Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury

Gray matter abnormalities in pediatric mild traumatic brain injury

Pediatric mild traumatic brain injury (pmTBI) is the most prevalent neurological insult in children and is associated with both acute and chronic neuropsychiatric sequelae. However, little is known about underlying pathophysiology changes in gray matter diffusion and atrophy from a prospective stand-point. Fifteen semi-acute pmTBI patients and 15 well-matched healthy controls were evaluated with a clinical and neuroimaging battery, with a subset of participants returning for a second visit. Clinical measures included tests of attention, processing speed, executive function, working memory, memory, and self-reported post-concussive symptoms. Measures of diffusion (fractional anisotropy [FA]) and atrophy were also obtained for cortical and subcortical gray matter structures to characterize effects of injury as a function of time. Patients exhibited decreased scores in the domains of attention and processing speed relative to controls during the semi-acute injury stage, in conjunction with increased anisotropic diffusion in the left superior temporal gyrus and right thalamus. Evidence of increased diffusion in these regions was also present at four months post-injury, with performance on cognitive tests partially normalizing. In contrast, signs of cortical atrophy in bilateral frontal areas and other left-hemisphere cortical areas only emerged at four months post-injury for patients. Current results suggest potentially differential time-courses of recovery for neurobehavioral markers, anisotropic diffusion and atrophy following pmTBI. Importantly, these data suggest that relying on patient self-report or standard clinical assessments may underestimate the time for true injury recovery.

Long-Term Caregiver Mental Health Outcomes Following a Predominately Online Intervention for Adolescents With Complicated Mild to Severe Traumatic Brain Injury

OBJECTIVE

To examine the efficacy of counselor-assisted problem solving (CAPS) in improving long-term caregiver psychological functioning following traumatic brain injury (TBI) in adolescents.

METHODS

This randomized clinical trial compared CAPS (n = 65), a predominantly online problem-solving intervention, with an Internet resource comparison (n = 67) program. Families of adolescents with TBI completed a baseline assessment and follow-up assessments 6, 12, and 18 months later. General linear mixed models were used to examine longitudinal changes in caregiver global psychological distress, depressive symptoms, and caregiving self-efficacy. Family income and injury severity were examined as moderators of treatment efficacy.

RESULTS

Family income moderated long-term changes in caregiver psychological distress. For lower-income caregivers, the CAPS intervention was associated with lower levels of psychological distress at 6, 12, and 18 months post baseline.

CONCLUSIONS

These findings support the utility of Web-based interventions in improving long-term caregiver psychological distress, particularly for lower-income families.

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Introduction

The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion.

Methods

The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians.

Results

Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion.

Conclusion

Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

Knowledge of paediatric concussion among front-line primary care providers

OBJECTIVE

To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers.

METHODS

Experts from the Concussions Ontario Diagnosis and Early Education Working Group developed a 34-item survey incorporating case vignettes with the collaboration of experts in medical education. Electronic surveys were distributed via FluidSurveys using a modified version of Dillman's tailored design method. The survey was distributed to five Ontario professional associations. The target participants were front-line health care providers (family physicians, emergency medicine physicians, general paediatricians, nurse practitioners and physician assistants) in Ontario; only providers who diagnose and/or manage paediatric concussions were eligible to participate.

RESULTS

The survey was fully completed by 577 health care providers who treat paediatric concussion. Of the respondents, 78% (95% CI 74% to 81%) reported diagnosing ≥5 concussions annually. Physicians and nonphysicians equally recognized concussion (90% [95% CI 86% to 92%]; 85% [95% CI 77% to 90%], respectively). Only 37% (95% CI 32% to 41%) of physicians correctly applied graduated return to play guidelines. Return to learn recommendations were also insufficient: 53% (95% CI 49% to 58%) neglected to recommend school absence and 40% (95% CI (35% to 44%) did not recommend schoolwork accommodations. Only 26% (95% CI 22% to 30%) of physicians reported regular use of concussion scoring scales.

CONCLUSIONS

Considerable gaps in knowledge exist in front-line primary care providers with inadequate application of graduated return to play and return to learn following concussion, as demonstrated by the present broad population-based survey. Consistent application of best evidence-based management using comprehensive guidelines may help to reduce the impact of concussion and persistent postconcussive problems in children and adolescents.

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.

Postconcussive symptom exaggeration after pediatric mild traumatic brain injury

BACKGROUND

A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing.

METHODS

Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery.

RESULTS

A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems).

CONCLUSIONS

A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologic statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsychologists should be incorporated routinely into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries.

National Athletic Trainers' Association position statement: management of sport concussion

OBJECTIVE

To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions.

BACKGROUND

An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries.

RECOMMENDATIONS

The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations.

Neuropsychiatry of pediatric traumatic brain injury

Pediatric traumatic brain injury (TBI) is a major public health problem. Psychiatric disorders with onset before the injury are more common than population base rates. Novel (postinjury onset) psychiatric disorders (NPD) are also common and complicate child function after injury. Novel disorders include personality change due to TBI, secondary attention-deficit/hyperactivity disorder, other disruptive behavior disorders, and internalizing disorders. This article reviews preinjury psychiatric disorders as well as biopsychosocial risk factors and treatments for NPD.

Prevalence of and risk factors for poor functioning after isolated mild traumatic brain injury in children

This study aimed to determine the prevalence and predictors of poor 3 and 12 month quality of life outcomes in a cohort of pediatric patients with isolated mild TBI. We conducted a prospective cohort study of children and adolescents <18 years of age treated for an isolated mild TBI, defined as "no radiographically apparent intracranial injury" or "an isolated skull fracture, and no other clinically significant non-brain injuries." The main outcome measure was the change in quality of life from baseline at 3 and 12 months following injury, as measured by the Pediatric Quality of Life index (PedsQL). Poor functioning was defined as a decrease in total PedsQL score of >15 points between baseline and follow-up scores (at 3 and 12 months). Of the 329 patients who met inclusion criteria, 11.3% (95% CI 8.3-15.3%) at 3 months and 12.9% (95% CI 9.6-17.2%) at 12 months following injury had relatively poor functioning. Significant predictors of poor functioning included less parental education, Hispanic ethnicity (at 3 months following injury, but not at 12 months); low household income (at 3 and 12 months), and Medicaid insurance (at 12 months only). Children and adolescents sustaining a mild TBI who are socioeconomically disadvantaged may require additional intervention to mitigate the effects of mild TBI on their functioning.

Current practices of the child neurologist in managing sports concussion

Given the 2010 position statement issued by the American Academy of Neurology that neurologists be consulted on return-to-play decisions following a concussion, we surveyed members of the Child Neurology Society to asses clinical practice management of concussion among child neurologists. Among the 239 respondents, the majority continued to rely on the American Academy of Neurology's 1997 Practice Parameter to guide their decision-making process. Although the 2008 consensus statement from the Third International Conference on Concussion in Sport (Zurich Guidelines) is currently considered the most up-to-date guideline, few respondents relied exclusively on this guideline. More respondents who completed continuing medical education on concussion reported making clinical decisions based on the Zurich guidelines. The finding that child neurologists who completed continuing medical education had a greater familiarity with the more recently proposed consensus-based concussion guidelines supports the development of additional education in sports concussion at all levels of child neurology training.

Parental anxiety at initial acute presentation is not associated with prolonged symptoms following pediatric concussion

OBJECTIVES

Anxiety modulates symptom perception in adults following concussion, prolonging the time to full recovery. The authors sought to determine whether parental anxiety was associated with persistent postconcussive symptoms (PCS) in their children following concussion.

METHODS

A prospective observational cohort with 98 children aged 5 to 17 years following concussion participated from a tertiary pediatric emergency department (ED). The main exposure was parental anxiety at the time of acute presentation following pediatric concussion, measured using the self-administered, validated Spielberger State-Trait Anxiety Inventory-State Anxiety Scale (STAI-S). The primary outcome measured was presence of PCS in the child at 1 month, per the validated Post-Concussive Symptom Inventory (PCSI). Secondary outcome measures included parental anxiety score over time, school absenteeism, and return to sports. Data were collected during the initial ED visit and at 3-day, 7-day, 2-week, 1-month, and 3-month follow-ups.

RESULTS

Of 98 children enrolled, 27% (95% confidence interval [CI] = 19% to 36%) developed PCS at 1 month. No significant associations were detected between parental anxiety at the index visits and the number of previous pediatric concussions (p = 0.73), sex (p = 0.61), loss of consciousness (p = 0.43), history of migraines (p = 0.31), or history of anxiety diagnosed in the patients (p = 0.09). A significant association was noted between patient diagnosis of attention deficit hyperactivity disorder (ADHD) and parental anxiety at the index visits (p = 0.001). Parental anxiety at acute presentation was not associated with children's prolonged symptoms at 1 month (p = 0.63). Parental anxiety remained elevated in parents whose children had prolonged symptoms compared to those parents whose children's symptoms resolved (median = 30, interquartile range [IQR] = 22 to 44; and median = 21, IQR = 20 to 25, respectively; p < 0.001). Initial parental anxiety presentation was not associated with school absenteeism (p = 0.23) or not returning to sport or gym class (p = 0.89). There were no significant effects involving ADHD alone (p = 0.44) or together with baseline parental anxiety (p = 0.36 for ADHD and p = 0.55 for anxiety) using logistic regression analysis to examine potential predictive effects of child's ADHD combined with parental anxiety at the index visit on persistent symptoms at 1 month.

CONCLUSIONS

Parental anxiety at time of acute presentation does not appear to be associated with prolongation of postconcussive symptoms in their children. However, parents of persistently symptomatic children remain significantly more anxious than those whose children's symptoms have resolved. Future research should attempt to reduce the familial burden of concussion through expectation management strategies.

Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion

INTRODUCTION

Persistent postconcussive symptoms (PCSs) is the persistence of somatic, cognitive, physical, psychological and/or behavioural changes lasting more than 1 month following concussion. Persistent concussion impacts the quality of life through impaired cognition, memory and attention affecting school performance, mood and social engagement. No large epidemiological studies have determined the true prevalence of persistent concussion symptoms. Validated, easy-to-use prognosticators do not exist for clinicians to identify children at highest risk. The goal of Predicting and Preventing Postconcussive Problems in Pediatrics study is to derive a clinical prediction rule for the development of persistent postconcussion symptoms in children and adolescents presenting to emergency department following acute head injury.

METHODS AND ANALYSIS

This study is a prospective, multicentre cohort study across nine academic Canadian paediatric emergency departments. We will recruit the largest prospective epidemiological cohort of children with concussion. Eligible children will be followed using Post-Concussion Symptom Inventory, a validated tool in children as young as 5 years. Patients will follow-up at 1, 2, 4, 8 and 12 weeks postinjury. The main outcome will be the presence/absence of PCSs defined as three or more persistent concussion symptoms 1 month following the injury. 1792 patients provide adequate power to derive a clinical decision rule using multivariate analyses to find predictor variables sensitive for detecting cases of persistent postconcussion symptoms.

ETHICS AND DISSEMINATION

Results of this large prospective study will enable clinicians to identify children at highest risk, optimise treatment and provide families with realistic and appropriate anticipatory guidance. Ethics has been obtained through the Children's Hospital of Eastern Ontario Research Ethics Board. Results will be disseminated at international conferences and in four manuscripts to peer-reviewed journals.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov through the US National Institute of Health/National Library of Medicine (NCT01873287; http://clinicaltrials.gov/ct2/show/NCT01873287).

Diffusion abnormalities in pediatric mild traumatic brain injury

Pediatric mild traumatic brain injury (pmTBI) is the most prevalent neurological insult in children and is associated with both acute and chronic neurobehavioral sequelae. However, little is known about underlying pathophysiology and how injuries change as a function of recovery. Fractional anisotropy, axial diffusivity, and radial diffusivity were examined in 15 semi-acute pmTBI patients and 15 well-matched controls, with a subset of participants returning for a second visit. A novel analytic strategy was applied to capture spatially heterogeneous white matter injuries (lesions) in addition to standard analyses. Evidence of cognitive dysfunction after pmTBI was observed in the domains of attention (p = 0.02, d = -0.92) and processing speed (p = 0.05, d = -0.73) semi-acutely. Region of interest (ROI) and voxelwise analyses indicated increased anisotropic diffusion for pmTBI patients, with an elevated number of clusters with high anisotropy. Metrics of increased anisotropy were able to objectively classify pmTBI from healthy controls at 90% accuracy but were not associated with neuropsychological deficits. Little evidence of recovery in white matter abnormalities was observed over a 4-month interval in returning patients, indicating that physiological recovery may lag behind subjective reports of normality. Increased anisotropic diffusion has been previously linked with cytotoxic edema after TBI, and the magnitude and duration of these abnormalities appear to be greater in pediatric patients. Current findings suggest that developing white matter may be more susceptible to initial mechanical injury forces and that anisotropic diffusion provides an objective biomarker of pmTBI.

Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department

OBJECTIVE

To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury.

DESIGN

Retrospective analysis of a prospective observational study.

SETTING

Pediatric emergency department (ED) in a children's hospital.

PARTICIPANTS

Four hundred six children and adolescents aged 5 to 18 years.

MAIN EXPOSURE

Closed head trauma.

MAIN OUTCOME MEASURES

The Rivermead Post Concussion Symptoms Questionnaire administered 3 months after the injury.

RESULTS

Of the patients presenting to the ED with mild traumatic brain injury, 29.3% developed PCS. The most frequent PCS symptom was headache. Predictors of PCS, while controlling for other factors, were being of adolescent age, headache on presentation to the ED, and admission to the hospital. Patients who developed PCS missed a mean (SD) of 7.4 (13.9) days of school.

CONCLUSIONS

Adolescents who have headache on ED presentation and require hospital admission at the ED encounter are at elevated risk for PCS after mild traumatic brain injury. Interventions to identify this population and begin early treatment may improve outcomes and reduce the burden of disease.

Injury versus noninjury factors as predictors of postconcussive symptoms following mild traumatic brain injury in children

OBJECTIVE

To examine the relative contributions of injury characteristics and noninjury child and family factors as predictors of postconcussive symptoms (PCS) following mild traumatic brain injury (TBI) in children.

METHOD

Participants were 8- to 15-year-old children, 186 with mild TBI and 99 with mild orthopedic injuries (OI). Parents and children rated PCS shortly after injury and at 1, 3, and 12 months postinjury. Hierarchical regression analyses were conducted to predict PCS from (1) demographic variables; (2) premorbid child factors (WASI IQ; WRAT-3 Reading; Child Behavior Checklist; ratings of preinjury PCS); (3) family factors (Family Assessment Device General Functioning Scale; Brief Symptom Inventory; and Life Stressors and Social Resources Inventory); and (4) injury group (OI, mild TBI with loss of consciousness [LOC] and associated injuries [AI], mild TBI with LOC but without AI, mild TBI without LOC but with AI, and mild TBI without LOC or AI).

RESULTS

Injury group predicted parent and child ratings of PCS but showed a decreasing contribution over time. Demographic variables consistently predicted symptom ratings across time. Premorbid child factors, especially retrospective ratings of premorbid symptoms, accounted for the most variance in symptom ratings. Family factors, particularly parent adjustment, consistently predicted parent, but not child, ratings of PCS.

CONCLUSIONS

Injury characteristics predict PCS in the first months following mild TBI but show a decreasing contribution over time. In contrast, noninjury factors are more consistently related to persistent PCS.

Neuropsychological evaluation and management of sport-related concussion

PURPOSE OF REVIEW

Sport-related concussion (SRC) is common in children and adolescents. Although symptoms are typically self-limiting and short-lived, some individuals suffer persistent negative outcomes. The risk of repeat injury and prolonged recovery can be reduced by accurate diagnosis and management. In the absence of reported symptoms, neuropsychological assessment has been identified as objective means of determining dysfunction following concussion. Most research to date has focused on adult populations. This review summarizes the literature regarding neuropsychological evaluation of SRC in the pediatric athlete.

RECENT FINDINGS

As with adult populations, neuropsychological evaluation of children and adolescents diagnosed with SRC has documented skills and abilities that are particularly sensitive to head injury. Difficulties with attention and concentration, speed of information processing, and memory are commonly reported in the literature. There is also some evidence to suggest that younger children are particularly vulnerable to neurologic insult and are at greater risk for secondary consequences. Although such findings argue for more conservative management, the availability of diagnostic tools, including computerized neurocognitive assessment batteries, is limited.

SUMMARY

The neuropsychological impact of SRC on functioning is well established. Because documented deficits have the potential to interfere with critical aspects of normal development in children and adolescents, accurate diagnosis and management of SRC are especially important. Despite some limitations, there is good evidence to support the use of neuropsychological assessment to inform treatments and return-to-play decision making.

Design and usability of a medical computing system for diagnosis of mild traumatic brain injury

In this paper, we present a prototype design of POCTENA (Point-Of-Care Testing Environment for Neurological Assessment), a medical computing system that will be used to assist with diagnosis of mild traumatic brain injury. The design includes an initial set of neurological tests that are built into the system. Component-based usability testing was conducted to examine the effectiveness of the user interface. Results from usability testing are then used to suggest possible system design revisions.