Brain Injury, November 2009; 23(12): 956–964
Active rehabilitation for children who are slow to recover following
ISABELLE GAGNON1,2, CARLO GALLI1, DEBBIE FRIEDMAN1, LISA GRILLI1, &
GRANT L. IVERSON3
1Montreal 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)
Primary objective: To present an innovative approach to the management of children who are slow to recover after a sport-
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
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
athletes recover quickly from concussions, with
organizations , professional associations [10, 14]
some recovering in 1–2 days and most recovering
and research groups  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 
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: email@example.com
ISSN 0269–9052 print/ISSN 1362–301X online ß 2009 Informa Healthcare Ltd.
Rehabilitation after concussion
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
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
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.
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,
impatience and general overall negativity .
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 . 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
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 . 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 . 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
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
I. Gagnon et al.
Table I. Theoretical rational for the Montreal Children’s
Table II. Criteria for referral to the Montreal Children’s Hospital
Prolonged loss of consciousness (>1 minute) at time of injury
I. Aerobic Activity
Increase brain-derived neurotrophic factor (BDNF)
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
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
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-
patient basis when referred from community part-
III. Visualization of Positive and Successful Activities Related to
Preferred Physical Activity
ners (paediatricians, family doctors, schools and
Reassurance and increased confidence relating to ability to
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
concussion. This form was designed to ensure that
IV. Education and Motivation
Education and reassurance leads to empowerment and
all injury variables useful for diagnostic and prog-
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.
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
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
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
the Province of Quebec, Canada. The MCH
Trauma mandate consists of five different pro-
grammes (Trauma, Neurotrauma, MTBI/Return to
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
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
History, physical, and appropriate
History, physical, and
-Graded rehab (MCH-RAC) until
Physical and cognitive
asymptomatic for 1 week
-Management by team: PT,
psychologist, MD, etc.
Remains symptom free
Asymptomatic for 1 week
Gradual return to sports guidelines
-Return appointment for
Gradual return to sports
-Education and weekly
Discharge from clinic
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) ,
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 .
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 . 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)  and in some cases
where activities are stopped.
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
aiming to review new interventions within the MCH
towards the injury and further normalize their
situation to facilitate recovery. They are also taught
sport-specific visualization and imagery techniques.
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-
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
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
course while in the MCH-RAC until recovery and
4.4 (SD ¼2.6) weeks after a mean of 7.0 (SD¼4.1)
weeks of persistent symptoms. Parents qualitatively
reported high satisfaction with the programme and
the comprehensive nature of the follow-up, empha-
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
slow recovery were seen in the MCH-RAC pro-
discussed their feelings of empowerment in relation
gramme over the covered period. This corresponds
to the active nature of the intervention and the fact
to 11.2% of children and is consistent with the
that ‘. . . finally something was being done for my
reported prevalence of persistent symptoms in the
literature . 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  at initial
He was seen at the beginning of May with
assessment was 30.0 (SD ¼20.8) and decreased to
complaints of persistent headaches since the injury.
6.7 (SD ¼5.7) 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
Main complaint at
in symptoms) (min)
Feeling depressed, fatigue
Feeling depressed, fatigue
Fall on the street
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
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 hÀ1 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 hÀ1. 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  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
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-
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 Sante´ du Que´bec.
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 Sante´ du Que´bec Rehabillitation
in this clientele and allow one to possibly identify
Rehabilitation after concussion
Declaration of interest: The authors report no
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