Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms

Longitudinal Assessment of Health-Related Quality of Life following Adolescent Sports-Related Concussion

To examine initial and longitudinal health-related quality of life (HRQOL) in adolescent sports-related concussion (SRC) patients, a prospective observational case-series study was conducted among adolescent SRC patients who were evaluated at a multi-disciplinary pediatric concussion program. Health-related quality of life was measured using the child self-report Pediatric Quality of Life Inventory (PedsQL) generic score scale (age 13-18 version) and the PedsQL Cognitive Functioning scale. Initial and longitudinal HRQOL outcomes were compared between patients who did and did not develop post-concussion syndrome (PCS). A total of 63 patients met the inclusion criteria during the study period. The mean age of the cohort was 14.57 years (standard deviation, 1.17) and 61.9% were male. The median time from injury to initial consultation was 6.5 days (interquartile range, 5, 11). At initial consultation, impairments in physical and cognitive HRQOL but not social or emotional HRQOL were observed. Initial symptom burden and length of recovery were associated with greater impairment in physical and cognitive HRQOL. Patients who went on to develop PCS had significantly worse physical and cognitive HRQOL at initial consultation and demonstrated a slower rate of recovery in these domains, compared with those who recovered in less than 30 days. Adolescent SRC was associated with HRQOL impairments that correlated with clinical outcomes. No persistent impairments in HRQOL were detected among patients who achieved physician-documented clinical recovery. Future studies are needed to evaluate the clinical utility of HRQOL measurement in the longitudinal management of adolescent SRC and PCS patients.

Cerebral Perfusion Changes in Post-Concussion Syndrome: A Prospective Controlled Cohort Study

The biology of post-concussive symptoms is unclear. Symptoms are often increased during activities, and have been linked to decreased cerebrovascular reactivity and perfusion. The aim of this study was to examine cerebral blood flow (CBF) in children with different clinical recovery patterns following mild traumatic brain injury (mTBI). This was a prospective controlled cohort study of children with mTBI (ages 8 to 18 years) who were symptomatic with post-concussive symptoms at one month post-injury (symptomatic, n = 27) and children who had recovered quickly (asymptomatic, n = 24). Pseudo continuous arterial spin labeling magnetic resonance imaging (MRI) was used to quantify CBF. The mTBI groups were imaged at 40 days post-injury. Global and regional CBF were compared with healthy controls of similar age and sex but without a history of mTBI (n = 21). Seventy-two participants (mean age: 14.1 years) underwent neuroimaging. Significant differences in CBF were found: global CBF was higher in the symptomatic group and lower in the asymptomatic group compared with controls, (F(2,69) 9.734; p < 0.001). Post-injury symptom score could be predicted by pre-injury symptoms and CBF in presence of mTBI (adjusted R2 = 0.424; p < 0.001). Altered patterns of cerebral perfusion are seen following mTBI and are associated with the recovery trajectory. Symptomatic children have higher CBF. Children who "recovered" quickly, have decreased CBF suggesting that clinical recovery precedes the cerebral recovery. Further longitudinal studies are required to determine if these perfusion patterns continue to change over time.

Health-Related Quality of Life after Pediatric Mild Traumatic Brain Injury/Concussion: A Systematic Review

Health-related quality of life (HRQOL) is an emerging method to quantify the consequences of pediatric mild traumatic brain injury (mTBI)/concussion in both clinical practice and research. However, to utilize HRQOL measurements to their full potential in the context of mTBI/concussion recovery, a better understanding of the typical course of HRQOL after these injuries is needed. The objective of this study was to summarize current knowledge on HRQOL after pediatric mTBI/concussion and identify areas in need of further research. The following databases from their earliest date of coverage through June 1, 2015 were used: MEDLINE(®), PubMed, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTDiscus, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Child Development and Adolescent Studies (CDAS). Studies must have examined and reported HRQOL in a pediatric population after mTBI/concussion, using a validated HRQOL measurement tool. Eight of 1660 records identified ultimately met inclusion criteria. Comprehensive data were extracted and checked by a second reviewer for accuracy and completeness. There appears to be a small but important subgroup of patients who experience poor HRQOL outcomes up to a year or longer post-injury. Potential predictors of poor HRQOL include older age, lower socioeconomic status, or a history of headaches or trouble sleeping. Differing definitions of mTBI precluded meta-analysis. HRQOL represents an important outcome measure in mTBI/concussion clinical practice and research. The evidence shows that a small but important proportion of patients have diminished HRQOL up to a year or longer post-injury. Further study on this topic is warranted to determine the typical longitudinal progression of HRQOL after pediatric concussion.

Diagnosis and management of paediatric concussion

Heightened recognition of concussions and concerns about their sequelae in children has become an increasing community and public health concern. Biomarkers and clinical tests are being explored, but the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. While the majority of children go on to recover from post-concussive symptoms within 2 weeks, it is unclear which patients with concussion will go on to develop short- or long-term sequelae. A number of more or less evidence-based guidelines have become available which seek to guide clinicians on how to manage children post-concussion. In general, care after the emergency department is focused on reducing the risk of re-injury and rest until cerebral recovery with a graduated return to school and then play.

Health-related quality of life in children and youth with acquired brain injury: Two years after injury

OBJECTIVE

To determine health-related quality of life (HRQoL) in children and youth with acquired brain injury (ABI) two years post-injury and explore associated factors.

DESIGN

Cross-sectional.

SUBJECTS

Children and youth (n = 72; aged 6-22 years) with mild to severe ABI (87% mild).

METHODS

The primary outcome measures self-reported and parent-reported HRQoL were assessed with the Paediatric Quality of Life Inventory (PedsQL) and compared with age-appropriate reference values of the Dutch population. Spearman correlation coefficients (Rs) were used to explore relationships between HRQoL and sociodemographic and ABI characteristics, severity of impairments and presence of post-injury problems.

RESULTS

Children and youth with ABI and the reference population had similar self-reported HRQoL. However, as reported by parents, children with ABI aged 6-7 years and youth aged 13-18 years had poorer HRQoL regarding psychosocial health. Children's post-injury cognitive, behavioural and social problems were moderately associated with poorer HRQoL, especially psychosocial health (Rs ≥ 0.40). Severity nor type of injury were associated with children's HRQoL.

CONCLUSION

Two years post-injury, in children and youth with mild to severe ABI, reported HRQoL is similar to that in the general population, whereas parents reported less favourable outcomes. Post-injury cognitive, behavioural and social problems require ongoing attention during long-term follow-up.

Postconcussion Syndrome: A Review

Postconcussion syndrome is a symptom complex with a wide range of somatic, cognitive, sleep, and affective features, and is the most common consequence of traumatic brain injury. Between 14% and 29% of children with mild traumatic brain injury will continue to have postconcussion symptoms at 3 months, but the pathophysiological mechanisms driving this is poorly understood. The relative contribution of injury factors to postconcussion syndrome decreases over time and, instead, premorbid factors become important predictors of symptom persistence by 3 to 6 months postinjury. The differential diagnoses include headache disorder, cervical injury, anxiety, depression, somatization, vestibular dysfunction, and visual dysfunction. The long-term outcome for most children is good, although there is significant morbidity in the short term. Management strategies target problematic symptoms such as headaches, sleep and mood disturbances, and cognitive complaints.

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.

Parent-Reported Health-Related Quality of Life in Children With Traumatic Brain Injury: A Prospective Study

OBJECTIVE

To identify which specific aspects of health-related quality of life (HRQL) are affected by traumatic brain injury (TBI) injury severity (Severity), time since injury (Time), and the interaction between Severity and Time, in a pediatric sample. It was hypothesized that Severity would decrease HRQL, Time would increase HRQL, and time to recover would be protracted for children with severe TBI.

METHODS

This study followed a pediatric sample (n = 182, aged 6-14 years, recruited through three Australian hospitals) who sustained a mild or moderate-severe TBI across 3, 6, 12, and 18 months post-TBI. 12 specific HRQL outcomes were assessed via the Child Health Questionnaire-Parent Form 50 questionnaire.

RESULTS

Dimensions of HRQL were differentially affected. Children with moderate-severe TBI generally experienced greater initial dysfunction than children with mild TBI; however, this difference disappeared by 18 months post-TBI.

CONCLUSIONS

Specific time points where HRQL outcomes may remediate are identified, and clinical recommendations regarding intervention strategies are discussed.

Determinants of Effective Caregiver Communication After Adolescent Traumatic Brain Injury

OBJECTIVE

To characterize the effects of caregiver mental health and coping strategies on interactions with an injured adolescent acutely after traumatic brain injury (TBI).

DESIGN

Multi-site, cross-sectional study.

SETTING

Outpatient setting of 3 tertiary pediatric hospitals and 2 tertiary general medical centers.

PARTICIPANTS

Adolescents (N = 125) aged 12-17 years, 1-6 months after being hospitalized with complicated mild to severe TBI.

METHODS

Data were collected as part of a multi-site clinical trial of family problem-solving therapy after TBI. Multiple regression analyses were used to examine the relationship of caregiver and environmental characteristics to the dimensions of effective communication, warmth, and negativity during caregiver-adolescent problem-solving discussions.

MAIN OUTCOMES MEASURES

Adolescent and caregiver interactions, as measured by the Iowa Family Interaction Rating Scales.

RESULTS

Caregivers who utilized problem-focused coping strategies were rated as having higher levels of effective communication (P < .01), as were those with higher socioeconomic status (P < .01). Problem-focused coping style and higher socioeconomic status were also associated lower levels of negative interactions (P < .01 and P < .05, respectively). Female gender of the adolescent and fewer children in the home were associated with increased parental warmth during the interaction (P < .01 and P < .05, respectively). Neither adolescent TBI severity nor caregiver depression significantly influenced caregiver-teen interactions.

CONCLUSIONS

Problem-focused coping strategies are associated with higher levels of effective communication and lower levels of caregiver negativity during the initial months after adolescent TBI, suggesting that effective caregiver coping may facilitate better caregiver-adolescent interactions after TBI.

Part I--Evaluation of pediatric post-traumatic headaches

BACKGROUND

Brain injury is one of the most common injuries in the pediatric age group, and post-traumatic headache is one of the most common symptoms following mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. Part I will focus on an overview and approach to the evaluation of post-traumatic headache. Part II will focus on the medical management of post-traumatic headache. Relevant articles were reviewed, and an algorithm is proposed.

RESULTS

We review the epidemiology, classification, pathophysiology, and clinical approach to evaluating patients with post-traumatic headache. A comprehensive history and physical examination are fundamental to identifying the headache type(s). Identifying the precise headache phenotype is important to help guide treatment. Most of the post-traumatic headaches are migraine or tension type, but occipital neuralgia, cervicogenic headache, and medication overuse headache also occur. Postconcussive signs often resolve within 1 month, and individuals whose signs persist longer may benefit from an interprofessional approach.

CONCLUSIONS

Rigorous evaluation and diagnosis are vital to treating post-traumatic headaches effectively. A multifaceted approach is needed to address all the possible contributing factors to the headaches and any comorbid conditions that may delay recovery or alter treatment choices.

Quality-of-life after brain injury in childhood: time, not severity, is the significant factor

OBJECTIVE

Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.

METHODS

The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.

RESULTS

The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.

CONCLUSIONS

QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children's posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.

Direct medical charges of pediatric traumatic brain injury in multiple clinical settings

Background

Data limited to emergency department and inpatient visits undoubtedly underestimate the medical charges associated with traumatic brain injury. The objective of this study was to estimate the direct medical charges of pediatric traumatic brain injuries across all clinical settings in one large, pediatric hospital in the United States.

Methods

Traumatic brain injuries sustained by children ≤20 years of age treated across all clinical settings at one large pediatric hospital from August 1, 2010-July 31, 2011 were identified using ICD-9-CM codes 310.2, 800–801.9, 803–804.9, 850–854.16, and 959.01.

Results

3,971 individuals ≤20 years of age were seen during 5,429 traumatic brain injury-related visits. Total medical charges for pediatric traumatic brain injury-related visits were $13,131,547. Inpatient (68.7%) and emergency department (16.1%) visits accounted for the highest proportion of TBI-related charges; however, >15% of all charges were associated with visits to clinic outpatient, urgent care, and diagnostic/therapy outpatient settings. Fracture of the vault or base of the skull (37.1%) and brain injury with contusion, laceration, or hemorrhage (27.1%) accounted for the largest proportion of total charges. Although unspecified head injuries made up almost half of all TBI-related visits (47.4%), they accounted for only 12.6% of total charges. Mild traumatic brain injuries accounted for 92.0% of all traumatic brain injury-related visits but only 44.7% of all traumatic brain injury-related charges. Mild traumatic brain injuries treated in the emergency department had a higher median total charge than those treated in urgent care (p < 0.0001) or clinic outpatient setting (p < 0.001).

Conclusions

This study, the first to evaluate the direct medical charges of pediatric traumatic brain injury across all clinical settings at one large pediatric hospital, found that pediatric traumatic brain injuries present to a wide variety of clinical settings, and differences exist in total charges by diagnosis, severity of the injury, and clinical site/setting. Investigating traumatic brain injuries across the full spectrum of clinical care is needed for a better understanding of the true medical cost and public health burden of pediatric traumatic brain injury.

Electronic supplementary material

The online version of this article (doi:10.1186/2197-1714-1-13) contains supplementary material, which is available to authorized users.

Posttraumatic reduction of edema with aquaporin-4 RNA interference improves acute and chronic functional recovery

Traumatic brain injury (TBI) is common in young children and adolescents and is associated with long-term disability and mortality. The neuropathologic sequelae that result from juvenile TBI are a complex cascade of events that include edema formation and brain swelling. Brain aquaporin-4 (AQP4) has a key role in edema formation. Thus, development of novel treatments targeting AQP4 to reduce edema could lessen the neuropathologic sequelae. We hypothesized that inhibiting AQP4 expression by injection of small-interfering RNA (siRNA) targeting AQP4 (siAQP4) after juvenile TBI would decrease edema formation, neuroinflammation, neuronal cell death, and improve neurologic outcomes. The siAQP4 or a RNA-induced silencing complex (RISC)-free control siRNA (siGLO) was injected lateral to the trauma site after controlled cortical impact in postnatal day 17 rats. Magnetic resonance imaging, neurologic testing, and immunohistochemistry were performed to assess outcomes. Pups treated with siAQP4 showed acute (3 days after injury) improvements in motor function and in spatial memory at long term (60 days after injury) compared with siGLO-treated animals. These improvements were associated with decreased edema formation, increased microglial activation, decreased blood-brain barrier disruption, reduced astrogliosis and neuronal cell death. The effectiveness of our treatment paradigm was associated with a 30% decrease in AQP4 expression at the injection site.

On the joys of missing data

We provide conceptual introductions to missingness mechanisms--missing completely at random, missing at random, and missing not at random--and state-of-the-art methods of handling missing data--full-information maximum likelihood and multiple imputation--followed by a discussion of planned missing designs: Multiform questionnaire protocols, 2-method measurement models, and wave-missing longitudinal designs. We reviewed 80 articles of empirical studies published in the 2012 issues of the Journal of Pediatric Psychology to present a picture of how adequately missing data are currently handled in this field. To illustrate the benefits of using multiple imputation or full-information maximum likelihood and incorporating planned missingness into study designs, we provide example analyses of empirical data gathered using a 3-form planned missing design.

Persistence of disability 24 to 36 months after pediatric traumatic brain injury: a cohort study

This study examined the outcome of 0- to 17-year-old children 36 months after traumatic brain injury (TBI), and ascertained if there was any improvement in function between 24 and 36 months. Controls were children treated in the emergency department for an arm injury. Functional outcome 36 months after injury was measured by the Pediatric Quality of Life Inventory (PedsQL), the self-care and communication subscales of the Adaptive Behavior Assessment Scale-2nd edition (ABAS-II), and the Child and Adolescent Scale of Participation (CASP). At 36 months after TBI, those with moderate or severe TBI continued to have PedsQL scores that were 16.1 and 17.9 points, respectively, lower than at baseline, compared to the change seen among arm injury controls. Compared to the baseline assessment, children with moderate or severe TBI had significantly poorer functioning on the ABAS-II and poorer participation in activities (CASP). There was no significant improvement in any group on any outcomes between 24 and 36 months. Post-injury interventions that decrease the impact of these deficits on function and quality of life, as well as preventive interventions that reduce the likelihood of TBI, should be developed and tested.