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Eye Movements, Dizziness, and Mild Traumatic Brain Injury (mTBI): A Topical Review of Emerging Evidence and Screening Measures. J Neurol Phys Ther 2020; 43 Suppl 2:S31-S36. [PMID: 30883491 DOI: 10.1097/npt.0000000000000272] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Eye movements may be adversely affected after mild traumatic brain injury (mTBI) and should be examined. The purpose of this topical review is to provide the clinician with the most up-to-date knowledge related to eye movement abnormalities, screening measures, and evidence related to exercise interventions that are designed to enhance outcomes in persons after mTBI. SUMMARY OF KEY POINTS Presence of eye misalignment such as tropias or phoria or symptoms with head/eye movements such as vestibulo-ocular reflex (VOR) × 1, saccades, or smooth pursuits may slow the person's recovery. Tools such as the Convergence Insufficiency Symptom Survey, the Vestibular/Ocular Motor Screening, the Pediatric Vestibular Symptom Questionnaire, and the Pediatric Visually Induced Dizziness questionnaire may aid in identifying visual concerns to target in the physical therapy intervention program. There is emerging evidence that vestibular rehabilitation enhances recovery in persons after mTBI. RECOMMENDATIONS FOR CLINICAL PRACTICE A thorough eye examination is highly recommended after mTBI to identify targeted areas for intervention.
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52
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Kent M, Brilliant A, Erickson K, Meehan W, Howell D. Symptom Presentation After Concussion and Pre-existing Anxiety Among
Youth Athletes. Int J Sports Med 2020; 41:682-687. [DOI: 10.1055/a-1107-3025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractOur purpose was to evaluate the effect of self-reported pre-injury anxiety
diagnosis on persistent symptom development, vestibular symptom severity, and
balance control among youth who sustained a concussion. We performed a
retrospective study of patients seen at a specialty pediatric concussion clinic.
Patients were 18 years of age or younger, examined within 10 days of concussion,
and received care until full recovery. A questionnaire was used to assess
pre-existing medical and psychiatric conditions, including anxiety. Our main
outcomes were prolonged symptom recovery defined as persistent symptoms for
> 28 days after concussion) and severity of vestibular symptoms.
Patients who reported pre-injury anxiety (n=43; median age=14.9
years; 37% female) were more likely to experience symptoms>28
days post-injury (76 vs. 54%; p=0.04) than those without
pre-existing anxiety (n=241; median age=14.9 years; 53%
female). After adjusting for sex, history of migraine, depression and ADHD,
however, there was no independent association between pre-existing anxiety and
prolonged symptom duration (adjusted odds ratio=2.34; 95%
CI=0.083–6.63; p=0.11). Pre-existing anxiety was
independently associated with self-reported nausea/vomiting severity
(β coefficient=0.59, 95% CI=0.07–1.11).
A pre-existing anxiety diagnosis does not appear to be associated with
persistent symptoms after concussion, although it may be associated with
post-injury nausea.
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Affiliation(s)
- Matthew Kent
- Department of Psychology University of Pittsburgh, Pittsburgh, United
States
| | - Anna Brilliant
- Department of Sports Medicine, Children’s Hospital Boston,
Boston, United States
| | - Kirk Erickson
- Department of Psychology University of Pittsburgh, Pittsburgh, United
States
| | - William Meehan
- Department of Sports Medicine, The Micheli Center for Sports Injury
Prevention, Waltham, United States
| | - David Howell
- Department of Orthopedics, University of Colorado Denver School of
Medicine, Aurora, United States
- Sports Medicine Center, Children’s Hospital Colorado, Aurora,
CO, USA
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53
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Aggarwal SS, Ott SD, Padhye NS, Schulz PE. Sex, race, ADHD, and prior concussions as predictors of concussion recovery in adolescents. Brain Inj 2020; 34:809-817. [DOI: 10.1080/02699052.2020.1740942] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Seema S. Aggarwal
- Center for Nursing Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Summer D. Ott
- Department of Orthopedics, McGovern Medical School of UTHealth, the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nikhil S. Padhye
- Center for Nursing Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Paul E. Schulz
- Department of Neurology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, Texas, USA
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54
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Less Than Half of Patients Recover Within 2 Weeks of Injury After a Sports-Related Mild Traumatic Brain Injury: A 2-Year Prospective Study. Clin J Sport Med 2020; 30:96-101. [PMID: 32132366 DOI: 10.1097/jsm.0000000000000811] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe clinical recovery time and factors that might impact on recovery after a sports-related mild traumatic brain injury (SR-mTBI; concussion). DESIGN Prospective cohort study (level IV evidence). SETTING New Zealand Sports Concussion Clinic. PARTICIPANTS Eight hundred twenty-two patients presenting within 14 days of a SR-mTBI/concussion over a 2-year period. MAIN OUTCOME MEASURES Clinical recovery measured as number of days after injury. INTERVENTIONS METHODS Participants were assessed and managed using a standardized protocol consisting of relative rest followed by controlled cognitive and physical loading. A reassessment was performed 14 days after injury with initiation of an active rehabilitation program consisting of a subsymptom threshold exercise program ± cervicovestibular rehabilitation (if required) for participants who remained symptomatic. Participants were then assessed every 2 weeks until clinical recovery. RESULTS A total of 594 participants were eligible for analysis (mean age 20.2 ± 8.7 years, 77% males) and were grouped into 3 age cohorts: children (≤12 years), adolescents (13-18 years), and adults (≥19 years). Forty-five percent of participants showed clinical recovery within 14 days of injury, 77% by 4 weeks after injury, and 96% by 8 weeks after injury. There was no significant difference in recovery time between age groups. Prolonged recovery was more common in females (P = 0.001), participants with "concussion modifiers" (P = 0.001), and with increased time between injury and the initial appointment (P = 0.003). CONCLUSIONS This study challenges current perceptions that most people with a SR-mTBI (concussion) recover within 10 to 14 days and that age is a determinant of recovery rate. Active rehabilitation results in high recovery rates after SR-mTBI.
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55
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Coxe KA, Sullivan L, Newton A, Yang J. Barriers to the Implementation of State Concussion Laws Within High Schools. J Adolesc Health 2020; 66:233-239. [PMID: 31757625 DOI: 10.1016/j.jadohealth.2019.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE All 50 U.S. states and the District of Columbia enacted concussion laws between 2009 and 2014 to mitigate the consequences of concussion among children and adolescents. In response, many high schools started to implement their respective state law that includes three main tenets: (1) concussion education, (2) removal from play, and (3) return-to-play. We aimed to identify barriers to the implementation of these tenets at the school level. METHODS We conducted 64 semistructured telephone interviews with high school athletic trainers from 26 states and the District of Columbia whose school participated in High School Reporting Information Online during the 2014-2015 and 2015-2016 academic years. Data were analyzed using thematic analysis. RESULTS All 64 high schools employed at least one athletic trainer, and most schools were public schools (90.6%). Implementation barriers to the concussion education tenet were (1) lack of quality education, (2) lack of buy-in to educational requirements, and (3) lack of time for and attendance at educational meetings. Implementation barriers to the removal from play tenet included (1) athletes underreporting concussion symptoms, (2) lack of communication, (3) resistance from parents and coaches, and (4) sport culture and "old school" mentality. Finally, (1) cost of and access to medical care, (2) resistance from stakeholders, and (3) lack of understanding of concussion were identified as implementation barriers to the return-to-play tenet. CONCLUSIONS Identification of implementation barriers is key to the successful execution and application of state concussion laws at the school level. Future research should identify strategies to reduce these barriers.
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Affiliation(s)
- Kathryn A Coxe
- College of Social Work, The Ohio State University, Columbus, Ohio
| | - Lindsay Sullivan
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Alison Newton
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jingzhen Yang
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio.
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56
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Stumph J, Young J, Singichetti B, Yi H, Valasek A, Bowman E, MacDonald J, Yang J, Fischer A. Effect of Exercise Recommendation on Adolescents With Concussion. J Child Neurol 2020; 35:95-101. [PMID: 31599706 DOI: 10.1177/0883073819877790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examined the effect of a noncontact, subsymptom exacerbation early exercise recommendation on recovery from sports-related concussion. Retrospective analysis of adolescents, 10-17 years old, with symptomatic concussion, within 30 days of injury was performed. Time to recovery was measured between the early exercise group and a comparison group. A total of 187 patients studied-112 in the exercise group and 75 in the comparison group; 55% were male (n = 103). The exercise group had a significantly longer duration of concussion symptoms (18.5 days vs 14, P = .002), although both groups recovered within the expected time to recovery for concussion. When analyzed separately, males experienced longer time to recovery from injury (19 days vs 14, P = .003), than females, respectively (18 days vs 14.5, P = .18). Recommendation of early exercise resulted in significantly longer recovery from concussion in male adolescents but had no significant effect in female adolescents; both groups recovered within the expected time frame.
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Affiliation(s)
- Justin Stumph
- Department of Family Medicine, Cleveland Clinic Health System, Cleveland, OH, USA
| | - Julie Young
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,School of Health and Rehabilitation Sciences, Ohio State University, Columbus, OH, USA
| | - Bhavna Singichetti
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Honggang Yi
- Department of Biostatistics, Nanjing Medical University, Nanjing, Jiangsu Province, China, USA
| | - Amy Valasek
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Eric Bowman
- Orthopedic Surgery and Sports Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - James MacDonald
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Jingzhen Yang
- Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA.,Center for Injury Research and Policy, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Anastasia Fischer
- Division of Sports Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA
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57
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Wilmoth K, Curcio N, Tarkenton T, Meredith-Duliba T, Tan A, Didehbani N, Hynan LS, Miller SM, Bell KR, Cullum CM. Utility of Brief Psychological Measures for Prediction of Prolonged Symptom Clearance in Concussed Student Athletes. Arch Clin Neuropsychol 2019; 36:430-436. [DOI: 10.1093/arclin/acz061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/14/2019] [Accepted: 10/05/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Objective
Variability in recovery time following sport-related concussion (SRC) is poorly understood. We explored the utility of brief mood, anxiety, and sleep questionnaires as postinjury predictors of SRC symptom clearance in adolescents.
Method
At initial visit 0–2 weeks postinjury, concussed athletes aged 12–18 years self-reported injury/medical factors (prior concussion, loss of consciousness, amnesia, and concussion symptom severity) and were administered psychological symptom measures. At 3 months, medical record review determined return-to-play (RTP) date. Subjects were divided into two datasets, with the first utilized for developing cutoff scores and then validated with the second dataset.
Results
A total of 64% of the 141 participants had early RTP (within 21 days postinjury), and 23% had late RTP (postinjury day 30 or later). The Generalized Anxiety Disorder Screener (GAD-7, M = 2.1, SD = 3.1) was the only significant predictor (p = .001), with a 1.4-fold [95% CI 1.2–1.8] increased risk for every point. No other factors in the full model discriminated recovery groups (ps > .05). Receiver operating characteristic curve analysis derived a GAD-7 cut score ≥3 (sensitivity= 56.7%, specificity = 74.2%, AUCs = 0.63–0.79, ps < .001).
Conclusions
Postconcussion anxiety symptoms may help identify individuals at increased risk for prolonged recovery.
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Affiliation(s)
- Kristin Wilmoth
- Departments of Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nicholas Curcio
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tahnae Tarkenton
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tawny Meredith-Duliba
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alexander Tan
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Nyaz Didehbani
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Linda S Hynan
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Population and Data Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shane M Miller
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern Medical Center and Department of Sports Medicine, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Kathleen R Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Munro Cullum
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Departments of Neurology & Neurotherapeutics and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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58
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Integrating Neuropsychology Services in a Multidisciplinary Concussion Clinic. J Head Trauma Rehabil 2019; 34:419-424. [DOI: 10.1097/htr.0000000000000541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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59
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Trbovich AM, Sherry NK, Henley J, Emami K, Kontos AP. The utility of the Convergence Insufficiency Symptom Survey (CISS) post-concussion. Brain Inj 2019; 33:1545-1551. [DOI: 10.1080/02699052.2019.1658131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Alicia M. Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Natalie K. Sherry
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jill Henley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kouros Emami
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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60
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Biological Sex/Gender and Biopsychosocial Determinants of Traumatic Brain Injury Recovery Trajectories. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00238-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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61
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Rasouli MR, Kavin M, Stache S, Mahla ME, Schwenk ES. Anesthesia for the patient with a recently diagnosed concussion: think about the brain! Korean J Anesthesiol 2019; 73:3-7. [PMID: 31257815 PMCID: PMC7000285 DOI: 10.4097/kja.19272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 06/30/2019] [Indexed: 11/15/2022] Open
Abstract
Some patients require emergent, urgent, or elective surgery in the time period immediately following diagnosis of concussion. However, changes in brain homeostatic mechanisms following a concussion and concern for secondary brain injury can complicate the decision as to whether or not a surgery should proceed or be postponed. Given the paucity of available evidence, further evaluation of the use of anesthesia in a patient with concussion is warranted. This article summarizes what is currently known about the relevant pathophysiology of concussion, intraoperative anesthesia considerations, and effects of anesthesia on concussion outcomes in an attempt to help providers understand the risks that may accompany surgery and anesthesia in this patient population. While most contraindications to the use of anesthesia in concussed patients are relative, there are nonetheless pathophysiologic changes associated with a concussion that can increase risk of its use. Understanding these changes and anesthetic implications can help providers optimize outcomes in this patient population.
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Affiliation(s)
- Mohammed R Rasouli
- Department of Anesthesiology, Duke University School of Medicine Durham, NC, USA
| | | | - Stephen Stache
- Rothman Orthopaedics, Philadelphia, PA, USA.,Department of Family and Community Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia, PA, USA
| | - Michael E Mahla
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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62
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Thibeault CM, Thorpe S, Canac N, Wilk SJ, Hamilton RB. Sex-Based Differences in Transcranial Doppler Ultrasound and Self-Reported Symptoms After Mild Traumatic Brain Injury. Front Neurol 2019; 10:590. [PMID: 31244755 PMCID: PMC6579811 DOI: 10.3389/fneur.2019.00590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022] Open
Abstract
The possibility of sex-related differences in mild traumatic brain injury (mTBI) severity and recovery remains a controversial subject. With some studies showing that female subjects suffer a longer period of symptom recovery, while others have failed to demonstrate differences. In this study, we explored the sex-related effects of mTBI on self-reported symptoms and transcranial Doppler ultrasound (TCD) measured features in an adolescent population. Fifty-eight subjects were assessed—at different points post-injury—after suffering an mTBI. Subjects answered a series of symptom questions before the velocity from the middle cerebral artery was measured. Subjects participated in breath-holding challenges to evaluate cerebrovascular reactivity. The Pulsatility Index (PI), the ratio of the first peaks (P2R), and the Breath-Hold Index (BHI), were computed. Linear mixed effects models were developed to explore the interactions between measured features, sex, and time since injury while accounting for within subject variation. Over the first 10 days post-injury, the female group had significant interactions between sex and time since injury that was not present in the TCD features. This is the first study to compare sex-related differences in self-reported symptoms and TCD measurements in adolescents suffering an mTBI. It illustrates the pitfalls clinicians face when relying on subjective measures alone during diagnosis and tracking of mTBI patients. In addition, it highlights the need for more focused research on sex-related differences in concussion pathophysiology.
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Affiliation(s)
| | - Samuel Thorpe
- Neural Analytics, Inc., Los Angeles, CA, United States
| | - Nicolas Canac
- Neural Analytics, Inc., Los Angeles, CA, United States
| | - Seth J Wilk
- Neural Analytics, Inc., Los Angeles, CA, United States
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63
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McKeithan L, Hibshman N, Yengo-Kahn AM, Solomon GS, Zuckerman SL. Sport-Related Concussion: Evaluation, Treatment, and Future Directions. Med Sci (Basel) 2019; 7:medsci7030044. [PMID: 30884753 PMCID: PMC6473667 DOI: 10.3390/medsci7030044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 01/16/2023] Open
Abstract
Sport-related concussion (SRC) is a highly prevalent injury predominantly affecting millions of youth through high school athletes every year. In recent years, SRC has received a significant amount of attention due to potential for long-term neurologic sequelae. However, the acute symptoms and possibility of prolonged recovery account for the vast majority of morbidity from SRC. Modifying factors have been identified and may allow for improved prediction of a protracted course. Potential novel modifying factors may include genetic determinants of recovery, as well as radiographic biomarkers, which represent burgeoning subfields in SRC research. Helmet design and understanding the biomechanical stressors on the brain that lead to concussion also represent active areas of research. This narrative review provides a general synopsis of SRC, including relevant definitions, current treatment paradigms, and modifying factors for recovery, in addition to novel areas of research and future directions for SRC research.
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Affiliation(s)
- Lydia McKeithan
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Natalie Hibshman
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Aaron M Yengo-Kahn
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Gary S Solomon
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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64
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Ledoux AA, Tang K, Yeates KO, Pusic MV, Boutis K, Craig WR, Gravel J, Freedman SB, Gagnon I, Gioia GA, Osmond MH, Zemek RL. Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population. JAMA Pediatr 2019; 173:e183820. [PMID: 30398522 PMCID: PMC6583432 DOI: 10.1001/jamapediatrics.2018.3820] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE The natural progression of symptom change and recovery remains poorly defined in children after concussion. OBJECTIVES To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery. DESIGN, SETTING, AND PARTICIPANTS Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018. EXPOSURES Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point. MAIN OUTCOMES AND MEASURES The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed. RESULTS A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, -5.3; 95% CI, -5.5 to -5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, -9.0; 95% CI, -9.6 to -8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, -28.6; 95% CI, -30.8 to -26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12. CONCLUSIONS AND RELEVANCE Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.
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Affiliation(s)
- Andrée-Anne Ledoux
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken Tang
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Keith O. Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada,Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Martin V. Pusic
- Department of Emergency Medicine, New York University School of Medicine, New York
| | - Kathy Boutis
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - William R. Craig
- Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Jocelyn Gravel
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Stephen B. Freedman
- Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Gagnon
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gerard A. Gioia
- Children’s National Health System, George Washington University School of Medicine, Rockville, Maryland
| | - Martin H. Osmond
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Roger L. Zemek
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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65
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Solomito MJ, Reuman H, Wang DH. Sex differences in concussion: a review of brain anatomy, function, and biomechanical response to impact. Brain Inj 2018; 33:105-110. [DOI: 10.1080/02699052.2018.1542507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Matthew J. Solomito
- Elite Sports Medicine, Connecticut Children’s Medical Center, Farmington, Connecticut, USA
| | - Hannah Reuman
- Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - David H. Wang
- Elite Sports Medicine, Connecticut Children’s Medical Center, Farmington, Connecticut, USA
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Zuckerman SL, Brett BL, Jeckell AS, Yengo-Kahn AM, Solomon GS. Prognostic Factors in Pediatric Sport-Related Concussion. Curr Neurol Neurosci Rep 2018; 18:104. [PMID: 30397831 DOI: 10.1007/s11910-018-0909-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Sport-related concussion (SRC) and mild traumatic brain injury (mTBI) have been thrust into the national spotlight, with youth athletes bearing the burden of this public health problem. The current review aims to provide a practical summary of pediatric SRC, including key terminology, return to play/school, and risk factors for post-concussion syndrome (PCS). RECENT FINDINGS While the majority of youth athletes recover within 2 to 4 weeks, approximately 10% of athletes experience a protracted recovery with symptoms lasting months, impacting social, scholastic, and sporting activities. In the pediatric population, the strongest predictors of PCS are initial symptom burden and prior concussion, with mixed results behind the factors of gender, headaches, and learning disability. The role of psychiatric, family history, sports, and socioeconomic factors remain in their infancy.
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Affiliation(s)
- Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, 37212, USA.
| | - Benjamin L Brett
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron S Jeckell
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron M Yengo-Kahn
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, 37212, USA
| | - Gary S Solomon
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, 37212, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
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Paquin H, Taylor A, Meehan WP. Office-based concussion evaluation, diagnosis, and management: pediatric. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:107-117. [PMID: 30482337 DOI: 10.1016/b978-0-444-63954-7.00011-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Hugo Paquin
- Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montreal, QC, Canada.
| | - Alex Taylor
- Division of Neurology and Psychiatry, Boston Children's Hospital, Boston, MA, United States
| | - William P Meehan
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, United States
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Abstract
PURPOSE OF REVIEW The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations. RECENT FINDINGS Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.
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Affiliation(s)
- David A Brent
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Room 311 Bellefield Towers, Pittsburgh, PA, 15213, USA. .,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jeffrey Max
- Department of Psychiatry, University of California, San Diego, CA, USA.,Rady Children's Hospital, San Diego, CA, USA
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Manzanero S, Elkington LJ, Praet SF, Lovell G, Waddington G, Hughes DC. Post-concussion recovery in children and adolescents: A narrative review. JOURNAL OF CONCUSSION 2017. [DOI: 10.1177/2059700217726874] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Silvia Manzanero
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
- Research Institute for Sport and Exercise, University of Canberra, Bruce, Australia
| | - Lisa J Elkington
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
| | - Stephan F Praet
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
- Research Institute for Sport and Exercise, University of Canberra, Bruce, Australia
| | - Greg Lovell
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
| | - Gordon Waddington
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
- Research Institute for Sport and Exercise, University of Canberra, Bruce, Australia
| | - David C Hughes
- Department of Sports Medicine, Australian Institute of Sport, Bruce, Australia
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