Concussion in the Pediatric and Adolescent Population: “Different Population, Different Concerns”

A systematic review of neuroimaging findings in children and adolescents with sports-related concussion

BACKGROUND

Sport-related concussion (SRC) generally does not result in structural anomalies revealed through clinical imaging techniques such as MRI and CT. While advanced neuroimaging techniques offer another avenue to investigate the subtle alterations following SRC, the current pediatric literature in this area has yet to be reviewed. The aim of this review is to systematically explore the literature on magnetic resonance spectroscopy (MRS), diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and cortical thickness following SRC in children and adolescents.

METHODS

A systematic Pubmed search using the preferred reporting items for systematic reviews and meta-analysis guidelines was conducted independently for each neuroimaging method. Studies were screened for inclusion based on pre-determined criteria.

RESULTS

A total of 26 studies were included (MRS = 4, DTI = 10, fMRI = 11, cortical thickness = 1). A total of 16 studies were conducted solely with male athletes, while 10 studies recruited an unequal number of male and female athletes.

CONCLUSIONS

While MRI and CT are generally unrevealing, advanced neuroimaging techniques demonstrated neurometabolic, microstructural, and functional alterations following SRC in athletes younger than 19 years of age in the acute, subacute, and chronic phases of recovery. However, more studies are needed to fully understand the impact of SRC on the developing brain in children and adolescents.

Impact of Early Follow-Up Intervention on Parent-Reported Postconcussion Pediatric Symptoms: A Feasibility Study

OBJECTIVES

To investigate the effectiveness and feasibility of early intervention telephone counseling with parents in limiting postconcussion symptoms and impacts on children and youth.

SETTING

Recruitment occurred postdischarge from one pediatric emergency department.

PARTICIPANTS

Sixty-six parents of children aged 5 to 16 years with a diagnosis of a concussion injury.

DESIGN

A pilot, randomized controlled study compared the efficacy of telephone counseling (reviewing symptom management and return to activity with parents at 1 week and 1 month postinjury) with usual care (no formalized follow-up).

MAIN MEASURES

The Post-Concussion Symptom Inventory and the Family Burden of Injury Interview administered with parents by a blinded therapist at 3 months postinjury.

RESULTS

No significant difference between the groups at 3 months postinjury in postconcussion symptoms (P = .67) and family stress (P = .647).

CONCLUSION

The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children.

What do coaches want to know about sports-related concussion? A needs assessment study

PURPOSE

This study aims to identify the concussion-related training and education needs of Gaelic Athletic Association (GAA) coaches in Ireland, as well as the preferred method of concussion education delivery.

METHODS

We used a self-report questionnaire to collect data from a convenience sample of 108 GAA coaches in Ireland. Data were captured on (1) informational needs and desires, (2) preferred methods of delivery, and (3) concussion practices and procedures. Questionnaires were completed electronically from June 3rd-September 29th, 2015.

RESULTS

Coaches indicated that they were most interested in receiving information about the (1) signs and symptoms of concussion, (2) assessment of concussion, and (3) return-to-play guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population. Additionally, only 10% coaches reported that before the start of the season they talked to their athletes about concussion management and safety, and this was more common among coaches who reported being formally educated about concussion.

CONCLUSION

Our findings reveal a disconnect between the concussion education needs and the education that is currently provided to GAA coaches, in terms of content and delivery modality. Our results suggest a need for a multifaceted approach to concussion education, tailored to the needs and learning preferences of the target population.

Office-based concussion evaluation, diagnosis, and management: pediatric

More children and adolescents are participating in competitive sports than ever before, causing an overall increase in sport-related injuries. Concussion is a common injury in the pediatric population and its prevalence has increased with increased visibility and awareness. This chapter will discuss the clinical presentation, evaluation, and management of concussions sustained by pediatric athletes, while addressing the distinctive factors that pertain to this population. Management of concussion should be tailored to patients' symptoms and should focus on an early and gradual return to both cognitive and noncontact low-risk physical activity. A multidisciplinary approach is often helpful in addressing more specific symptoms, which fall into the somatic, cognitive, vestibular, emotional, and sleep domains. A prolonged recovery is defined by symptoms lasting more than 4 weeks. Individualized return-to-play decisions should focus on the safety of the young athlete.

Comparison of Impact Performance between Youth and Varsity Football Helmets

Current youth football helmets, intended for players under the age of 14 years old, are similar in design and are tested under the same standard as varsity football helmets. This study evaluated the impact performance of matched youth and adult varsity football helmets. Eight helmet models were evaluated using an impact pendulum, with a modified National Operating Committee on Standards for Athletic Equipment (NOCSAE) medium sized headform mounted on a Hybrid III 50th percentile neck. Four locations on the helmet shell at three impact velocities were tested for three trials, for a total of 576 impact tests. Linear acceleration, rotational acceleration, and a concussion correlate were recorded for each test and a comparison between the youth and varsity helmets were made. It was found that the age group the helmet is intended for did not have a significant effect on the impact performance of the helmet in either linear acceleration, rotational acceleration, or concussion correlate. These results are likely due to the similarities in helmet design resulting from being tested to the same standard. Although it is unknown how a youth helmet should differ from a varsity helmet, differences in impact exposure, anthropometry, physiology, and injury tolerance are factors to consider. These data serves as a reference point for future youth-specific helmet design and helmet standards.

Football helmet impact standards in relation to on-field impacts

Youth football helmets currently undergo the same impact testing and must satisfy the same criteria as varsity helmets, although youth football players differ from their adult counterparts in anthropometry, physiology, and impact exposure. This study aimed to relate football helmet standards testing to on-field head impact magnitudes for youth and varsity football helmets. Head impact data, filtered to include only impacts to locations in the current National Operating Committee on Standards for Athletic Equipment standard, were collected for 48 collegiate players (ages 18-23 years) and 25 youth players (ages 9-11 years) using helmet-mounted accelerometer arrays. These on-field data were compared to a series of National Operating Committee on Standards for Athletic Equipment standard drop tests with a youth and varsity Riddell Speed helmet. In the on-field data, the adult players had a higher frequency of impact than the youth players, and a significant difference in head acceleration magnitude only existed at the top location (p < 0.001). In the laboratory drop tests, the only significant difference between the youth and varsity helmets was at the 3.46 m/s (61 cm) impact to the front location (p = 0.0421). Drop tests generated head accelerations within the top 10% of measured on-field impacts, at all locations and drop heights, demonstrating that drop tests are representative of the most severe head impacts experienced by youth and adult football players on the field. Current standards have been very effective at eliminating skull fracture and severe brain injury in both populations. This analysis suggests that there is not currently a need for a youth-specific drop test standard. However, there may be such a need if helmet testing standards are updated to address concussion, paired with a better understanding of differences in concussion tolerance between youth and adult populations.

Is temperature an important variable in recovery after mild traumatic brain injury?

With nearly 42 million mild traumatic brain injuries (mTBIs) occurring worldwide every year, understanding the factors that may adversely influence recovery after mTBI is important for developing guidelines in mTBI management. Extensive clinical evidence exists documenting the detrimental effects of elevated temperature levels on recovery after moderate to severe TBI. However, whether elevated temperature alters recovery after mTBI or concussion is an active area of investigation. Individuals engaged in exercise and competitive sports regularly experience body and brain temperature increases to hyperthermic levels and these temperature increases are prolonged in hot and humid ambient environments. Thus, there is a strong potential for hyperthermia to alter recovery after mTBI in a subset of individuals at risk for mTBI. Preclinical mTBI studies have found that elevating brain temperature to 39°C before mTBI significantly increases neuronal death within the cortex and hippocampus and also worsens cognitive deficits. This review summarizes the pathology and behavioral problems of mTBI that are exacerbated by hyperthermia and discusses whether hyperthermia is a variable that should be considered after concussion and mTBI. Finally, underlying pathophysiological mechanisms responsible for hyperthermia-induced altered responses to mTBI and potential gender considerations are discussed.

Post-concussion recovery in children and adolescents: A narrative review

Objectives

To determine if current evidence supports a slower recovery from concussion in children and adolescents when compared to adults, and to assess current management guidelines in view of this evidence.

Design

Narrative review.

Methods

We examined key recent research studies relating to the question “do children take longer to recover from concussion than adults?” Concussion management strategies and a sample of guidelines from different organisations were analysed in view of the current literature.

Results

Recovery has been defined as return to baseline on self-reported concussion symptoms or measures of cognitive deficit. Some studies have compared measures of recovery between children and young adults, and a number of cross-sectional studies have compared groups of children of different ages. The findings varied; however, most studies suggested that children may take longer to recover than adults. Age-related differences have been considered when designing guidelines for the management of concussion.

Conclusions

In view of the differences in time to recovery in children, this review supports the use of more conservative concussion management guidelines in children than in adults.

Sport Concussion Management Using Facebook: A Feasibility Study of an Innovative Adjunct "iCon"

CONTEXT

  Sport concussion is currently the focus of much international attention. Innovative methods to assist athletic trainers in facilitating management after this injury need to be investigated.

OBJECTIVE

  To investigate the feasibility of using a Facebook concussion-management program termed iCon (interactive concussion management) to facilitate the safe return to play (RTP) of young persons after sport concussion.

DESIGN

  Observational study.

SETTING

  Facebook group containing interactive elements, with moderation and support from trained health care professionals.

PATIENTS OR OTHER PARTICIPANTS

  Eleven participants (n = 9 men, n = 2 women; range, 18 to 28 years old) completed the study.

DATA COLLECTION AND ANALYSIS

  The study was conducted over a 3-month period, with participant questionnaires administered preintervention and postintervention. The primary focus was on the qualitative experiences of the participants and the effect of iCon on their RTP. Usage data were also collected.

RESULTS

  At the completion of the study, all participants (100%) stated that they would recommend an intervention such as iCon to others. Their supporting quotes all indicated that iCon has the potential to improve the management of concussion among this cohort. Most participants (n = 9, 82%) stated they were better informed with regard to their RTP due to participating in iCon.

CONCLUSIONS

  This interactive adjunct to traditional concussion management was appreciated among this participant group, which indicates the feasibility of a future, larger study of iCon. Athletic trainers should consider the role that multimedia technologies may play in assisting with the management of sport concussion.

Response of School Districts to the New York State Concussion Awareness and Management Act: Review of Policies and Procedures

BACKGROUND

By 2014, all states implemented concussion laws that schools must translate into daily practice; yet, limited knowledge exists regarding implementation of these laws. We examined the extent to which concussion management policies and procedure (P&P) documents of New York State school districts comply with the State's Concussion Awareness and Management Act (the Act). We also aimed to identify barriers to compliance.

METHODS

Forty-seven school districts provided P&P documents. We examined compliance with the Act and the relationship between compliance and each district's demographics.

RESULTS

Compliance varied across school districts, with higher overall compliance in large city school districts compared to county districts. However, there was low compliance for several critical items. We found no statistically significant relationship between compliance and demographics.

CONCLUSIONS

School districts need to increase compliance with concussion legislation to ensure the adequate implementation necessary for the law to impact health and educational outcomes. The results provide important information to individuals charged with the responsibility of implementation and ultimately reducing the negative outcomes associated with brain injuries in schools.

What Definition Is Used to Describe Second Impact Syndrome in Sports? A Systematic and Critical Review

Concern about what has been termed, "second impact syndrome" (SIS) is a major factor determining return-to-play decisions after concussion. However, definitions of SIS vary. We used Scopus to conduct a systematic review and categorize the definitions used to describe SIS. Of the 91 sources identified, 79 (87%) clearly specified that SIS involved either cerebral edema or death after a concussion when a prior concussion had not resolved. Twelve articles (13%) could be interpreted as merely the events of two consecutive concussions. Among the articles that listed mortality rates, nearly all (33/35, 94%) said the rate of death was "high" (e.g., 50% to 100%). Our review found that most articles define SIS as a syndrome requiring catastrophic brain injury after consecutive concussive episodes. Given that it is unclear how common it is to have a second concussion while not fully recovered from a first concussion, the actual mortality rate of SIS is unknown.

Same Care, Different Populations

The authors conducted a cross-sectional survey of Massachusetts school nurses examining return-to-learn practices for children recovering from concussion in prekindergarten through high school. Regardless of school setting, all students received academic accommodations to support learning during recovery. School nurses perceived less benefit to prolonged cognitive rest (>4 days) for high school students relative to students in elementary school, but provided academic accommodations to them for comparatively longer periods of time (10-14 days vs 6-10 days). In all settings, respondents indicated a need for improved communication among treating physicians, parents, and school personnel, as well as improved education and standardized management tools for younger children and those who sustain non-sport-related injuries. Despite serving children at different developmental stages, school return-to-learn practices are essentially the same in primary and secondary schools, highlighting the need for standardized, developmentally appropriate return-to-learn plans and additional education for the providers and school personnel who implement them.

Head injuries in children's football-results from two prospective cohort studies in four European countries

Head injuries are considered harmful in children. We analyzed head and neck injuries in organized football in 7- to 12-year-old children. Data for this analysis were obtained from a prospective cohort study over two consecutive football seasons in two European countries, and a randomized intervention trial over one season in four European countries. Football exposure and injuries were documented through an online database. Detailed information regarding injury characteristics and medical follow-up was retrieved from coaches, children and parents by phone. Thirty-nine head injuries and one neck injury (5% of all 791 injuries) were documented during 9933 player-seasons (total football exposure 688 045 hours). The incidence was 0.25 [95%CI 0.15, 0.35] head/neck injuries per 1000 match hours (N=23 match injuries) and 0.03 [95%CI 0.02, 0.03] per 1000 training hours. Eleven concussions (27.5%), nine head contusions (22.5%), eight lacerations or abrasions (20%), two nose fractures (2.5%), and two dental injuries (2.5%) occurred. The remaining eight injuries were nose bleeding or other minor injuries. Thirty injuries (75%) resulted from contact with another player, and ten injuries were due to collision with an object, falling or a hit by the ball. Whereas 70% of all head injuries (N=28) were due to frontal impacts, 73% of concussions (N=8) resulted from an impact to the occiput. The incidence and severity of head injuries in children's football are low. Coaches and parents, however, should be sensitized regarding the potential of concussions, particularly after an impact to the occiput.

The Effect of the "Zero Tolerance for Head Contact" Rule Change on the Risk of Concussions in Youth Ice Hockey Players

BACKGROUND

Ice hockey is a popular winter sport in Canada. Concussions account for the greatest proportion of all injuries in youth ice hockey. In 2011, a policy change enforcing "zero tolerance for head contact" was implemented in all leagues in Canada.

PURPOSE

To determine if the risk of game-related concussions and more severe concussions (ie, resulting in >10 days of time loss) and the mechanisms of a concussion differed for Pee Wee class (ages 11-12 years) and Bantam class (ages 13-14 years) players after the 2011 "zero tolerance for head contact" policy change compared with players in similar divisions before the policy change.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The retrospective cohort included Pee Wee (most elite 70%, 2007-2008; n = 891) and Bantam (most elite 30%, 2008-2009; n = 378) players before the rule change and Pee Wee (2011-2012; n = 588) and Bantam (2011-2012; n = 242) players in the same levels of play after the policy change. Suspected concussions were identified by a team designate and referred to a sport medicine physician for diagnosis. Incidence rate ratios (IRRs) were estimated based on multiple Poisson regression analysis, controlling for clustering by team and other important covariates and offset by game-exposure hours. Incidence rates based on the mechanisms of a concussion were estimated based on univariate Poisson regression analysis.

RESULTS

The risk of game-related concussions increased after the head contact rule in Pee Wee (IRR, 1.85; 95% CI, 1.20-2.86) and Bantam (IRR, 2.48; 95% CI, 1.17-5.24) players. The risk of more severe concussions increased after the head contact rule in Pee Wee (IRR, 4.12; 95% CI, 2.00-8.50) and Bantam (IRR, 7.91; 95% CI, 3.13-19.94) players. The rates of concussions due to body checking and direct head contact increased after the rule change.

CONCLUSION

The "zero tolerance for head contact" policy change did not reduce the risk of game-related concussions in Pee Wee or Bantam class ice hockey players. Increased concussion awareness and education after the policy change may have contributed to the increased risk of concussions found after the policy change.

[School re-integration after child brain dislocation : The trauma surgeon's role]

Concussion injury of the brain is still a frequently underestimated injury, which can be associated with long-lasting consequences. Compared to adults, the recovery phase is often prolonged in childhood. Primary treatment consists of symptom-dependent physical and mental activities. Re-integration into daily life is crucial. In childhood, the primary focus is therefore on returning to school. New symptoms, or an increased presence of symptoms must be detected, to avoid prolonged recovery courses. School restrictions have to be minimized. Corresponding concepts are already implemented in North America. Comparable concepts are not established in Germany. In addition to well-known standard return-to-play protocols for sport re-integration, it is urgently recommended to integrate gradual return-to-learn protocols.Thus, academic adaptations and support must be established as well as symptom-oriented organizational and teaching modules.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment.

OBJECTIVE

To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion.

METHODS

On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device.

RESULTS

A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%.

CONCLUSION

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

ABBREVIATIONS

ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Physical Rehabilitation Interventions for Post-mTBI Symptoms Lasting Greater Than 2 Weeks: Systematic Review

BACKGROUND

Heightened awareness of the lasting effects of mild traumatic brain injury (mTBI) has amplified interest in interventions that facilitate recovery from persistent post-mTBI symptoms.

PURPOSE

The purpose of this study was to systematically review the literature to identify potential physical rehabilitation interventions that are safe, feasible, and appropriate for physical therapists to utilize with patients with persistent mTBI-related symptoms.

DATA SOURCES

The electronic databases PubMed, Cochrane Library, CINAHL, Scopus, SPORTDiscus, and Web of Science were systematically searched from database inception until June 2015.

STUDY SELECTION

Studies were included if they utilized physical rehabilitation interventions and the study's participants had a diagnosis of mTBI, a mean age of 8 years or older, and symptoms persisting an average of 2 weeks or longer. Exclusion criteria included blast injuries, diagnosis of moderate or severe TBI, or psychosis.

DATA EXTRACTION

Data extraction and methodological risk of bias assessments were performed for each study.

DATA SYNTHESIS

Eight studies with a range of study designs, intervention types, and outcome measures were included. The interventions investigated by the included studies were categorized into 3 types: physiological, vestibulo-ocular, and cervicogenic.

LIMITATIONS

The identified studies had several significant limitations including: small sample sizes and low-level study designs.

CONCLUSIONS

The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions. Conclusions surrounding efficacy and ideal dosing parameters for these interventions are limited at this time due to the small number of studies, the range of interventional protocols, and lower levels of study design.

Management of Sport-Related Concussion in the Pediatric and Adolescent Population

Concussions make up nearly 10% of all high school athletic injuries. Recent changes in concussion management guidelines and legislation aim to make concussion care more standardized and safe but simultaneously pose a challenge for the primary care and sports medicine physician. Pediatric and adolescent concussions may cause anxiety for the treating physician due to concerns over return-to-play decisions, academic issues, and the potential for second impact syndrome. Determining when to refer a patient to an emergency department acutely, to an outpatient concussion clinic, or to other subspecialists may be a difficult decision for the primary care physician. The aim of this article is to review current evidence regarding concussion treatment and return-to-school and return-to-play recommendations to provide the primary care and sports medicine physician with practical guidelines for managing concussions.

Prolonged cognitive-motor impairments in children and adolescents with a history of concussion

Aim:

We investigated whether children and adolescents with concussion history show cognitive–motor integration (CMI) deficits.

Method:

Asymptomatic children and adolescents with concussion history (n = 50; mean 12.84 years) and no history (n = 49; mean: 11.63 years) slid a cursor to targets using their finger on a dual-touch-screen laptop; target location and motor action were not aligned in the CMI task.

Results:

Children and adolescents with concussion history showed prolonged CMI deficits, in that their performance did not match that of no history controls until nearly 2 years postevent.

Conclusion:

These CMI deficits may be due to disruptions in fronto-parietal networks, contributing to an increased vulnerability to further injury. Current return-to-play assessments that do not test CMI may not fully capture functional abilities postconcussion.

An evaluation of Gaelic Athletic Association (GAA) athletes' self-reported practice of playing while concussed, knowledge about and attitudes towards sports-related concussion

BACKGROUND/AIM

Sports-related concussions are now recognized as a major public health concern. However, despite the association of concussion with short- and long-term health consequences, many young athletes still lack basic knowledge about concussion and seem to believe that concussions may be "toughed out" and do not require medical attention. This study assessed self-reported practice of playing in training or a match while concussed among Gaelic Athletic Association (GAA) athletes in Ireland aged 13-25 years old (M=19.19, SD=3.54). This study also assessed knowledge about and attitudes towards sports-related concussion in GAA players in Ireland.

METHODS

Using a self-report questionnaire, data were captured electronically on GAA athletes aged 13-25 years old (n=80) regarding knowledge about the detection, assessment and management of sports-related concussion, as well as participant's attitudes towards concussion and self-reported practice of playing in training or a match while concussed. Data were collected from June to August 2013.

RESULTS

This study revealed that approximately one in four athletes reported having played while concussed in practice or during a match. Males were significantly more likely to play while concussed than females (40.9% and 17.2%, respectively). Results from this study indicated participants lack a complete understanding of concussion, as common misconceptions about concussion prevailed. Analyses revealed that participants generally have safe attitudes towards concussion and concussion management.

CONCLUSION

Generating awareness of the potential short- and long-term health consequences of concussion, coupled with the promotion of safer attitudes towards this injury, could minimize the number of players who return-to-play pre-maturely and promote a more safety-conscious sports culture in Ireland.

Challenges in Determining the Role of Rest and Exercise in the Management of Mild Traumatic Brain Injury

Current consensus guidelines recommending physical and cognitive rest until a patient is asymptomatic after a sports concussion (ie, a mild traumatic brain injury) are being called into question, particularly for patients who are slower to recover and in light of preclinical and clinical research demonstrating that exercise aids neurorehabilitation. The pathophysiological response to mild traumatic brain injury includes a complex neurometabolic cascade of events resulting in a neurologic energy deficit. It has been proposed that this energy deficit leads to a period of vulnerability during which the brain is at risk for additional injury, explains why early postconcussive symptoms are exacerbated by cognitive and physical exertion, and is used to rationalize absolute rest until all symptoms have resolved. However, at some point, rest might no longer be beneficial and exercise might need to be introduced. At both extremes, excessive exertion and prolonged avoidance of exercise (physical and mental) have negative consequences. Individuals who have experienced a concussion need guidance for avoidance of triggers of severe symptoms and a plan for graduated exercise to promote recovery as well as optimal functioning (physical, educational, and social) during the postconcussion period.

Brain Network Activation as a Novel Biomarker for the Return-to-Play Pathway Following Sport-Related Brain Injury

Children and adolescent athletes are at a higher risk for concussion than adults, and also experience longer recovery times and increased associated symptoms. It has also recently been demonstrated that multiple, seemingly mild concussions may result in exacerbated and prolonged neurological deficits. Objective assessments and return-to-play criteria are needed to reduce risk and morbidity associated with concussive events in these populations. Recent research has pushed to study the use of electroencephalography as an objective measure of brain injury. In the present case study, we present a novel approach that examines event-related potentials via a brain network activation (BNA) analysis as a biomarker of concussion and recovery. Specifically, changes in BNA scores, as indexed through this approach, offer a potential indicator of neurological health as the BNA assessment qualitatively and quantitatively indexes the network dynamics associated with brain injury. Objective tools, such as these support accurate and efficient assessment of brain injury and may offer a useful step in categorizing the temporal and spatial changes in brain activity following concussive blows, as well as the functional connectivity of brain networks, associated with concussion.

Impact of preseason concussion education on knowledge, attitudes, and behaviors of high school athletes

BACKGROUND

The benefit of preseason concussion education on athletes' knowledge, attitudes, and behaviors is unclear. The purpose of the study was to determine the influence of preseason concussion education on knowledge and self-reported attitudes and reporting behaviors. We hypothesized that preseason education would lead to better knowledge and self-reported attitudes and better reporting of concussion symptoms during the season.

METHODS

This study involved a prospective cohort comparing the benefits of a preseason lectured-based concussion education session at one high school with a control school. Participants included males and females age 13 years to 18 years from two community high schools who were participating in higher concussion risk, fall or winter sports (football, soccer, wrestling, and basketball). The education school and control school included 234 and 262 participants, respectively. Outcomes were a preseason and postseason survey assessing knowledge and self-reported attitudes about concussions and an end-of-season questionnaire assessing concussion reporting behaviors during the season.

RESULTS

Total scores on the combined (p < 0.0001), knowledge-based (p = 0.016), and behavioral-based (p < 0.0001) questions demonstrated statistically significant improvement in the education group. Scores peaked immediately after education but dissipated at the end of the season. There was a lower proportion in the education school (72%) compared with the control school (88%) that reported continued play despite having concussion symptoms during the season (p = 0.025). A similar proportion of athletes diagnosed with concussion during the season in the education (27%) and control schools (23%) reported returning to play before symptoms resolved (p = 0.81).

CONCLUSION

These findings suggest that a didactic-based preseason concussion education likely has minimal benefits. Other factors besides knowledge are likely influencing student-athlete concussion reporting behavior. Future research focused on changing the culture of concussion reporting is needed.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Qualitative Examination of Adolescent Health-Related Quality of Life at 1 Year Postconcussion

CONTEXT

Moderate to severe traumatic brain injuries can negatively influence health-related quality of life (HRQOL) in adolescent patients. The effect of sport-related concussion on adolescent HRQOL remains unclear.

OBJECTIVE

To investigate the perceptions of adolescent student-athletes and their parents regarding the adolescents' HRQOL 1 year after sport-related concussion.

DESIGN

Qualitative study.

SETTING

Secondary school.

PATIENTS OR OTHER PARTICIPANTS

Seven adolescent student-athletes (age range, 12-16 years) who sustained a sport-related concussion at least 1 year (15.3 ± 2.8 months) before the study participated along with their primary care-giving parents (n = 7).

DATA COLLECTION AND ANALYSIS

Fourteen semistructured face-to-face interviews (7 adolescents, 7 parents) were completed. Interviews were transcribed and inductively analyzed by a team of 3 athletic trainers with 32 combined years of professional experience. Themes were negotiated through a consensual review process. Participant checks were completed to ensure trustworthiness of the results.

RESULTS

Four major themes emerged from the interviews: (1) significant effect of symptoms, (2) feelings of frustration, (3) influence on school attendance and activities, and (4) nature of interpersonal and team relationships. Participants indicated that the physical symptoms of the concussion substantially affected their emotional and academic function. The influence of the concussion on social interactions seemed to depend on the nature of interpersonal relationships.

CONCLUSIONS

Sport-related concussion can negatively influence physical and emotional function, academics, and interpersonal interactions as perceived by adolescent student-athletes and their parents. Education of parents and their children, school professionals, coaches, and teammates remains critical to effectively recognize and manage sport-related concussion. Secondary school districts also play a critical role in the concussion-management process by establishing and implementing accommodation policies that alleviate student concerns about falling behind while ensuring a healthy return to normal school routines. Furthermore, adolescent support systems must be considered throughout the recovery process.

Cognitive-motor integration deficits in young adult athletes following concussion

BACKGROUND

The ability to perform visually-guided motor tasks requires the transformation of visual information into programmed motor outputs. When the guiding visual information does not align spatially with the motor output, the brain processes rules to integrate the information for an appropriate motor response. Here, we look at how performance on such tasks is affected in young adult athletes with concussion history.

METHODS

Participants displaced a cursor from a central to peripheral targets on a vertical display by sliding their finger along a touch sensitive screen in one of two spatial planes. The addition of a memory component, along with variations in cursor feedback increased task complexity across conditions.

RESULTS

Significant main effects between participants with concussion history and healthy controls without concussion history were observed in timing and accuracy measures. Importantly, the deficits were distinctly more pronounced for participants with concussion history compared to healthy controls, especially when the brain had to control movements having two levels of decoupling between vision and action. A discriminant analysis correctly classified athletes with a history of concussion based on task performance with an accuracy of 94 %, despite the majority of these athletes being rated asymptomatic by current standards.

CONCLUSIONS

These findings correspond to our previous work with adults at risk of developing dementia, and support the use of cognitive motor integration as an enhanced assessment tool for those who may have mild brain dysfunction. Such a task may provide a more sensitive metric of performance relevant to daily function than what is currently in use, to assist in return to play/work/learn decisions.

Test-retest reliability of KINARM robot sensorimotor and cognitive assessment: in pediatric ice hockey players

BACKGROUND

Better diagnostic and prognostic tools are needed to address issues related to early diagnosis and management of concussion across the continuum of aging but particularly in children and adolescents. The purpose of the current study was to evaluate the reliability of robotic technology (KINARM robot) assessments of reaching, position sense, bimanual motor function, visuospatial skills, attention and decision making in youth ice hockey players (ages 10-14).

METHODS

Thirty-four male children attended two testing days, one week apart. On day one, each subject completed five tasks on the robot with two examiners (alternating examiner sequence); the 2(nd) examiner followed the same procedure as the 1(st) immediately afterwards. One consistent examiner tested subjects one week later. This is a test-retest reliability study. The robotic tasks characterize sensorimotor and/or cognitive performance; 63 parameters from 5 tasks are reported. Session 1 was the 1(st) time the subject performed the 5 tasks, session 2 the 2(nd) time on day 1, and session 3 one week following.

RESULTS

Intra-class correlation coefficients ranged from 0.06 to 0.91 and 0.09 to 0.90 for session 1 to 2 and 2 to 3, respectively. Bland-Altman plots showed agreement in a majority of the parameters and a learning effect in 25 % and 24 % of parameters in session 1 vs 2 and 1 vs 3, respectively but none for session 2 vs 3. Of those that showed a learning effect, only 8 % of parameters in session 1 vs 2 and 10 % in session 1 vs 3 had a clinical relevance measure ≥ 0.8.

CONCLUSIONS

The relative homogeneity of the sample and the effect of learning seen in some of the task parameters appears to have negatively impacted the intra-class correlation coefficients from session 1 to 2, with less impact for 2 to 3. The Bland-Altman analysis supports good absolute reliability in healthy male children with no neurological impairment ranging in age from 10 to 14. The clinically relevant learning effect seen, in a small number of parameters could be addressed by creating a learning effect adjustment factor and/or implementing a practice session, which would eliminate the learning effect.

A Balanced Protocol for Return to School for Children and Youth Following Concussive Injury

BACKGROUND

Few protocols exist for returning children/youth to school after concussion. Childhood concussion can significantly affect school performance, which is vital to social development, academic learning, and preparation for future roles. The goal of this knowledge translation research was to develop evidence based materials to inform physicians about pediatric concussion.

METHODS

The Return to School (RTS) concussion protocol was developed following the National Institute for Health and Care Excellence procedures.

RESULTS

Based on a scoping review, and stakeholder opinions, an RTS protocol was developed for children/youth. This unique protocol focuses on school adaptation in 4 main areas: (a) timetable/attendance, (b) curriculum, (c) environmental modifications, and (d) activity modifications.

CONCLUSION

A balance of cognitive rest and timely return to school need to be considered for returning any student to school after a concussion. Implementation of these new recommendations may be an important tool in prevention of prolonged absence from school and academic failure while supporting brain recovery.

Repetitive head trauma, chronic traumatic encephalopathy and tau: Challenges in translating from mice to men

Chronic traumatic encephalopathy (CTE) is a neurological and psychiatric condition marked by preferential perivascular foci of neurofibrillary and glial tangles (composed of hyperphosphorylated-tau proteins) in the depths of the sulci. Recent retrospective case series published over the last decade on athletes and military personnel have added considerably to our clinical and histopathological knowledge of CTE. This has marked a vital turning point in the traumatic brain injury (TBI) field, raising public awareness of the potential long-term effects of mild and moderate repetitive TBI, which has been recognized as one of the major risk factors associated with CTE. Although these human studies have been informative, their retrospective design carries certain inherent limitations that should be cautiously interpreted. In particular, the current overriding issue in the CTE literature remains confusing in regard to appropriate definitions of terminology, variability in individual pathologies and the potential case selection bias in autopsy based studies. There are currently no epidemiological or prospective studies on CTE. Controlled preclinical studies in animals therefore provide an alternative means for specifically interrogating aspects of CTE pathogenesis. In this article, we review the current literature and discuss difficulties and challenges of developing in-vivo TBI experimental paradigms to explore the link between repetitive head trauma and tau-dependent changes. We provide our current opinion list of recommended features to consider for successfully modeling CTE in animals to better understand the pathobiology and develop therapeutics and diagnostics, and critical factors, which might influence outcome. We finally discuss the possible directions of future experimental research in the repetitive TBI/CTE field.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions

Background:

Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.

Hypothesis:

This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 5.

Methods:

Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.

Results:

Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.

Conclusion:

Parents with low income and education levels may benefit from additional concussion-related education.

Clinical Relevance:

There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

Repetitive concussions in adolescent athletes - translating clinical and experimental research into perspectives on rehabilitation strategies

Sports-related concussions are particularly common during adolescence, a time when even mild brain injuries may disrupt ongoing brain maturation and result in long-term complications. A recent focus on the consequences of repetitive concussions among professional athletes has prompted the development of several new experimental models in rodents, as well as the revision of guidelines for best management of sports concussions. Here, we consider the utility of rodent models to understand the functional consequences and pathobiology of concussions in the developing brain, identifying the unique behavioral and pathological signatures of concussive brain injuries. The impact of repetitive concussions on behavioral consequences and injury progression is also addressed. In particular, we focus on the epidemiological, clinical, and experimental evidence underlying current recommendations for physical and cognitive rest after concussion, and highlight key areas in which further research is needed. Lastly, we consider how best to promote recovery after injury, recognizing that optimally timed, activity-based rehabilitative strategies may hold promise for the adolescent athlete who has sustained single or repetitive concussions. The purpose of this review is to inform the clinical research community as it strives to develop and optimize evidence-based guidelines for the concussed adolescent, in terms of both acute and long-term management.

Concussion symptoms in youth motocross riders: a prospective, observational study

OBJECT

Action motorsports, including motocross, have been gaining popularity among children and adolescents, raising concerns for increased risk of concussions in participating youth. The authors undertook this study to test the following hypotheses: 1) that there is a high rate of concussion symptoms associated with a number of preventable or adjustable risk factors, and 2) that a high percentage of these symptoms are not be reported to adults and medical personnel.

METHODS

The authors identified all motocross riders under the age of 18 at a regional racetrack during the riding season between May and October 2010. The participants completed questionnaires pertaining to demographic characteristics and variables associated with motocross. The questionnaire results were compared with the incidence of self-reported concussion symptoms.

RESULTS

Two hundred two riders were identified who met the criteria for participation in the study, and 139 of them completed the study questionnaire. Of these 139 riders, 67 (48%) reported at least 1 concussion symptom during the season. The majority of riders (98%) reported "always" wearing a helmet, and 72% received professional help with fitting of their helmets. Proper helmet fitting was associated with a 41% decreased risk of concussion symptoms (RR 0.59, 95% CI 0.44-0.81, p < 0.01). Sixty-six riders (47%) reported having received sponsor support for motocross participation. Sponsor support conferred a relative risk for concussion symptoms of 1.48 (95% CI 1.05-2.08, p = 0.02).

CONCLUSIONS

Nearly half of all motocross competitors under the age of 18 reported concussion symptoms. Preventive measures are necessary to limit the negative impact from concussions. The risk of concussive injury can be decreased for pediatric motocross riders if they receive professional help with proper helmet fitting and through implementation of stricter guidelines regarding sponsorship.

Development of a conservative protocol to return children and youth to activity following concussive injury

BACKGROUND

Consensus-based guidelines exist for adult athletes returning to play after concussion, but there are no protocols developed specifically for children. The goal of this knowledge translation research was to develop evidence-based materials to inform physicians about pediatric concussion.

METHODS

A pediatric concussion protocol was developed based on the National Institute for Health and Care Excellence procedures.

RESULTS

This return to activity protocol was developed to guide management when children/youth sustain a concussion. The protocol incorporated 3 main themes: (a) a protocol must include return to all activity, including sport and school; (b) existing consensus-based adult protocols are not appropriate for children; and (c) a more conservative protocol is needed. After pilot testing, the developed protocol is being used across Ontario.

CONCLUSION

Implementation of these new pediatric recommendations is an important addition to prevention of subsequent concussions during vulnerable recovery periods, with potential to facilitate recovery by preventing prolonged symptomatology, and secondary sequelae.

Postconcussion Postural Sway Variability Changes in Youth: The Benefit of Structural Variability Analyses

PURPOSE

The purpose of this study was to evaluate the utility of postural sway variability as a potential assessment to detect altered postural sway in youth with symptoms related to a concussion.

METHODS

Forty participants (20 who were healthy and 20 who were injured) aged 10 to 16 years were assessed using the Balance Error Scoring System (BESS) and postural sway variability analyses applied to center-of-pressure data captured using a force plate.

RESULTS

Significant differences were observed between the 2 groups for postural sway variability metrics but not for the BESS. Specifically, path length was shorter and Sample and Renyi Entropies were more regular for the participants who were injured compared with the participants who were healthy (P < .05).

CONCLUSION

The results of this study indicate that postural sway variability may be a more valid measure than the BESS to detect postconcussion alterations in postural control in young athletes.

Concussion knowledge in high school football players

CONTEXT

Participating in sports while experiencing symptoms of a concussion can be dangerous. An athlete's lack of knowledge may be one factor influencing his or her decision to report symptoms. In an effort to enhance concussion education among high school athletes, legislation in Florida has attempted to address the issue through parental consent forms.

OBJECTIVE

To survey high school varsity football players to determine their level of knowledge about concussions after the initiation of new concussion-education legislation.

DESIGN

Cross-sectional study.

SETTING

Descriptive survey administered in person during a team meeting.

PATIENTS OR OTHER PARTICIPANTS

A total of 334 varsity football players from 11 high schools in Florida.

MAIN OUTCOME MEASURE(S)

Participants completed a survey and identified the symptoms and consequences of a concussion among distractors. They also indicated whether they had received education about concussions from a parent, formal education, neither, or both.

RESULTS

The most correctly identified symptoms were headache (97%), dizziness (93%), and confusion (90%), and the most correctly identified consequence was persistent headache (93%). Participants reported receiving education from their parents (54%) or from a formal source (60%). Twenty-five percent reported never receiving any education regarding concussions. No correlations were found between the method of education and the knowledge of symptoms or consequences of concussion.

CONCLUSIONS

The high school football players we surveyed did not have appropriate knowledge of the symptoms and consequences of concussions. Nausea or vomiting, neck pain, grogginess, difficulty concentrating, and personality or behavioral changes were often missed by participants, and only a small proportion correctly identified brain hemorrhage, coma, and death as possible consequences of inappropriate care after a concussion. Even with parents or guardians signing a consent form indicating they discussed concussion awareness with their child, 46% of athletes suggested they had not.

Post-concussion return to play and return to school guidelines for children and youth: a scoping methodology

PURPOSE

The objective of this study was to identify and describe management strategies to ensure safe return to activity (RTA) and return to school (RTS) of children with mild traumatic brain injury (MTBI) and determine whether they are evidence-based.

METHODS

A scoping methodology was conducted using research published between 1990 and 2013, gray literature and clinical expertise. Once the data had been charted, an expert panel of physicians and clinicians was consulted to inform and validate study findings. An analytical and thematic framework was used to examine the study findings.

RESULTS

A total of 400 potentially relevant published articles, 100 websites and 24 iPad Applications were found. Ten articles and three web-based resources met inclusion criteria and were included in the final review. Nine articles recommended a more conservative approach to RTA, as well as identified a step-wise or severity-oriented approach. General recommendations were also found regarding safe RTS. One study recommended a stepwise RTS protocol for children.

CONCLUSIONS

This scoping methodology determined that the most comprehensive guidelines for management are focused on adults. Evidence concerning prolonged recovery patterns in children and the impact of concussion on the developing brain suggests that pediatric-specific guidelines are needed for RTA and RTS after MTBI/concussion.

IMPLICATIONS FOR REHABILITATION

Although concussion in children is an increasing concern, it has been determined that the most comprehensive guidelines for management are focused on adults. These guidelines are primarily consensus-based and are not proven fact through quality research. Evidence concerning prolonged recovery patterns in youth and the impact of concussion on the developing brain suggest that pediatric guidelines should be more conservative than for adults. Therefore, pediatric-specific guidelines need to be developed for return to activity and return to school after MTBI/concussion.

An epidemiologic profile of pediatric concussions: identifying urban and rural differences

BACKGROUND

The objective of this study was to describe the epidemiology of concussions presenting to the emergency department (ED).

METHODS

A retrospective cohort of concussions for pediatric (age < 18 years) patients treated in the ED of a regional pediatric Level 1 trauma center from 2006 to 2011 was examined. Descriptive and geographic analyses were completed, with comparisons by age groups and residence (urban/rural).

RESULTS

There were a total of 2,112 treated pediatric concussions. Two thirds of the concussions occurred in males (67%), with a median age of 13 years (interquartile range [IQR], 6). Nearly half of the pediatric concussions were sports related (48%); 36% of these concussions were from hockey. Significant differences were found in the distribution of the mechanism of injury across age groups (p < 0.001). Falls were most prevalent among young children, and sports concussions, for children 10 years and older. Two fifths of concussions occurred during winter months. Discharge disposition significantly differed by age (p < 0.001), with home discharge increasing with age up to 14 years. There were a total of 387 rural (19%) and 1,687 urban (81%) concussed patients, for a mean ED concussion visit rate of 2.2 per 1,000 and 3.5 per 1,000, respectively. Rural patients were older (14 [IQR, 6] vs. 13 [IQR, 6], p = 0.019] and sustained 2.5 times more concussions from a motor vehicle crash compared with urban youth patients (p < 0.001).

CONCLUSION

Males in early adolescence are at highest risk for concussion, particularly from sport-related activities. Urban and rural children have differences in their etiology and severity of concussions. Concussions are predictable, and their prevention should be targeted based on epidemiologic and environmental data.

LEVEL OF EVIDENCE

Epidemiologic, study, level III.

Combining whole-brain voxel-wise analysis with in vivo tractography of diffusion behavior after sports-related concussion in adolescents: a preliminary report

We have previously shown that sports-related concussion in adolescents is associated with changes in whole-brain properties of white-matter pathways. Here, we assess local changes within these pathways. Twelve adolescents with a clinical diagnosis of subacute concussion and 10 healthy adolescents matched for age, gender, and physical activity completed magnetic resonance imaging scanning. Voxel-wise tract-based spatial statistics and tractography were performed to assess local changes in diffusion-based measures of microstructural properties of white-matter pathways (fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity) between the two groups. Fractional anisotropy values were higher for the concussed group in multiple cluster regions using tract-based spatial statistics, primarily in frontal white-matter regions, including the anterior corona radiata bilaterally. Using these regions of altered diffusion characteristics to seed fiber tractography, significantly reduced axial diffusivity in tracts passing through these areas were detected in the concussed group (p=0.04). A trend toward reduced mean and radial diffusivity in the concussed group was also observed within the same reconstructed tracts. Diffusion behavior within these tracts was significantly correlated with an assessment of concussion status (Sports Concussion Assessment Tool 2). Fractional anisotropy within the reconstructed tracts was not significantly different between the two groups. These results suggest that subacute concussion in adolescents is associated with altered diffusion properties within regional white-matter tissue and along reconstructed fiber pathways. Combining voxel-wise analysis with fiber tractography provides an alternative objective approach to evaluate and identify subtle changes in white-matter fiber integrity after concussion.

Cognitive rest and school-based recommendations following pediatric concussion: the need for primary care support tools

OBJECTIVES

(1) Assess pediatric primary care providers' understanding of cognitive rest for concussion and (2) describe their concussion management practices.

METHODS

This study included (1) a survey of general pediatric providers and (2) an electronic medical record (EMR) review of children 5 to 18 years old treated for concussion from September 1, 2010, to May 31, 2011. The survey asked about treatment recommendations for concussion, and results were coded to identify cognitive rest recommendations. The EMR review included the following: injury details, medical evaluation, and recommendations for resuming school and sports/recreation.

RESULTS

In all, 89 of 201 providers responded to the survey, and 52 of the 84 clinicians who included comments about concussion management mentioned cognitive rest (62%, 95% confidence interval [CI] = 51%-72%). Of the 91 EMRs reviewed for patients' first visits following the concussion, only 10 (11%, 95% CI = 6%-19%) included written cognitive rest recommendations.

CONCLUSIONS

Although the majority of pediatric providers identified cognitive rest as important in pediatric concussion management, few provided written recommendations in the EMR.

Sex-specific differences in the severity of symptoms and recovery rate following sports-related concussion in young athletes

INTRODUCTION

While research on adult recovery from concussion indicates sex-specific symptoms and recovery rates, there is little existing data on younger patient populations.

OBJECTIVE

To determine sex-specific differences in the severity of presenting symptoms and recovery rate between groups of young athletes who presented ≤ 7 or > 7 days after sports-related concussion.

METHODS

This study was a retrospective review of athletes aged 9 to 17 years who were referred for evaluation of a sports-related concussion over a 24-month period. The study groups were divided by sex and post-injury presentation to the clinic at ≤ 7 days and > 7 days from the date of injury. Athletes with learning disabilities were excluded from the study and data analysis. Age, height, and weight were recorded for each subject. Each subject also reported their initial degree of confusion, amnesia, or loss of consciousness, and whether a helmet was worn when the injury was sustained. A 22-item post-concussion symptom score (SS) scale was completed by both groups on initial assessment (SS1) and follow-up visit (SS2). The recovery rate (SSR) was calculated as (SS2-SS1)/days between SS2 and SS1. Sex and group comparisons for SS1 and SSR were performed using 2 × 2 analysis of variance. A similar analysis was also performed for effects of sex on SS1 and SSR in patients who were not wearing a helmet.

RESULTS

Thirty-seven athletes aged 15.0 ± 1.9 years were evaluated. Males, regardless of day of presentation, had a lower SS1 evaluation than females (15.8 vs 30.9; P < 0.05). Males without helmets did not differ from females without helmets, but this was not significantly different (14.1 vs 29.6; P = 0.1). There was not a significant difference in SS1 evaluation between the groups who presented at ≤ 7 or > 7 days. The overall mean SSR was -1.2/day, with no significant difference seen between groups or sex. There were no significant differences in degree of loss of consciousness, amnesia, confusion, or age between the sexes or groups.

CONCLUSION

Whether presenting at ≤ 7 or > 7 days following a sports-related concussion, female athletes reported a higher SS1 evaluation. With SSR being similar between sexes, the current data suggest that young, female athletes may take longer to become symptom free following sports-related concussion. This information may be an important factor in returning a young athlete to sport after sports-related concussion.

Pediatric providers' self-reported knowledge, practices, and attitudes about concussion

OBJECTIVE

To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network.

METHODS

A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried.

RESULTS

There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%-95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 "not a barrier" to 5 "significant barrier" was used to assess providers' barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%-23%), inadequate time to educate 15% (95% CI: 12%-24%), and not my role to educate 1% (95% CI: 0.4%-5%). Ninety-six percent (95% CI: 91%-98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%-100%) of providers without discharge instructions specific to concussion believed these resources would be helpful.

CONCLUSIONS

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.