Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics

Eye Movements, Dizziness, and Mild Traumatic Brain Injury (mTBI): A Topical Review of Emerging Evidence and Screening Measures

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.

Symptom Presentation After Concussion and Pre-existing Anxiety Among Youth Athletes

Our 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.

Less Than Half of Patients Recover Within 2 Weeks of Injury After a Sports-Related Mild Traumatic Brain Injury: A 2-Year Prospective Study

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.

Barriers to the Implementation of State Concussion Laws Within High Schools

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.

Effect of Exercise Recommendation on Adolescents With Concussion

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.

Utility of Brief Psychological Measures for Prediction of Prolonged Symptom Clearance in Concussed Student Athletes

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.

Anesthesia for the patient with a recently diagnosed concussion: think about the brain!

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.

Sex-Based Differences in Transcranial Doppler Ultrasound and Self-Reported Symptoms After Mild Traumatic Brain Injury

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.

Sport-Related Concussion: Evaluation, Treatment, and Future Directions

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.

Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population

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.

Prognostic Factors in Pediatric Sport-Related Concussion

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.

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.

Psychiatric Sequelae of Concussions

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.

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.