital affiliated or impairments lasting more than 4 weeks (Figure 1).
with McGill University in Montreal, Canada. It is The latter slow to recover group is the focus of this
one of two designated paediatric Trauma centres in paper.
the Province of Quebec, Canada. The MCH
Trauma mandate consists of five different pro-
grammes (Trauma, Neurotrauma, MTBI/Return to
Intervention
Sports, Burns and Injury Prevention). The manage-
ment of children who sustain a concussion within the The MCH-RAC programme is therefore an inter-
institution is a comprehensive multilevel programme vention for children and adolescents who do not
Rehabilitation after concussion 959

Referral to Concussion/Return to Sports clinic


(team members include: trauma coordinator, clinic coordinator, physiotherapist, psychologist, neurosurgeon, other
consultants as needed)

Children with slow recovery


Elite athletes symptom
free at rest for 1 week

Initial evaluation:
Initial evaluation: History, physical, and appropriate
History, physical, and cognitive evaluation
appropriate cognitive
evaluation

-Graded rehab (MCH-RAC) until


Physical and cognitive asymptomatic for 1 week
exertion testing -Management by team: PT,
psychologist, MD, etc.

Remains symptom free

Yes No Asymptomatic for 1 week

Gradual return to sports guidelines

-Return appointment for


Gradual return to sports re-evaluation
-Education and weekly
Discharge from clinic follow-up

Figure 1. The MCH MTBI/Return to Sports Clinic. Children seen in this clinic belong to one of two categories: Elite athletes (defined as
practicing more than 8 hours of competitive level sports per week) and children who are slow to recover, defined here as presenting with
symptoms or impairments lasting more than 4 weeks.

recover in the initial days or weeks following the the Balance Error Scoring System (BESS) [4],
injury, either because they may have a more severe (3) coordination testing using the BOTMP-2 and
injury than initially thought or they may present with (4) a post-concussion symptoms checklist [38].
pre-injury characteristics placing them at risk of After the assessment, they initiate a graded
developing more chronic symptoms. rehabilitation, as presented in Figure 2. They begin
Before being considered eligible for this interven- with sub-maximal (50–60% maximal capacity) aer-
tion, children undergo an evaluation by the obic training either on a treadmill or a stationary
Neurotrauma Program Coordinator of the MCH. bicycle for up to 15 minutes. Children are then
Following this initial evaluation, they are provided introduced to light coordination exercises that are
with standard education and reassurance material, tailored to the child’s favourite or main sport. For
ongoing telephone follow-up, as well as referrals to example, basketball players will be introduced to
any other services (e.g. neuropsychology, school light coordination drills including ball activities and
services, neurology or neurosurgery) thought to be footwork as used in usual sports practices. These will
necessary for their condition. All children are also be performed for up to 10 minutes. The purpose of
required to have been evaluated by a physician, most these exercises is to continue light aerobic activities
often in the MCH ED, where an algorithm is in but also to reintroduce familiar activities in a
place to ensure a coherent and consistent approach successful context, one of the means of increasing
in the medical management of these cases. self-efficacy. Self-efficacy is a key element of perfor-
Prior to their entry into the MCH-RAC pro- mance and satisfaction with the practice of physical
gramme, children complete several assessment mea- activities [39, 40] and found to be decreased follow-
sures. These measures include: (1) standard ing concussion [41]. Children are monitored closely
neurological and physical examination, (2) balance, for any increase in symptoms during the physical
using the Bruininks-Oseretsky Test of Motor activities. An increase in symptoms is the point
Proficiency (BOTMP-2) [37] and in some cases where activities are stopped.
960 I. Gagnon et al.

Figure 2. Schematic representation of the MCH-RAC programme.

Throughout the aerobic and coordination phase of of the children who had received the intervention
the intervention, children and parents are provided during the first 17 months of its implementation.
with education, reassurance and motivation to This was completed as part of an evaluative process
address knowledge, attitudes and behaviours aiming to review new interventions within the MCH
towards the injury and further normalize their Trauma Programmes.
situation to facilitate recovery. They are also taught
sport-specific visualization and imagery techniques. Participants
This is also thought to improve confidence and self- All children/adolescents aged 10–17 years who
efficacy towards the ability to recover as well as to sustained a concussion and experienced post-
return to sports/activities. concussion symptoms for more than 4 weeks
The final but essential phase of the MCH-RAC post-injury were seen in the initial months of
intervention is the inclusion of a home programme implementation of the MCH-RAC at the Montreal
designed to allow children to continue training Children’s Hospital. They were followed prospec-
outside the clinic, thus facilitating school attendance tively for the duration of their involvement in the
and minimizing disruptions to their daily life. The programme. All children had been referred to
home programme consists of sub-maximal aerobic the programme after having been seen by a physician
training and coordination exercises, chosen among and, for some of them, by a concussion clinic
the child’s usual activities, for the duration the child elsewhere. The reason for their referral was the
was able to tolerate without his symptoms increasing incomplete resolution of their symptoms after the
during the supervised session. The child and parents expected recovery period.
are also instructed to interrupt the home session and
contact the Neurotrauma Programme if any deteri- Data collection
oration occurs. Finally, the child is followed weekly
and this goes on until he or she reports being The MCH Trauma Programs maintain a central
symptom-free at rest for 1 week. At that time, the database of all children and adolescents referred for
child enters the standard return to activity protocol, services, whether admitted to hospital or treated
including exertion testing and graded return solely in the ED. The medical records of all children
to activities. A schematic representation of the seen in the MCH-RAC programme between 1 July
programme is presented in Figure 2. 2007 and 15 December 2008 were reviewed after
Institutional authorization was obtained. For each
child, data was collected using a standardized form
by a single investigator. Variables of interest
Case studies
included information about the injury sustained,
In an initial effort to assess the process and impact of course of recovery, time of referral to MCH-RAC
the intervention, the authors reviewed the outcome programme, assessments done in rehabilitation and
Rehabilitation after concussion 961

course while in the MCH-RAC until recovery and 4.4 (SD ¼ 2.6) weeks after a mean of 7.0 (SD ¼ 4.1)
discharge. weeks of persistent symptoms. Parents qualitatively
reported high satisfaction with the programme and
the comprehensive nature of the follow-up, empha-
Results sizing the positive impact of the intervention on their
child’s mood, as illustrated by the following quote:
Over the initial 17 months of implementation, 142
‘. . . it was like there was a light in her eyes, her whole
children were seen in the MTBI/Return to Sports
face changed after the exercise’. Parents also
clinic. A total of 16 children and adolescents with
discussed their feelings of empowerment in relation
slow recovery were seen in the MCH-RAC pro-
to the active nature of the intervention and the fact
gramme over the covered period. This corresponds
that ‘. . . finally something was being done for my
to 11.2% of children and is consistent with the
reported prevalence of persistent symptoms in the child’.
literature [42]. A summary of the children’s char- The results from a single case are presented in
acteristics is presented in Table III. Children were detail to illustrate the application of the programme.
able to participate in 5–15 minutes (mean A 13-year old male soccer player sustained a
9.3 minutes) of aerobic activity at their initial visit concussion in early March 2007. Immediately after
before an increase in symptoms was reported. This the hit, he felt dizzy. He did not seek medical
tolerance gradually increased over time with a mean attention at the time. It was only 4 weeks later, after
of 12.2 minutes at the second visit and of continuing to experience severe headaches and
14.2 minutes at the third visit. sensitivity to light and sounds that he was seen in
Children reported being motivated to engage in the MCH Emergency Department. A CT scan was
physical activities after the rest period imposed on done (negative). He was given a dose of IV
them following their injury. All participants for Metoclopramide with some headache relief. He
whom data were collected showed significant and was also referred to the MTBI/Return to Sports
rapid improvement of symptoms. Indeed, the mean Clinic of the MCH.
Post-Concussion Scale-Revised Score [43] at initial He was seen at the beginning of May with
assessment was 30.0 (SD ¼ 20.8) and decreased to complaints of persistent headaches since the injury.
6.7 (SD ¼ 5.7) at discharge from the programme. All He often felt very tired and missed playing soccer.
children were able to resume their normal physical He rated his constant headaches at 2–3 on a 10-point
activity participation at the end of the programme. visual analogue scale. His neurological exam was
Mean duration of the MCH-RAC intervention was normal, as were his balance and coordination skills.

Table III. Characteristics and outcome of children involved in the Montreal Children’s Hospital Concussion Rehabilitation Intervention
(MCH-RAC).

Duration
Duration of of involvement
initial aerobic in MCH-RAC
Time to Main complaint at session before resolution
Age Cause of MCH-RAC presentation to (before increase of symptoms
Case (years) Gender injury LOC (weeks) MCH-RAC in symptoms) (min) (weeks)

1 16 M Rugby yes 6 Feeling depressed, fatigue 12 6


2 14 F Soccer no 8 Headache 15 2
3 17 M Kayak no 5 Feeling depressed, fatigue 8 5
4 13 M Soccer no 9 Fatigue 15 2
5 13 M Football no 6 Fatigue 12 2
6 17 F Cheerleading no 6 Headache 13 3
7 15 M Hit, assault no 6 Fatigue, headache 12 4
8 17 F Fall on the street no 4 Headache 8 2
9 13 F Skiing no 4 Headache 15 2
10 8 M Soccer no 5 Poor endurance 5 5
11 15 M Hockey no 4 Headache 12 12
12 12 M Football no 4 Fatigue, headache 10 4
13 13 M Hockey no 4 Headache 5 4
14 16 M Football no 16 Headache 10 8
15 14 F Soccer no 18 Headache 10 5
16 15 M Hockey no 7 Headache 9 5
962 I. Gagnon et al.

Because of current management guidelines that sub-groups of patients for whom the intervention
require children to be symptom-free before initiating will be more or less effective.
return to activity protocols, he had been resting It is understood that active rehabilitation for
for more than 9 weeks without major children and adolescents who remain symptomatic
improvements. After the assessment, he began light following a concussion is somewhat controversial.
aerobic training on the treadmill at 3.6 km h"1 for Several published agreement statements [10, 11,
10 minutes (60–70% of max HR). He did not 14, 44] emphasize that athletes should be asympto-
experience any increase in symptoms and stated that matic at rest prior to engaging in exercise.
it ‘felt good to move’. He also began light jumping This model works very well for the majority of
drills as well as 10 pushups. He was sent home with injured children and adolescents. However, a minor-
instructions to continue with 15 minutes of daily ity have persistent symptoms for many weeks. For
light aerobic activity for 1 week. them, significant lifestyle restrictions, including
Five days later he returned to clinic reporting avoiding physical activity, can actually contribute
improvement. Headaches were now only sporadic to symptom maintenance over time. That is, the
and rated as 2/10. He reported no increase in longer a person has symptoms, the more likely it is
symptoms with activity and felt he had more that other factors that are separate from or only
energy. After being reassessed (had no symptoms partially related to the neurobiology of the original
at the time of the visit), he proceeded to the aerobic injury are causing or maintaining the symptoms.
training now consisting of 15 minutes of treadmill at Thus, at some point, active rehabilitation seems
3.6 km h"1. He also performed ball activities specific indicated. Exercise has been shown to have positive
to soccer and light jumping drills under supervision. effects on mood and self-esteem and it promotes a
He was sent home with instructions to continue with general sense of well-being [45–48]. In adults,
20–30 minutes of daily light aerobic activity for exercise can be an effective treatment for mild
1 week. Foot handling drills with ball on his own depression [28, 49, 50]. Exercise promotes neuro-
were added to the home programme. plasticity in animal studies [51] and exercise done
His next visit was a month later because he was after a period of recovery in animal studies involving
studying for exams and could not attend clinic. concussion is also associated with neuroplasticity
Throughout that month, phone contacts were done [31–33]. Active rehabilitation and exercise is used
and rehabilitation had progressed. He had been with older adults following stroke. Therefore, it is
symptom-free at rest for more than 1 week and
believed that a gradual, closely-supervised active
physical exertion did not trigger symptoms. He was
rehabilitation programme for children and adoles-
ready to enter progressive return to play protocols, as
cents in the post-acute period (i.e. after 1 month post
per concussion management guidelines.
injury) is appropriate.
The theoretical rationale presented in this paper
(Table I) is presently the object of an external expert
Conclusion consultation and validation process. This will likely
The presented cases suggest that involvement in contribute to further improvement in the interven-
controlled and closely monitored rehabilitation tion, ensure solid theoretical bases for its implemen-
in the post-acute period may promote recovery in tation and assist with the preparation of a clinical
children and adolescents who are slow to recover trial to formally investigate the effectiveness of this
following a concussion. The MCH-RAC was created approach with children and adolescents who are
out of a clinical need to better care for children and slow to recover after a concussion.
adolescents who are slow to recover following a
concussion. It is an individualized intervention
developed for children to address persistent symp- Acknowledgements
toms and other issues related to the injury. All 16 of
the children and adolescents who participated in the Part of this manuscript was presented at the 7th
programme experienced a relatively rapid recovery World Congress on Brain Injury, Lisbon, 2008 and
and they returned to their normal lifestyles and sport at the 3rd International Conference on Concussion
participation. In the recent months, multiple out- in Sport, Zurich, 2008. Dr Gagnon is presently
come measures were added to the clinical follow-up funded by a Clinician-Scientist Career Award from
of these patients in order to better monitor their the Fonds de la Recherche en Santé du Québec.
mood, anxiety, fatigue level, cognitive abilities and Further development of the MCH-RAC Program
postural stability. Those outcome measures will is supported by a research grant from the Fonds de la
further enlighten one’s understanding of recovery Recherche en Santé du Québec Rehabillitation
in this clientele and allow one to possibly identify Research Network.
Rehabilitation after concussion 963

Declaration of interest: The authors report no 17. Chan RCK. Base rate of post-concussion symptoms among
conflicts of interest. The authors alone are respon- normal people and its neuropsychological correlates. Clinical
Rehabilitation 2001;15:266–273.
sible for the content and writing of the paper. 18. Iverson GL. Misdiagnosis of the persistent postconcussion
syndrome in patients with depression. Archives of Clinical
Neuropsychology 2006;21:303–310.
References 19. Iverson GL, Zasler ND, Lange RT. Post-concussive disorder.
In: Zasler ND, Katz DI, Zafonte RD, editors. Brain injury
1. Schulz MR, Marshall SW, Mueller FO, Yang J, Weaver NL, medicine: Principles and practice. New York: Demos
Kalsbeek WD, Bowling JM. Incidence and risk factors Medical Publishing; 2006. p 373–405.
for concussion in high school athletes, North Carolina, 20. Manuel JC, Shilt JS, Curl WW, Smith JA, Drant RH,
1996–1999. American Journal of Epidemiology 2004;160: Lester L, Sinal SH. Coping with sports injuries: An exam-
937–944. ination of the adolescent athlete. Journal of Adolescent
2. Cassidy JD, Carroll LJ, Peloso, PM, Borg J, von Holst H, Health 2002;31:391–393.
Holm L, Kraus J, Coronado VG. Incidence, risk factors and 21. Walker N, Thatcher J, Lavallee D. Psychological responses to
prevention of mild traumatic brain injury: Results of the injury in competitive sport: A critical review. The Journal of
WHO collaborating centre task force on mild traumatic brain the Royal Society for the Promotion of Health 2007;127:
injury. Journal of Rehabilitation Medicine 2004;(suppl 174–180.
43):28–60. 22. Podlog L, Eklund RC. The psychosocial aspects of a return to
3. Boden BP, Kirkendall DT, Garrett Jr WE. Concussion sport following serious injury: A review of the literature from
incidence in elite College soccer players. American Journal of a self-determination perspective. Psychology of Sport and
Sports Medicine 1998;26:238–241. Exercise 2007;8:535–566.
4. Guskiewicz K. Postural stability assessment following con- 23. Nippert AH, Smith AM. Psychologic stress related to injury
cussion: One piece of the puzzle. Clinical Journal of Sport and impact on sport performance. Physical Medicine and
Medicine 2001;11:182–189. Rehabilitation Clinics of North America 2008;19:399–418.
5. Iverson GL. Outcome from mild traumatic brain injury. 24. Wiese-bjornstal DM, Smith AM, Shaffer SM, Morrey MA.
Current Opinion in Psychiatry 2005;18:s301–s317. An integrated model of response to sport injury:
6. Lovell M, Collins MW, Iverson GL, Field M, Maroon JC, Psychological and sociological dynamics. Journal of applied
Cantu RC, Podell K, Powell JW, Belza M, Fu FH. Recovery sport psychology 1998;10:46–69.
from mild concussion in high school athletes. Journal of 25. Weinberg RS, Gould D. Foundations of sport and exercise
Neurosurgery 2003;98:296–301. psychology. Champaign, IL: Human Kinetics; 2007.
7. Davis G, McCrory P. Paediatric sport related concussion 26. Tracey J. The emotional response to the injury and rehabil-
pilot study. British Journal of Sports Medicine 2005;39. itation process. Journal of Applied Sport Psychology 2003;15:
8. McClincy MP, Lovell M, Pardini J, Collins MW, Spore MK. 279–293.
Recovery from sports concussion in high school and colle- 27. Bauman JP. Returning to play: The mind does matter.
giate athletes. Brain Injury 2006;20:33–39. Clinical Journal of Sport Medicine 2005;15:432–435.
9. Theye F, Mueller KA. ‘Heads up’: Concussions in high 28. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M,
school sports. Clinical Medicine & Research 2004;2:165–171.
Lawlor DA. Exercise for depression. Cochrane Database of
10. Canadian Pediatric Society. Identification and management
Systematic Reviews 2009; Issue 3. Art. No.:CD004366.
of children with sport-related concussion. Pediatric and Child
29. Chen CC, Johnston KM, Frey S, Petrides M, Worsley KJ,
Health 2006;11:420–428.
Ptito A. Functional abnormalities in symptomatic concussed
11. McCrory P, Johnston KM, Meeuwisse W, Aubry M,
athletes: An fMRI study. NeuroImage 2004;22:68–82.
Cantu R, Dvorak J, Graf-Baumann T, Kelly JP, Lovell M,
30. Chen JK, Johnston KM, Petrides M, Ptito A. Neural
Schamasch P. Summary and agreement statement of the 2nd
substrates of symptoms of depression following concussion
International Conference on Concussion in Sport, Prague
in male athletes with persisting postconcussion symptoms.
2004. British Journal of Sports Medicine 2005;39(suppl 1):
Archives of General Psychiatry 2008;65:81–89.
i78–i86.
31. Griesbach GS, Hovda DA, Gomez-Pinilla F, Sutton RL.
12. Carroll LJ, Cassidy JD, Holm L, Kraus J, Coronado VGJ.
Voluntary exercise or amphetamine treatment, but not the
Methodological issues and research recommendations for
combination, increases hippocampal brain derived neuro-
mild traumatic brain injury: The WHO collaborating centre
trophic factor and synapsin I following cortical contusion
task force on mild traumatic brain injury. Journal of
injury in rats. Neuroscience 2008;154:530–540.
Rehabilitation Medicine 2004;(suppl 43):113–125.
32. Griesbach GS, Hovda DA, Molteni R, Wu A,
13. Ministère de la santé et des services sociaux du Québec.
Orientations ministérielles pour le traumatisme craniocéréb- Gomez-Pinilla F. Voluntary exercise following traumatic
ral léger. Quebec, QC: Gouvernement du Québec; 2005. brain injury: Brain-derived neurotrophic factor upregulation
14. Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, and recovery of function. Neuroscience Letters 2004;125:
McCrea M, Putukian M, Valovich TC. Research based 129–139.
recommendations on management of sports related concus- 33. Griesbach GS, Gomez-Pinilla F, Hovda DA. Time window
sion: Summary of the National Athletic Trainers’ Association for voluntary exercise—induced increases in hippocampal
position statement. British Journal of Sports Medicine neuroplasticity molecules after traumatic brain injury is
2006;40:6–10. severity dependent. Journal of Neurotrauma 2007;24:
15. Iverson GL, Brooks BL, Azevedo A, Gaetz M. Modifying the 1161–1171.
British Columbia Concussion Rehabilitation Program for use 34. Gagnon I, Swaine B, Friedman D, Forget R. Children
with injured adults with the post-concussion syndrome. Brain demonstrate decreased dynamic balance following a mild
Injury Conference of the Americas. Miami, FL; 2006. traumatic brain injury. Archives of Physical Medicine and
16. Willer B, Leddy J. Management of concussion and post- Rehabilitation 2004;85:444–452.
concussion syndrome. Current Treatment Options in 35. Gagnon I, Swaine B, Friedman D, Forget R.
Neurology 2006;8:415–426. Visuomotor response time in children with a mild traumatic
964 I. Gagnon et al.

brain injury. Journal of Head Trauma Rehabilitation Meeuwisse WH, Schamasch P. Summary and agreement
2004;19:391–404. statement of the 1st International Symposium on Concussion
36. Gagnon I, Swaine B, Friedman D, Forget R. Exploring in Sport, Vienna 2001. Clinical Journal of Sport Medicine
children’s self-efficacy related to physical activity perfor- 2002;12:6–11.
mance after a mild traumatic brain injury. Journal of Head 45. Christie BR, Eadie BD, Kannangara TS, Robillard JM,
Trauma Rehabilitation 2005;20:436–449. Shin J, Titterness AK. Exercising our brains: How physical
37. Bruininks BD, Bruininks RH. Bruininks-Oseretsky Test of activity impacts synaptic plasticity in the dentate gyrus.
Motor Proficiency. 2nd Ed (BOT-2). Circle Pines, MN: Neuromolecular Medicine 2008;10:47–58.
American Guidance Service; 2006. 46. Vaynman S, Gomez-Pinilla F. License to run: Exercise
38. Lovell MR, Collins MW. Neuropsychological assessment of impacts functional plasticity in the intact and injured central
the college football player. Journal of Head Trauma nervous system by using neurotrophins. Neurorehabilitation
Rehabilitation 1998;13:9–26. and Neural Repair 2005;19:283–295.
39. Bandura A. Social foundations of thought and action: A social 47. van Praag H. Neurogenesis and exercise: Past and future
cognitive theory. Englewood Cliffs, NJ: Prentice Hall; 1986. directions. Neuromolecular Medicine 2008;10:128–140.
40. Bandura A. Self-efficacy: The exercise of control. New-York: 48. Duman RS. Neurotrophic factors and regulation of mood:
Freeman; 1997. Role of exercise, diet and metabolism. Neurobiology of Aging
41. Gagnon I, Swaine B, Friedman D, Forget R. Mild traumatic 2005;26(suppl 1):88–93.
brain injury affects children’s self-efficacy related to their 49. Penninx BW, Rejeski WJ, Pandya J, Miller ME, Di Bari M,
physical activity performance. Journal of Head Trauma Applegate WB, Pahor M. Exercise and depressive symptoms:
Rehabilitation 2005;20:446–459. A comparison of aerobic and resistance exercise effects on
42. Carroll LJ, Cassidy JD, Peloso PM, Borg J, von Holst H, emotional and physical function in older persons with high
Holm L, Paniak C, Pépin M. Prognosis for mild traumatic and low depressive symptomatology. Journal of Gerontology
brain injury: Results of the WHO collaborating center task B: Psychological Science and Social Science 2002;57:
force on mild traumatic brain injury. Journal of Rehabilitation 124–132.
Medicine 2004;(suppl 43):84–105. 50. Dunn A, Trivedi MH, Kampert JB, Clark CJ,
43. Lovell MR, Iverson GL, Collins MW, Podell K, Chambliss HO. Exercise treatment for depression efficacy
Johnston KM, Pardini D, Pardini J, Norwig J, Maroon JC. and dose response. American Journal of Preventative
Measurement of symptoms following sports-related concus- Medicine 2005;28:1–8.
sion: Reliability and normative data for the post-concussion 51. Pietropaolo S, Sun Y, Li R, Brana C, Feldon J, Yee BK.
scale. Applied Neuropsychology 2006;13:166–174. The impact of voluntary exercise on mental health in rodents:
44. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, A neuroplasticity perspective. Behaviour and Brain Research
Johnston KM, Kelly J, Lovell M, McCrory P, 2008;192:42–60.

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