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

American Headache Society white paper on treatment of post-traumatic headache from concussion in youth

OBJECTIVE

To provide healthcare professionals guidance on youth at risk for prolonged recovery and post-traumatic headache (PTH), and on pharmacologic and non-pharmacologic management of PTH due to concussion and mild traumatic brain injury.

BACKGROUND

Headache is the most common persistent post-concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines.

METHODS

This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society.

RESULTS

Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair-to-poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro-modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective.

CONCLUSIONS

This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth.

Plasma Biomarkers of Traumatic Brain Injury in Adolescents With Sport-Related Concussion

Importance

Blood-based biomarkers may clarify underlying neuropathology and potentially assist in clinical management of adolescents with sport-related concussion (SRC).

Objective

To investigate the association between SRC and plasma biomarkers in adolescents.

Design, Setting, and Participants

Prospective cohort study in Canadian sport and clinic settings (Surveillance in High Schools and Community Sport to Reduce Concussions and Their Consequences study; September 2019 to November 2022). Participants were a convenience sample of 849 adolescent (ages 10-18 years) sport participants with blood samples. Data were analyzed from February to September 2023.

Exposures

Blood collection and clinical testing preseason (uninjured) and post-SRC follow-ups (ie, ≤72 hours, 1 week, and biweekly until medical clearance to return to play [RTP]).

Main Outcomes and Measures

Plasma glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light (NfL), and total tau (t-tau) were assayed. Group-level comparisons of biomarker levels were conducted between uninjured and post-SRC intervals (postinjury day [PID] 0-3, 4-10, 11-28, and >28) considering age and sex as modifiers. Secondary analyses explored associations between biomarker concentrations and clinical outcomes (Sport Concussion Assessment Tool, Fifth Edition [SCAT5] symptom scores and time to RTP).

Results

This study included 1023 plasma specimens from 695 uninjured participants (467 male participants [67.2%]; median [IQR] age, 15.90 [15.13-16.84] years) and 154 participants with concussion (78 male participants [51.0%]; median [IQR] age, 16.12 [15.31-17.11] years). Acute (PID 0-3) differences relative to uninjured levels were found for GFAP (female participants: 17.8% increase; β = 0.164; 95% CI, 0.064 to 0.263; P = .001; male participants: 17.1% increase; β = 0.157; 95% CI, 0.086 to 0.229; P < .001), UCH-L1 (female participants: 43.4% increase; β = 0.361; 95% CI, 0.125 to 0.596; P = .003), NfL (male participants: 19.0% increase; β = 0.174; 95% CI, 0.087 to 0.261; P < .001), and t-tau (female participants: -22.9%; β = -0.260; 95% CI, -0.391 to -0.130; P < .001; male participants: -18.4%; β = -0.203; 95% CI, -0.300 to -0.106; P < .001). Differences were observed for all biomarkers at PID 4 to 10, 11 to 28, and greater than 28 compared with uninjured groups. GFAP, NfL, and t-tau were associated with SCAT5 symptom scores across several PID intervals. Higher GFAP after 28 days post-SRC was associated with earlier clearance to RTP (hazard ratio, 4.78; 95% CI, 1.59 to 14.31; P = .01). Male participants exhibited lower GFAP (-9.7%), but higher UCH-L1 (21.3%) compared with female participants. Age was associated with lower GFAP (-5.4% per year) and t-tau (-5.3% per year).

Conclusions and Relevance

In this cohort study of 849 adolescents, plasma biomarkers differed between uninjured participants and those with concussions, supporting their continued use to understand concussion neuropathology. Age and sex are critical considerations as these biomarkers progress toward clinical validation.

Predicting Recovery After Concussion in Pediatric Patients: A Meta-Analysis

CONTEXT

Prognostic prediction models (PPMs) can help clinicians predict outcomes.

OBJECTIVE

To critically examine peer-reviewed PPMs predicting delayed recovery among pediatric patients with concussion.

DATA SOURCES

Ovid Medline, Embase, Ovid PsycInfo, Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Google Scholar.

STUDY SELECTION

The study had to report a PPM for pediatric patients to be used within 28 days of injury to estimate risk of delayed recovery at 28 days to 1 year postinjury. Studies had to have at least 30 participants.

DATA EXTRACTION

The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies checklist was completed.

RESULTS

Six studies of 13 PPMs were included. These studies primarily reflected male patients in late childhood or early adolescence presenting to an emergency department meeting the Concussion in Sport Group concussion criteria. No study authors used the same outcome definition nor evaluated the clinical utility of a model. All studies demonstrated high risk of bias. Quality of evidence was best for the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score.

LIMITATIONS

No formal PPM Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) process exists.

CONCLUSIONS

The 5P clinical risk score may be considered for clinical use. Rigorous external validations, particularly in other settings, are needed. The remaining PPMs require external validation. Lack of consensus regarding delayed recovery criteria limits these PPMs.

Self-Reported Traumatic Brain Injury and Its Biopsychosocial Risk Factors in Siblings of Individuals with Neurodevelopmental Conditions

Siblings of individuals with neurodevelopmental conditions (NDCs) are situated within a complex system of risk and resilience factors for poor outcomes, many of which overlap with the risk of traumatic brain injury (TBI) and correlate with poorer recovery trajectories. This study used Bayesian analyses to characterize and compare TBI and biopsychosocial risk factors among 632 siblings (207 NDC, 425 controls; mean age 20.54 years, range 10-30, 78.48% female). NDC siblings had a higher self-reported lifetime history of TBI compared to controls (14.98% versus 6.35%), with most reporting more than one TBI, and at an earlier age. TBI history was associated with psychiatric diagnoses and subclinical NDC features. Family and structural factors related to TBI included poorer parent-child relationship, NDC diagnoses of autism or fetal alcohol spectrum disorder, minority ethnicity, and lower income. Findings have implications for health literacy, TBI education and screening, and implementation of family support.

Trajectory of Health-Related Quality of Life Following Pediatric Concussion

OBJECTIVE

To assess changes in health-related quality of life (HRQOL) across a 12-month period following pediatric concussion and to explore whether psychological factors (ie, preinjury mental health history, current symptoms of anxiety and depression, sleep disturbance, or grit) were associated with HRQOL.

STUDY DESIGN

Prospective cohort study design using data collected from patients presenting to a specialty care concussion program, with each patient followed for 12 months after initial presentation. Comparison data were collected from nonconcussed controls recruited from the community. A total of 49 concussed patients (median = 15.4 years of age) completed the Pediatric Quality of Life Inventory, Patient-Reported Outcome Measure Information Systems Anxiety and Depressive Symptoms short forms, Pediatric Sleep Disturbance forms, and a Short Grit Scale. Mixed effects models explored change in HRQOL across time.

RESULTS

Total HRQOL at initial clinic presentation was significantly lower for concussed adolescents (Pediatric Quality of Life Inventory total score mean = 72 [SD = 16]) compared with nonconcussed controls (mean = 88 [SD = 11], P < .001). HRQOL improved in the patients with concussion over a 6-month period after initial assessment with no significant changes thereafter. Preinjury history of anxiety (coefficient = -11.388, CI = -18.49 to -4.28, P < .001), current depressive symptoms (coefficient = -0.317, CI = -0.62 to -0.01, P < .01), and sleep disturbance (coefficient = -0.336, CI = -0.71 to 0.04, P < .05) all predicted lower HRQOL.

CONCLUSIONS

HRQOL is significantly lower in the acute phase of pediatric concussion and steadily improves over the following 6 months. Psychological factors are linked to lower HRQOL and may serve as important indicators of risk for poor outcome.

Shared Decision-Making About Returning to Sport After Recovery From Pediatric Concussion: Clinician Perspectives

OBJECTIVE

Describe how sports medicine clinicians support decision making about sport participation after concussion recovery with adolescent patients and their parents. Specific areas of inquiry related to how clinicians framed the decision, what factors they considered in how they approached the decision process, and how they navigated discordance within families.

DESIGN

Qualitative study.

SETTING

Tertiary care sports medicine clinics at 4 children's hospitals in the United States.

PARTICIPANTS

Individual interviews were conducted with 17 clinicians practicing in sports medicine settings.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Semi-structured interviews explored clinician approaches to supporting decision making, with the question guide informed by components of the Ottawa Decision Support Framework.

RESULTS

Clinicians routinely incorporated aspects of shared decision making (SDM) into their conversations with families. This included ensuring all parties were informed about risk and aligned behind a shared value of adolescent well-being. Mediation strategies were used to manage discordance between adolescents and their parents, and between parents. These strategies aimed to facilitate a decision that was adolescent centered. When clinicians believed that there was a medical benefit to modifying the adolescent's sport participation practices, or when they did not believe the athlete was psychologically ready to return to the sport in which they were injured, they initiated conversations about alternative activities. In such situations, they used persuasive communication practices to encourage families to strongly consider this option.

CONCLUSION

The strengths and strategies used by sports medicine clinicians in this study provide a foundation for guidance or intervention development aimed at supporting SDM after concussion with adolescents and their families.

The association between symptom burden and processing speed and executive functioning at 4 and 12 weeks following pediatric concussion

OBJECTIVES

Symptoms and cognition are both utilized as indicators of recovery following pediatric concussion, yet their interrelationship is not well understood. This study aimed to investigate: 1) the association of post-concussion symptom burden and cognitive outcomes (processing speed and executive functioning [EF]) at 4 and 12 weeks after pediatric concussion, and 2) the moderating effect of sex on this association.

METHODS

This prospective, multicenter cohort study included participants aged 5.00-17.99 years with acute concussion presenting to four Emergency Departments of the Pediatric Emergency Research Canada network. Five processing speed and EF tasks and the Post-Concussion Symptom Inventory (PCSI; symptom burden, defined as the difference between post-injury and retrospective [pre-injury] scores) were administered at 4 and 12 weeks post-concussion. Generalized least squares models were conducted with task performances as dependent variables and PCSI and PCSI*sex interaction as the main predictors, with important pre-injury demographic and injury characteristics as covariates.

RESULTS

311 children (65.0% males; median age = 11.92 [IQR = 9.14-14.21 years]) were included in the analysis. After adjusting for covariates, higher symptom burden was associated with lower Backward Digit Span (χ2 = 9.85, p = .043) and Verbal Fluency scores (χ2 = 10.48, p = .033) across time points; these associations were not moderated by sex, ps ≥ .20. Symptom burden was not associated with performance on the Coding, Continuous Performance Test, and Color-Word Interference scores, ps ≥ .17.

CONCLUSIONS

Higher symptom burden is associated with lower working memory and cognitive flexibility following pediatric concussion, yet these associations were not moderated by sex. Findings may inform concussion management by emphasizing the importance of multifaceted assessments of EF.

Different trajectories of post-concussive symptom subscales after pediatric mild traumatic brain injury: Data from a prospective longitudinal study

PURPOSE

The aim of this study was to investigate the trajectory of parent-rated post-concussive symptoms (PCS), attentional performance and participation within 6 months in children after mild traumatic brain injury (mTBI).

METHODS

For this prospective longitudinal study, we included data on 64 children after mTBI and 57 healthy control children (age 8-16 years). Parents rated PCS using the Post-Concussion Symptom Inventory (PCSI) immediately (T0), 1 week (T1), and 3-6 months after injury (T2). Attentional performance (alertness, selective and divided attention) was measured using the Test of Attentional Performance (TAP) at T1 and T2 and participation was measured using the Child and Adolescent Scale of Participation (CASP) at T2.

RESULTS

Friedman tests showed different trajectories of PCS subscales over time: Compared to pre-injury level, the amount of somatic and cognitive PCS was still elevated at T1, while emotional PCS at T1 were already comparable to pre-injury level. The rating of sleep-related PCS at T2 was significantly elevated compared to the pre-injury rating. Quade ANCOVAs indicated group differences in PCS subscales between patients and controls at T1, but not at T2. Patients and controls showed a similar performance in tests of attention at T1 and T2, but parental rating of participation at school was significantly reduced. Although cognitive PCS and attention were not correlated, there were significantly negative Spearman correlations between participation at home and pre-injury and concurrent PCS at T2.

CONCLUSIONS

Our data imply that sleep-related PCS are still elevated weeks after injury and are thus a target for interventions after mTBI.

Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion

BACKGROUND

Aerobic exercise facilitates postconcussion symptom resolution at the group level, but patient-level characteristics may affect the likelihood of treatment efficacy.

PURPOSE

This study aimed to investigate demographic and clinical characteristics, which differentiate postconcussion aerobic exercise treatment efficacy from nonefficacy in the intervention arm of a randomized clinical trial.

METHODS

Adolescent and young adult participants initiated a standardized aerobic exercise intervention within 14 d of concussion, consisting of self-selected exercise for 100 min·wk -1 at an individualized heart rate (80% of heart rate induced symptom exacerbation during graded exercise testing). Treatment efficacy was defined as symptom resolution within 28-d postconcussion. Treatment efficacy and nonefficacy groups were compared on demographics, clinical characteristics, intervention adherence, and persistent symptom risk using the Predicting Persistent Postconcussive Problems in Pediatrics (5P) clinical risk score.

RESULTS

A total of 27 participants (16.1 ± 2.3 yr old; range, 11-21 yr; 52% female) began the intervention, with a mean of 9.5 ± 3.7 d after concussion; half ( n = 13; 48%) demonstrated treatment efficacy (symptom resolution within 28 d postconcussion). Those whose symptoms resolved within 28 d had significantly lower preintervention postconcussion symptom inventory scores (21.2 ± 13.2 vs 41.4 ± 22.2; P < 0.01), greater adherence to the intervention (77% vs 36%; P = 0.05), and longer average exercise duration (median [interquartile range], 49.7 [36.8-68.6] vs 30.4 [20.7-34.7] min; P < 0.01) than those whose symptoms lasted more than 28 d. Groups were similar in age, sex, timing of intervention, and preintervention 5P risk score.

CONCLUSIONS

A standardized aerobic exercise intervention initiated within 14 d of concussion demonstrated efficacy for approximately half of participants, according to our definition of treatment efficacy. This multisite aerobic exercise intervention suggests that lower symptom severity, higher intervention adherence, and greater exercise duration are factors that increase the likelihood of symptoms resolving within 28 d of concussion.

New Insights Into Accelerometer-Measured Habitual Physical Activity and Sedentary Time During Early Recovery in Pediatric Concussion

PURPOSE

Concussion management is shifting away from a rest-is-best approach, as data now suggest that exercise-is-medicine for this mild brain injury. Despite this, we have limited data on habitual physical activity following concussion. Therefore, our objective was to quantify accelerometer-measured physical activity and sedentary time in children with concussion (within the first month of injury) and healthy controls. We hypothesized that children with concussion would be less active than their healthy peers.

METHODS

We performed a secondary analysis of prospectively collected accelerometer data. Our sample included children with concussion (n = 60, 31 females) and historical controls (n = 60) matched for age, sex, and season of accelerometer wear.

RESULTS

Children with concussion were significantly more sedentary than controls (mean difference [MD], 38.3 min/d, P = .006), and spent less time performing light physical activity (MD, -19.5 min/d, P = .008), moderate physical activity (MD, -9.8 min/d, P < .001), and vigorous physical activity (MD, -12.0 min/d, P < .001); these differences were observed from 8:00 AM to 9:00 PM. Sex-specific analyses identified that girls with concussion were less active and more sedentary than both boys with concussion (P = .010) and healthy girls (P < .010).

CONCLUSION

There is an activity deficit observed within the first month of pediatric concussion. Physical activity guidelines should address this while considering sex effects.

Applicability and clinical utility of the German rivermead post-concussion symptoms questionnaire in proxies of children after traumatic brain injury: an instrument validation study

BACKGROUND

The German Rivermead Post-Concussion Symptoms Questionnaire (RPQ) can be used to assess post-concussion symptoms (PCS) after traumatic brain injury (TBI) in adults, adolescents, and children.

METHODS

In this study, we examined the psychometric properties of the German RPQ proxy version (N = 146) for children (8-12 years) after TBI at the item, total and scale score level. Construct validity was analyzed using rank correlations with the proxy-assessed Post-Concussion Symptoms Inventory (PCSI-P), the Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder Scale 7 (GAD-7). Furthermore, sensitivity testing was performed concerning subjects' sociodemographic and injury-related characteristics. Differential item functioning (DIF) was analyzed to assess the comparability of RPQ proxy ratings for children with those for adolescents.

RESULTS

Good internal consistency was demonstrated regarding Cronbach's α (0.81-0.90) and McDonald's ω (0.84-0.92). The factorial validity of a three-factor model was superior to the original one-factor model. Proxy ratings of the RPQ total and scale scores were strongly correlated with the PCSI-P (ϱ = 0.50-0.69), as well as moderately to strongly correlated with the PHQ-9 (ϱ = 0.49-0.65) and the GAD-7 (ϱ = 0.44-0.64). The DIF analysis revealed no relevant differences between the child and adolescent proxy versions.

CONCLUSIONS

The German RPQ proxy is a psychometrically reliable and valid instrument for assessing PCS in children after TBI. Therefore, RPQ self- and proxy-ratings can be used to assess PCS in childhood as well as along the lifespan of an individual after TBI.

Smartphone App-Delivered Mindfulness-Based Intervention for Mild Traumatic Brain Injury in Adolescents: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms.

OBJECTIVE

The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group.

METHODS

This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion.

RESULTS

The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted.

CONCLUSIONS

This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57226.

Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study

BACKGROUND

Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored.

OBJECTIVE

This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention.

METHODS

Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention.

RESULTS

Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would.

CONCLUSIONS

Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

Postconcussive Symptoms After Early Childhood Concussion

Importance

Research on postconcussive symptoms (PCS) following early childhood concussion has been hindered by a lack of measures suitable for this age group, resulting in a limited understanding of their evolution in young children.

Objective

To document PCS in the first 3 months after early childhood concussion using a developmentally appropriate measure.

Design, Setting, and Participants

This cohort study used data collected at 3 Canadian and 1 US urban pediatric emergency departments (EDs) and 8 Canadian daycares from December 2018 to December 2022 as part of the Kids' Outcomes and Long-Term Abilities (KOALA) project, a prospective, multicenter, longitudinal cohort study. Participants included children aged 6 to 72 months with early childhood concussion or orthopedic injury (OI) or uninjured children from the community to serve as controls. Data were analyzed from March 2023 to January 2024.

Exposure

Concussion sustained between ages 6 and 72 months.

Main Outcomes and Measures

Primary outcomes were cognitive, physical, behavioral and total PCS assessed prior to injury (retrospectively), acutely (within 48 hours), and at 10 days, 1 month, and 3 months after injury or recruitment through caregiver observations using the Report of Early Childhood Traumatic Injury Observations & Symptoms inventory. Group comparisons were analyzed using ordinal regression models.

Results

The study included 303 children (mean [SD] age, 35.8 [20.2] months; 152 [50.2%] male). Of these, 174 children had a concussion (mean [SD] age,  33.3 [19.9] months), 60 children had an OI (mean [SD] age, 38.4 [19.8] months) and 69 children were uninjured controls (mean [SD] age, 39.7 [20.8] months). No meaningful differences were found between the concussion and comparison groups in retrospective preinjury PCS. Significant group differences were found for total PCS at the initial ED visit (concussion vs OI: odds ratio [OR], 4.33 [95% CI, 2.44-7.69]; concussion vs control: OR, 7.28 [95% CI, 3.80-13.93]), 10 days (concussion vs OI: OR, 4.44 [95% CI, 2.17-9.06]; concussion vs control: OR, 5.94 [95% CI, 3.22-10.94]), 1 month (concussion vs OI: OR, 2.70 [95% CI, 1.56-4.68]; concussion vs control: OR, 4.32 [95% CI, 2.36-7.92]), and 3 months (concussion vs OI: OR, 2.61 [95% CI, 1.30-5.25]; concussion vs control: OR, 2.40 [95% CI, 1.36-4.24]). Significant group differences were also found for domain-level scores (cognitive, physical, behavioral) at various time points.

Conclusions and Relevance

In this early childhood cohort study, concussion was associated with more PCS than OIs or typical development up to 3 months after injury. Given the limited verbal and cognitive abilities typical of early childhood, using developmentally appropriate manifestations and behaviors is a valuable way of tracking PCS and could aid in concussion diagnosis in young children.

Longitudinal Brain Perfusion and Symptom Presentation Following Pediatric Concussion: A Pediatric Concussion Assessment of Rest and Exertion+MRI (PedCARE+MRI) Substudy

Emerging evidence suggests that advanced neuroimaging modalities such as arterial spin labelling (ASL) might have prognostic utility for pediatric concussion. This study aimed to: 1) examine group differences in global and regional brain perfusion in youth with concussion or orthopedic injury (OI) at 72 h and 4 weeks post-injury; 2) examine patterns of abnormal brain perfusion within both groups and their recovery; 3) investigate the association between perfusion and symptom burden within concussed and OI youths at both time-points; and 4) explore perfusion between symptomatic and asymptomatic concussed and OI youths. Youths ages 10.00-17.99 years presenting to the emergency department with an acute concussion or OI were enrolled. ASL-magnetic resonance imaging scans were conducted at 72 h and 4 weeks post-injury to measure brain perfusion, along with completion of the Health Behavior Inventory (HBI) to measure symptoms. Abnormal perfusion clusters were identified using voxel-based z-score analysis at each visit. First, mixed analyses of covariance (ANCOVAs) investigated the Group*Time interaction on global and regional perfusion. Post hoc region of interest (ROI) analyses were performed on significant regions. Second, within-group generalized estimating equations investigated the recovery of abnormal perfusion at an individual level. Third, multiple regressions at each time-point examined the association between HBI and regional perfusion, and between HBI and abnormal perfusion volumes within the concussion group. Fourth, whole-brain one-way ANCOVAs explored differences in regional and abnormal perfusion based on symptomatic status (symptomatic vs. asymptomatic) and OIs at each time-point. A total of 70 youths with a concussion [median age (interquartile range; IQR) = 12.70 (11.67-14.35), 47.1% female] and 29 with an OI [median age (IQR) = 12.05 (11.18-13.89), 41.4% female] were included. Although no Group effect was found in global perfusion, the concussion group showed greater adjusted perfusion within the anterior cingulate cortex/middle frontal gyrus (MFG) and right MFG compared with the OI group across time-points (ps ≤ 0.004). The concussion group showed lower perfusion within the right superior temporal gyrus at both time-points and bilateral occipital gyrus at 4 weeks, (ps ≤ 0.006). The number of hypoperfused clusters was increased at 72 h compared with 4 weeks in the concussion youths (p < 0.001), but not in the OIs. Moreover, Group moderated the HBI-perfusion association within the left precuneus and superior frontal gyrus at both time-points, (ps ≤ 0.001). No association was found between HBI and abnormal perfusion volume within the concussion group at any visits. At 4 weeks, the symptomatic sub-group (n = 10) showed lower adjusted perfusion within the right cerebellum and lingual gyrus, while the asymptomatic sub-group (n = 59) showed lower adjusted perfusion within the left calcarine, but greater perfusion within the left medial orbitofrontal cortex, right middle frontal gyrus, and bilateral caudate compared with OIs. Yet, no group differences were observed in the number of abnormal perfusion clusters or volumes at any visit. The present study suggests that symptoms may be associated with changes in regional perfusion, but not abnormal perfusion levels.

Longitudinal Functional Connectome in Pediatric Concussion: An Advancing Concussion Assessment in Pediatrics Study

Advanced magnetic resonance imaging (MRI) techniques indicate that concussion (i.e., mild traumatic brain injury) disrupts brain structure and function in children. However, the functional connectivity of brain regions within global and local networks (i.e., functional connectome) is poorly understood in pediatric concussion. This prospective, longitudinal study addressed this gap using data from the largest neuroimaging study of pediatric concussion to date to study the functional connectome longitudinally after concussion as compared with mild orthopedic injury (OI). Children and adolescents (n = 967) 8-16.99 years with concussion or mild OI were recruited from pediatric emergency departments within 48 h post-injury. Pre-injury and 1-month post-injury symptom ratings were used to classify concussion with or without persistent symptoms based on reliable change. Subjects completed a post-acute (2-33 days) and chronic (3 or 6 months via random assignment) MRI scan. Graph theory metrics were derived from 918 resting-state functional MRI scans in 585 children (386 concussion/199 OI). Linear mixed-effects modeling was performed to assess group differences over time, correcting for multiple comparisons. Relative to OI, the global clustering coefficient was reduced at 3 months post-injury in older children with concussion and in females with concussion and persistent symptoms. Time post-injury and sex moderated group differences in local (regional) network metrics of several brain regions, including degree centrality, efficiency, and clustering coefficient of the angular gyrus, calcarine fissure, cuneus, and inferior occipital, lingual, middle occipital, post-central, and superior occipital gyrus. Relative to OI, degree centrality and nodal efficiency were reduced post-acutely, and nodal efficiency and clustering coefficient were reduced chronically after concussion (i.e., at 3 and 6 months post-injury in females; at 6 months post-injury in males). Functional network alterations were more robust and widespread chronically as opposed to post-acutely after concussion, and varied by sex, age, and symptom recovery at 1-month post-injury. Local network segregation reductions emerged globally (across the whole brain network) in older children and in females with poor recovery chronically after concussion. Reduced functioning between neighboring regions could negatively disrupt specialized information processing. Local network metric alterations were demonstrated in several posterior regions that are involved in vision and attention after concussion relative to OI. This indicates that functioning of superior parietal and occipital regions could be particularly susceptibile to the effects of concussion. Moreover, those regional alterations were especially apparent at later time periods post-injury, emerging after post-concussive symptoms resolved in most and persisted up to 6 months post-injury, and differed by biological sex. This indicates that neurobiological changes continue to occur up to 6 months after pediatric concussion, although changes emerge earlier in females than in males. Changes could reflect neural compensation mechanisms.

The Role of Puberty and Sex on Brain Structure in Adolescents With Anxiety Following Concussion

BACKGROUND

Adolescence represents a window of vulnerability for developing psychological symptoms following concussion, especially in girls. Concussion-related lesions in emotion regulation circuits may help explain these symptoms. However, the contribution of sex and pubertal maturation remains unclear. Using the neurite density index (NDI) in emotion regulation tracts (left/right cingulum bundle [CB], forceps minor [FMIN], and left/right uncinate fasciculus), we sought to elucidate these relationships.

METHODS

No adolescent had a history of anxiety and/or depression. The Screen for Child Anxiety Related Emotional Disorders and Children's Depression Rating Scale were used at scan to assess anxiety and depressive symptoms in 55 concussed adolescents (41.8% girls) and 50 control adolescents with no current/history of concussion (44% girls). We evaluated if a mediation-moderation model including the NDI (mediation) and sex or pubertal status (moderation) could help explain this relationship.

RESULTS

Relative to control adolescents, concussed adolescents showed higher anxiety (p = .003) and lower NDI, with those at more advanced pubertal maturation showing greater abnormalities in 4 clusters: the left CB frontal (p = .002), right CB frontal (p = .011), FMIN left-sided (p = .003), and FMIN right-sided (p = .003). Across all concussed adolescents, lower NDI in the left CB frontal and FMIN left-sided clusters partially mediated the association between concussion and anxiety, with the CB being specific to female adolescents. These effects did not explain depressive symptoms.

CONCLUSIONS

Our findings indicate that lower NDI in the CB and FMIN may help explain anxiety following concussion and that adolescents at more advanced (vs less advanced) status of pubertal maturation may be more vulnerable to concussion-related injuries, especially in girls.

Longitudinal changes in brain metabolites following pediatric concussion

Concussion is commonly characterized by a cascade of neurometabolic changes following injury. Magnetic Resonance Spectroscopy (MRS) can be used to quantify neurometabolites non-invasively. Longitudinal changes in neurometabolites have rarely been studied in pediatric concussion, and fewer studies consider symptoms. This study examines longitudinal changes of neurometabolites in pediatric concussion and associations between neurometabolites and symptom burden. Participants who presented with concussion or orthopedic injury (OI, comparison group) were recruited. The first timepoint for MRS data collection was at a mean of 12 days post-injury (n = 545). Participants were then randomized to 3 (n = 243) or 6 (n = 215) months for MRS follow-up. Parents completed symptom questionnaires to quantify somatic and cognitive symptoms at multiple timepoints following injury. There were no significant changes in neurometabolites over time in the concussion group and neurometabolite trajectories did not differ between asymptomatic concussion, symptomatic concussion, and OI groups. Cross-sectionally, Choline was significantly lower in those with persistent somatic symptoms compared to OI controls at 3 months post-injury. Lower Choline was also significantly associated with higher somatic symptoms. Although overall neurometabolites do not change over time, choline differences that appear at 3 months and is related to somatic symptoms.

Multidomain Predictors of Protracted Recovery following Concussion among 5- to 9-Year-Old Patients: A Preliminary Study

OBJECTIVE

To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion.

STUDY DESIGN

A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery.

RESULTS

The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001).

CONCLUSIONS

Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

Cognition and post-concussive symptom status after pediatric mild traumatic brain injury

Cognitive impairment and post-concussive symptoms (PCS) represent hallmark sequelae of pediatric mild traumatic brain injury (pmTBI). Few studies have directly compared cognition as a function of PCS status longitudinally. Cognitive outcomes were therefore compared for asymptomatic pmTBI, symptomatic pmTBI, and healthy controls (HC) during sub-acute (SA; 1-11 days) and early chronic (EC; approximately 4 months) post-injury phases. We predicted worse cognitive performance for both pmTBI groups relative to HC at the SA visit. At the EC visit, we predicted continued impairment from the symptomatic group, but no difference between asymptomatic pmTBI and HCs. A battery of clinical (semi-structured interviews and self-report questionnaires) and neuropsychological measures were administered to 203 pmTBI and 139 HC participants, with greater than 80% retention at the EC visit. A standardized change method classified pmTBI into binary categories of asymptomatic or symptomatic based on PCS scores. Symptomatic pmTBI performed significantly worse than HCs on processing speed, attention, and verbal memory at SA visit, whereas lower performance was only present for verbal memory for asymptomatic pmTBI. Lower performance in verbal memory persisted for both pmTBI groups at the EC visit. Surprisingly, a minority (16%) of pmTBI switched from asymptomatic to symptomatic status at the EC visit. Current findings suggest that PCS and cognition are more closely coupled during the first week of injury but become decoupled several months post-injury. Evidence of lower performance in verbal memory for both asymptomatic and symptomatic pmTBI suggests that cognitive recovery may be a process separate from the resolution of subjective symptomology.

The Relationship Between Parental and Family Functioning and Post-Concussive Symptoms After Pediatric Mild Traumatic Brain Injury: A Scoping Review

This scoping review aimed to address the following questions: (1) Does mild traumatic brain injury (mTBI) result in more parental distress or poorer family functioning than other injuries? (2) Does pre-injury or acute parental distress and family functioning predict post-concussive symptoms (PCS) after mTBI? and (3) Do acute PCS predict later parental distress and family functioning? The subjects of this review were children/adolescents who had sustained an mTBI before age 18 and underwent assessment of PCS and parent or family functioning. MEDLINE®, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and CENTRAL databases were searched to identify original, empirical, peer-reviewed research published in English. PCS measures included parent- and child-reported symptom counts and continuous scales. Parent and family measures assessed parental stress, psychological adjustment, anxiety, psychiatric history, parent-child interactions, family burden, and general family functioning. A total of 11,163 articles were screened, leading to the inclusion of 15 studies, with 2569 participants (mTBI = 2222; control = 347). Collectively, the included articles suggest that mTBI may not result in greater parental distress or poorer family functioning than other types of injuries. Pre-injury or acute phase parental and family functioning appears to predict subsequent PCS after mTBI, depending on the specific family characteristic being studied. Early PCS may also predict subsequent parental and family functioning, although findings were mixed in terms of predicting more positive or negative family outcomes. The available evidence suggests that parent and family functioning may have an important, perhaps bidirectional, association with PCS after pediatric mTBI. However, further research is needed to provide a more thorough understanding of this association.

Acceptability, usability, and credibility of a mindfulness-based digital therapeutic for pediatric concussion: A mixed-method study

Background

The ability to cope with concussion symptoms and manage stress is an important determinant of risk for prolonged symptoms.

Objective

This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion.

Methods

Participants aged 12 to 18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1-month post-concussion (persisting symptoms cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10 to 15 minutes/day, at a minimum of 4 days/week. At 2 weeks, participants completed a credibility and expectancy questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability and working alliance, as well as a semi-structured phone interview.

Results

Ten participants completed the study outcomes (7 acute; 3 persisting symptoms). The intervention was perceived as credible (median/max possible = 6.50/9.00 [6.83,8.75]) and DTx was usable (median/max possible = 70.00/100.00 [55.00,82.50]). Participants rated their satisfaction with the DTx (median/max possible = 27.00/32.00 [24.50,29.50]) and the working alliance with the digital mindfulness guides (median/max possible = 3.92/5.00 [3.38-4.33]) as high. Four themes were identified from the qualitative data: (a) positive attributes; (b) negative attributes; (c) ideas for modifications; and (d) technical issues.

Conclusion

Results show modifications to the DTx, instructions and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx MBI to decrease the risk of persisting symptoms and reduce the symptom burden following pediatric concussion.

Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study

OBJECTIVE

To characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization.

METHODS

A retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization.

RESULTS

Eight hundred nineteen index visits (median [interquartile range] age, 14 [11-16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09-3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02-3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31-1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95-2.69) predicted increased utilization intensity.

CONCLUSIONS

Health care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability.

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study

BACKGROUND

Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion.

METHODS

Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined.

RESULTS

In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history.

CONCLUSIONS

There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

Mood and anxiety symptoms following pediatric mild traumatic brain injury: a scoping review

Background

Thousands of children sustain mild traumatic brain injuries (mTBI) worldwide each year. Multiple physical and somatic symptoms can occur following pediatric mTBI, including new-onset mood symptoms, headaches, and pain.

Objective

This scoping review examined the existing literature pertaining to mood and anxiety symptoms following pediatric mTBI, in order to summarize the current evidence and identify areas for future research.

Methods

The Pubmed, EMBase, and APA PsycINFO databases were searched to identify articles that examined mood and anxiety symptoms in children and adolescents following mTBI.

Results

A total of 20 published articles were included in the review. The existing research suggests that mood and anxiety symptoms are more common in children and adolescents with mTBI, when compared to orthopedically injured or healthy controls. Several factors may contribute to the development of these symptoms: injury characteristics, older age at injury, female sex, and psychosocial variables including lower socioeconomic status and family history of psychiatric disorders.

Conclusion

The findings of this review highlight the need for additional research on the relationship between pediatric mTBI and subsequent mood and anxiety symptoms. We particularly recommend long-term prospective cohort studies which include appropriate control groups as well as a neuroimaging component to distinguish complicated from uncomplicated mTBI.

Neurophysiological Effects of Repeated Soccer Heading in Youth

Repeated head loading in sports is associated with negative long-term brain health, and there is growing evidence of short-term neurophysiological changes after repeated soccer heading. The objective of this study was to quantify the head kinematics and effects of repetitive soccer headers in adolescents using an instrumented mouthguard. Adolescent soccer players aged 13-18 years were randomly assigned to a kicking control, frontal heading, or oblique heading group. Participants completed neurophysiological assessments at three-time points: immediately prior to, immediately after, and approximately 24 h after completing 10 headers or kicks. The suite of assessments included the Post-Concussion Symptom Inventory, visio-vestibular exam, King-Devick test, modified Clinical Test of Sensory Interaction and Balance with force plate sway measurement, pupillary light reflex, and visual evoked potential. Data were collected for 19 participants (17 male). Frontal headers resulted in significantly higher peak resultant linear acceleration (17.4 ± 0.5 g) compared to oblique headers (12.1 ± 0.4 g, p < 0.001), and oblique headers resulted in significantly higher peak resultant angular acceleration (frontal: 1147 ± 45 rad/s2, oblique: 1410 ± 65 rad/s2, p < 0.001). There were no neurophysiological deficits for either heading group or significant differences from controls at either post-heading timepoint, and therefore, a bout of repeated headers did not result in changes in the neurophysiological measures evaluated in this study. The current study provided data regarding the direction of headers with the goal to reduce the risk of repetitive head loading for adolescent athletes.

Longitudinal Gray Matter Trajectories in Pediatric Mild Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

This prospective, longitudinal cohort study examined trajectories of brain gray matter macrostructure after pediatric mild traumatic brain injury (mTBI).

METHODS

Children aged 8-16.99 years with mTBI or mild orthopedic injury (OI) were recruited from 5 pediatric emergency departments. Reliable change between preinjury and 1 month postinjury symptom ratings was used to classify mTBI with or without persistent symptoms. Children completed postacute (2-33 days) and/or chronic (3 or 6 months) postinjury T1-weighted MRI, from which macrostructural metrics were derived using automated segmentation. Linear mixed-effects models were used, with multiple comparisons correction.

RESULTS

Groups (N = 623; 407 mTBI/216 OI; 59% male; age mean = 12.03, SD = 2.38 years) did not differ in total brain, white, or gray matter volumes or regional subcortical gray matter volumes. However, time postinjury, age at injury, and biological sex-moderated differences among symptom groups in cortical thickness of the angular gyrus, basal forebrain, calcarine cortex, gyrus rectus, medial and posterior orbital gyrus, and the subcallosal area all corrected p < 0.05. Gray matter macrostructural metrics did not differ between groups postacutely. However, cortical thinning emerged chronically after mTBI relative to OI in the angular gyrus in older children (d [95% confidence interval] = -0.61 [-1.15 to -0.08]); and in the basal forebrain (-0.47 [-0.94 to -0.01]), subcallosal area (-0.55 [-1.01 to -0.08]), and the posterior orbital gyrus (-0.55 [-1.02 to -0.08]) in females. Cortical thinning was demonstrated for frontal and occipital regions 3 months postinjury in males with mTBI with persistent symptoms vs without persistent symptoms (-0.80 [-1.55 to -0.05] to -0.83 [-1.56 to -0.10]) and 6 months postinjury in females and younger children with mTBI with persistent symptoms relative to mTBI without persistent symptoms and OI (-1.42 [-2.29 to -0.45] to -0.91 [-1.81 to -0.01]).

DISCUSSION

These findings signal little diagnostic and prognostic utility of postacute gray matter macrostructure in pediatric mTBI. However, mTBI altered the typical course of cortical gray matter thinning up to 6 months postinjury, even after symptoms typically abate in most children. Collapsing across symptom status obscured the neurobiological heterogeneity of discrete clinical outcomes after pediatric mTBI. The results illustrate the need to examine neurobiology in relation to clinical outcomes and within a neurodevelopmental framework.

Premature white matter microstructure in female children with a history of concussion

Childhood concussion may interfere with neurodevelopment and influence cognition. Females are more likely to experience persistent symptoms after concussion, yet the sex-specific impact of concussion on brain microstructure in children is understudied. This study examined white matter and cortical microstructure, based on neurite density (ND) from diffusion-weighted MRI, in 9-to-10-year-old children in the Adolescent Brain Cognitive Development Study with (n = 336) and without (n = 7368) a history of concussion, and its relationship with cognitive performance. Multivariate regression was used to investigate relationships between ND and group, sex, and age in deep and superficial white matter, subcortical structures, and cortex. Partial least square correlation was performed to identify associations between ND and performance on NIH Toolbox tasks in children with concussion. All tissue types demonstrated higher ND with age, reflecting brain maturation. Group comparisons revealed higher ND in deep and superficial white matter in females with concussion. In female but not male children with concussion, there were significant associations between ND and performance on cognitive tests. These results demonstrate a greater long-term impact of childhood concussion on white matter microstructure in females compared to males that is associated with cognitive function. The increase in ND in females may reflect premature white matter maturation.

IQ After Pediatric Concussion

OBJECTIVES

This study investigated IQ scores in pediatric concussion (ie, mild traumatic brain injury) versus orthopedic injury.

METHODS

Children (N = 866; aged 8-16.99 years) were recruited for 2 prospective cohort studies from emergency departments at children's hospitals (2 sites in the United States and 5 in Canada) ≤48 hours after sustaining a concussion or orthopedic injury. They completed IQ and performance validity testing postacutely (3-18 days postinjury; United States) or 3 months postinjury (Canada). Group differences in IQ scores were examined using 3 complementary statistical approaches (linear modeling, Bayesian, and multigroup factor analysis) in children performing above cutoffs on validity testing.

RESULTS

Linear models showed small group differences in full-scale IQ (d [95% confidence interval] = 0.13 [0.00-0.26]) and matrix reasoning (0.16 [0.03-0.30]), but not in vocabulary scores. IQ scores were not related to previous concussion, acute clinical features, injury mechanism, a validated clinical risk score, pre- or postinjury symptom ratings, litigation, or symptomatic status at 1 month postinjury. Bayesian models provided moderate to very strong evidence against group differences in IQ scores (Bayes factor 0.02-0.23). Multigroup factor analysis further demonstrated strict measurement invariance, indicating group equivalence in factor structure of the IQ test and latent variable means.

CONCLUSIONS

Across multisite, prospective study cohorts, 3 complementary statistical models provided no evidence of clinically meaningful differences in IQ scores after pediatric concussion. Instead, overall results provided strong evidence against reduced intelligence in the first few weeks to months after pediatric concussion.

Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging

Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.

Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion

OBJECTIVE

To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit.

SETTING, DESIGN, AND PARTICIPANTS

We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study.

MAIN MEASURES

The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days.

RESULTS

Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small.

CONCLUSION

Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.

Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury

BACKGROUND AND AIMS

Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI.

METHODS

Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS.

RESULTS

The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up.

CONCLUSION

Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.

Altered longitudinal structural connectome in paediatric mild traumatic brain injury: an Advancing Concussion Assessment in Paediatrics study

Advanced diffusion-weighted imaging techniques have increased understanding of the neuropathology of paediatric mild traumatic brain injury (i.e. concussion). Most studies have examined discrete white-matter pathways, which may not capture the characteristically subtle, diffuse and heterogenous effects of paediatric concussion on brain microstructure. This study compared the structural connectome of children with concussion to those with mild orthopaedic injury to determine whether network metrics and their trajectories across time post-injury differentiate paediatric concussion from mild traumatic injury more generally. Data were drawn from of a large study of outcomes in paediatric concussion. Children aged 8-16.99 years were recruited from five paediatric emergency departments within 48 h of sustaining a concussion (n = 360; 56% male) or mild orthopaedic injury (n = 196; 62% male). A reliable change score was used to classify children with concussion into two groups: concussion with or without persistent symptoms. Children completed 3 T MRI at post-acute (2-33 days) and/or chronic (3 or 6 months, via random assignment) post-injury follow-ups. Diffusion-weighted images were used to calculate the diffusion tensor, conduct deterministic whole-brain fibre tractography and compute connectivity matrices in native (diffusion) space for 90 supratentorial regions. Weighted adjacency matrices were constructed using average fractional anisotropy and used to calculate global and local (regional) graph theory metrics. Linear mixed effects modelling was performed to compare groups, correcting for multiple comparisons. Groups did not differ in global network metrics. However, the clustering coefficient, betweenness centrality and efficiency of the insula, cingulate, parietal, occipital and subcortical regions differed among groups, with differences moderated by time (days) post-injury, biological sex and age at time of injury. Post-acute differences were minimal, whereas more robust alterations emerged at 3 and especially 6 months in children with concussion with persistent symptoms, albeit differently by sex and age. In the largest neuroimaging study to date, post-acute regional network metrics distinguished concussion from mild orthopaedic injury and predicted symptom recovery 1-month post-injury. Regional network parameters alterations were more robust and widespread at chronic timepoints than post-acutely after concussion. Results suggest that increased regional and local subnetwork segregation (modularity) and inefficiency occurs across time after concussion, emerging after post-concussive symptom resolve in most children. These differences persist up to 6 months after concussion, especially in children who showed persistent symptoms. While prognostic, the small to modest effect size of group differences and the moderating effects of sex likely would preclude effective clinical application in individual patients.

Associations between psychological resilience and metrics of white matter microstructure in pediatric concussion

This study investigated associations between psychological resilience and characteristics of white matter microstructure in pediatric concussion. This is a case control study and a planned substudy of a larger randomized controlled trial. Children with an acute concussion or orthopedic injury were recruited from the emergency department. Participants completed both the Connor-Davidson Resilience Scale 10 and an MRI at 72 h and 4-weeks post-injury. The association between resiliency and fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) at both timepoints were examined. We examined whether these associations were moderated by group. The association between resiliency captured at 72 h and diffusion tensor imaging metrics at 4 weeks was also investigated. Clusters were extracted using a significance threshold of threshold-free cluster enhancement corrected p < .05. A total of 66 children with concussion (median (IQR) age = 12.88 (IQR: 11.80-14.36); 47% female) and 29 children with orthopedic-injury (median (IQR) age = 12.49 (IQR: 11.18-14.01); 41% female) were included. A negative correlation was identified in the concussion group between 72 h resilience and 72 h FA. Meanwhile, positive correlations were identified in the concussion group with concussion between 72 h resilience and both 72 h MD and 72 h RD. These findings suggest that 72 h resilience is associated with white matter microstructure of the forceps minor, superior longitudinal fasciculus, and anterior thalamic radiation at 72 h post-concussion. Resilience seems to be associated with neural integrity only in the acute phase of concussion and thus may be considered when researching concussion recovery.

Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury

OBJECTIVE

This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury.

METHODS

Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site.

RESULTS

PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, β (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury.

CONCLUSIONS

Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.

Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes

OBJECTIVE

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors.

METHODS

Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03-1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002-1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85-1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77-1.34, P = 0.925).

CONCLUSIONS

Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.

The Effects of Extrinsic and Intrinsic Factors on Neurogenesis

In the mammalian brain, neurogenesis is maintained throughout adulthood primarily in two typical niches, the subgranular zone (SGZ) of the dentate gyrus and the subventricular zone (SVZ) of the lateral ventricles and in other nonclassic neurogenic areas (e.g., the amygdala and striatum). During prenatal and early postnatal development, neural stem cells (NSCs) differentiate into neurons and migrate to appropriate areas such as the olfactory bulb where they integrate into existing neural networks; these phenomena constitute the multistep process of neurogenesis. Alterations in any of these processes impair neurogenesis and may even lead to brain dysfunction, including cognitive impairment and neurodegeneration. Here, we first summarize the main properties of mammalian neurogenic niches to describe the cellular and molecular mechanisms of neurogenesis. Accumulating evidence indicates that neurogenesis plays an integral role in neuronal plasticity in the brain and cognition in the postnatal period. Given that neurogenesis can be highly modulated by a number of extrinsic and intrinsic factors, we discuss the impact of extrinsic (e.g., alcohol) and intrinsic (e.g., hormones) modulators on neurogenesis. Additionally, we provide an overview of the contribution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to persistent neurological sequelae such as neurodegeneration, neurogenic defects and accelerated neuronal cell death. Together, our review provides a link between extrinsic/intrinsic factors and neurogenesis and explains the possible mechanisms of abnormal neurogenesis underlying neurological disorders.

Association of Posttraumatic Headache With Symptom Burden After Concussion in Children

Importance

Headache is the most common symptom after pediatric concussion.

Objectives

To examine whether posttraumatic headache phenotype is associated with symptom burden and quality of life 3 months after concussion.

Design, Setting, and Participants

This was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) prospective cohort study, conducted September 2016 to July 2019 at 5 Pediatric Emergency Research Canada (PERC) network emergency departments. Children aged 8.0-16.99 years presenting with acute (<48 hours) concussion or orthopedic injury (OI) were included. Data were analyzed from April to December 2022.

Exposure

Posttraumatic headache was classified as migraine or nonmigraine headache, or no headache, using modified International Classification of Headache Disorders, 3rd edition, diagnostic criteria based on self-reported symptoms collected within 10 days of injury.

Main Outcomes and Measures

Self-reported postconcussion symptoms and quality-of-life were measured at 3 months after concussion using the validated Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0). An initial multiple imputation approach was used to minimize potential biases due to missing data. Multivariable linear regression evaluated the association between headache phenotype and outcomes compared with the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score and other covariates and confounders. Reliable change analyses examined clinical significance of findings.

Results

Of 967 enrolled children, 928 (median [IQR] age, 12.2 [10.5 to 14.3] years; 383 [41.3%] female) were included in analyses. HBI total score (adjusted) was significantly higher for children with migraine than children without headache (estimated mean difference [EMD], 3.36; 95% CI, 1.13 to 5.60) and children with OI (EMD, 3.10; 95% CI, 0.75 to 6.62), but not children with nonmigraine headache (EMD, 1.93; 95% CI, -0.33 to 4.19). Children with migraine were more likely to report reliable increases in total symptoms (odds ratio [OR], 2.13; 95% CI, 1.02 to 4.45) and somatic symptoms (OR, 2.70; 95% CI, 1.29 to 5.68) than those without headache. PedsQL-4.0 subscale scores were significantly lower for children with migraine than those without headache only for physical functioning (EMD, -4.67; 95% CI, -7.86 to -1.48).

Conclusions and Relevance

In this cohort study of children with concussion or OI, those with posttraumatic migraine symptoms after concussion had higher symptom burden and lower quality of life 3 months after injury than those with nonmigraine headache. Children without posttraumatic headache reported the lowest symptom burden and highest quality of life, comparable with children with OI. Further research is warranted to determine effective treatment strategies that consider headache phenotype.

Are Self-Reported and Parent-Reported Attention Problems and Hyperactivity Associated With Higher Rates of Concussion in Youth Ice Hockey Players?

OBJECTIVE

To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players.

DESIGN

Secondary analyses of 2 prospective cohort studies.

SETTING

Canadian youth ice hockey teams.

PARTICIPANTS

Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season).

ASSESSMENT OF RISK FACTORS

Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition.

MAIN OUTCOME MEASURES

Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression.

RESULTS

When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion.

CONCLUSIONS

Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies.

Sex-specific differences in resting-state functional brain activity in pediatric concussion

Pediatric concussion has a rising incidence and can lead to long-term symptoms in nearly 30% of children. Resting state functional magnetic resonance imaging (rs-fMRI) disturbances are a common pathological feature of pediatric concussion, though no studies have explicitly examined sex-differences with respect to this outcome, precluding a sex-specific understanding of the functional neuropathology of pediatric concussion. Therefore, we performed a secondary data analysis of rs-fMRI data collected on children with concussion (n = 29) recruited from in a pediatric hospital setting, with greater than 12:1 matched control data accessed from the open-source ABIDE-II database. Seed-based and region of interest (ROI) analyses were used to examine sex-based rs-fMRI differences; threshold-free cluster enhancement (TFCE) and a family-wise error (FWE) corrected p-values were used to identify significantly different clusters. In comparing females with concussion to healthy females, groupwise differences were observed irrespective of seed selected. Notably, we observed (in order of largest effect) hypo-connectivity between the anterior cingulate cortex of the salience network and the thalamus and precuneus (TFCE = 1473.5, p-FWE < 0.001) and the cingulate gyrus (TFCE = 769.3, p-FWE = 0.009), and the seed (posterior cingulate cortex (PCC)) of the default mode network and the paracingulate gyrus (TFCE = 1275.7, p-FWE  < 0.001), occipital pole right (TFCE = 1045.0, p-FWE = 0.001), and sub-callosal cortex (TFCE = 844.9, p-FWE = 0.005). Hyper-connectivity was observed between the salience network seed and the cerebellum (TFCE = 1719.3, p-FWE < 0.001) and the PCC and the thalamus (TFCE = 1198.3, p-FWE < 0.001), cuneal cortex (1070.9, p-FWE = 0.001), and lateral occipital cortex left (TFCE = 832.8, p-FWE = 0.006). ROI analyses showed 10 and 5 significant clusters of hypo- and hyper-connectivity in females, respectively. Only one cluster of difference was found between males with concussion and healthy males on seed-based analyses, and 3 clusters on ROI analyses. There are alterations in rs-fMRI in females with concussion at one-month post-injury that are minimally present in males, which provides further evidence that recovery timelines in pediatric concussion may differ by sex.

Computed Tomography Lesions and Their Association with Global Outcome in Young People with Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) can be accompanied by structural damage to the brain. Here, we investigated how the presence of intracranial traumatic computed tomography (CT) pathologies relates to the global functional outcome in young patients one year after mTBI. All patients with mTBI (Glasgow Coma Scale: 13-15) ≤24 years in the multi-center, prospective, observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study were included. Patient demographics and CT findings were assessed at admission, and the Glasgow Outcome Scale Extended (GOSE) was evaluated at 12 months follow-up. The association between a "positive CT" (at least one of the following: epidural hematoma, subdural hematoma, traumatic subarachnoid hemorrhage (tSAH), intraventricular hemorrhage, subdural collection mixed density, contusion, traumatic axonal injury) and functional outcome (GOSE) was assessed using multi-variable mixed ordinal and logistic regression models. A total of 462 patients with mTBI and initial brain CT from 46 study centers were included. The median age was 19 (17-22) years, and 322 (70%) were males. CT imaging showed a traumatic intracranial pathology in 171 patients (37%), most commonly tSAH (48%), contusions (40%), and epidural hematomas (37%). Patients with a positive CT scan were less likely to achieve a complete recovery 12 months post-injury. The presence of any CT abnormality was associated with both lower GOSE scores (odds ratio [OR]: 0.39 [0.24-0.63]) and incomplete recovery (GOSE <8; OR: 0.41 [0.25-0.68]), also when adjusted for demographical and clinical baseline factors. The presence of intracranial traumatic CT pathologies was predictive of outcome 12 months after mTBI in young patients, which might help to identify candidates for early follow-up and additional care.

Concurrent Psychosocial Concerns and Post-Concussive Symptoms Following Pediatric mTBI: An A-CAP Study

OBJECTIVES

To measure the association between psychosocial problems and persistent post-concussive symptoms (PCS) in youth who were seen in the emergency department with mild traumatic brain injury (mTBI) or orthopedic injury (OI).

METHODS

From a larger prospective cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP), 122 child-guardian pairs who presented to the emergency department with mTBI (N = 70) or OI (N = 52) were recruited for this cross-sectional sub-study. Each pair completed 2 measures assessing PCS burden at 2 weeks, 3 months, and 6 months post-injury. At one visit, pairs concurrently completed MyHEARTSMAP, a comprehensive, psychosocial self-assessment tool to evaluate 4 domains of mental wellness.

RESULTS

When measured at the same visit, children who self-reported moderate or severe Psychiatry domain concerns concurrently experienced a greater burden of cognitive symptoms (β = 5.49; 0.93-10.05) and higher overall PCS count (β = 2.59; 0.70-4.48) after adjusting for covariables, including retrospective pre-injury symptoms and injury group. Additionally, reports indicating mild Function domain severity were associated with increased cognitive (β = 3.34; 95% CI: 0.69-5.99) and somatic symptoms (β = 6.79; 2.15-11.42) and total symptom count (β = 1.29; 0.18-2.39).

CONCLUSION

Increasing severity in multiple domains of mental health is associated with more PCS in youth. While the differences in PCS between the mTBI and OI groups appeared somewhat larger for children with more mental health concerns, the interaction was not statistically significant; larger sample sizes are needed to evaluate the moderating effect of psychosocial difficulties on post-concussion symptoms.

Saliva Cortisol as a Biomarker of Injury in Youth Sport-Related Concussion

Increasing rates of sport-related concussion (SRC) in youth impose a significant burden on public health systems and the lives of young athletes. Accurate prediction for those likely to develop persistent post-concussion symptomology (PPCS) using a fluid biomarker, reflecting both acute injury and recovery processes, would provide the opportunity for early intervention. Cortisol, a stress hormone released through the hypothalamic-pituitary-adrenal (HPA) axis following injury, may provide a missing physiological link to clinical recovery. This cohort study investigated the change in saliva cortisol following SRC and the association between cortisol and symptom burden in pediatric ice hockey players. Further, the association between cortisol levels and medical clearance to return to play was explored. In total, cortisol samples from 233 players were included; 165 athletes (23.6% female) provided pre-injury saliva and 68 athletes (19.1% female) provided post-SRC saliva samples for cortisol analysis. Quantile (median) regressions were used to compare cortisol between pre-injury and post-SRC groups, and the association between total symptoms (/22) and symptom severity scores (/132) reported on the Sport Concussion Assessment Tool (SCAT)3/SCAT5 and post-SRC cortisol (adjusting for age, sex, history of concussion, and time from injury to sample collection). Results demonstrated significantly lower saliva cortisol in post-SRC athletes compared with the pre-injury group (β = -0.62, 95% confidence interval [CI; -1.08, -0.16], p = 0.009). Post-SRC cortisol was not significantly associated with the SCAT3/SCAT5 symptom totals or symptom severity scores; however, females were found to report more symptoms (β = 6.95, 95% CI [0.35, 13.55], p = 0.040) and greater symptom severity (β = 23.87, 95% CI [9.58, 38.15], p = 0.002) compared with males. Exploratory time-to-event analysis revealed a point estimate suggesting a potential association between low cortisol levels and days to medical clearance to return to play. Although preliminary, these findings suggest that the HPA axis may be dysregulated post-SRC. Further, our exploratory analysis and case presentation of post-injury outliers highlight the need to further research cortisol as a prognostic biomarker to inform individualized sex-specific care after SRC.

Changes in ImPACT Cognitive Subtest Networks Following Sport-Related Concussion

OBJECTIVE

High school athletes are administered ImPACT at the start of the academic year or sport season and again after suspected concussion. Concussion management involves the comparison of baseline and post-injury cognitive scores with declines in scores providing evidence for concussive injury. A network framework may provide additional information about post-concussive cognitive changes and expand characterization of sport-related concussion (SRC) recovery.

DESIGN

Retrospective cohort study.

SETTING

High school.

PARTICIPANTS

High school athletes (n = 1553) were administered ImPACT at baseline (T1), post-SRC (T2 = 72 h of injury), and prior to return to play (T3 = within two weeks post-injury).

INDEPENDENT VARIABLES

ImPACT cognitive subtest scores.

MAIN OUTCOME MEASURES

Cognitive networks were calculated and compared over three time points. Centrality indices were calculated to determine the relative importance of cognitive variables within networks.

RESULTS

Network connectivity increased from T1 to T2 and remained hyperconnected at T3. There was evidence of network reorganization between T1 and T3. Processing speed was central within each network, and visual memory and impulsivity became more central over time.

CONCLUSIONS

The results suggest potential evidence of cognitive network change over time. Centrality findings suggest research specific to visual memory and impulse control difficulties during the post-concussion recovery period is warranted. Network analysis may provide additional information about cognitive recovery following SRC and could potentially serve as an effective means of monitoring persisting cognitive symptoms after concussion.

Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury

Importance

Determining how the timing of return to school is related to later symptom burden is important for early postinjury management recommendations.

Objective

To examine the typical time to return to school after a concussion and evaluate whether an earlier return to school is associated with symptom burden 14 days postinjury.

Design, Setting, and Participants

Planned secondary analysis of a prospective, multicenter observational cohort study from August 2013 to September 2014. Participants aged 5 to 18 years with an acute (<48 hours) concussion were recruited from 9 Canadian pediatric emergency departments in the Pediatric Emergency Research Canada Network.

Exposure

The independent variable was the number of days of school missed. Missing fewer than 3 days after concussion was defined as an early return to school.

Main Outcomes and Measures

The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory (PCSI). Symptom burden was defined as symptoms status at 14 days minus preinjury symptoms. Propensity score analyses applying inverse probability of treatment weighting were performed to estimate the relationship between the timing of return to school and symptom burden.

Results

This cohort study examined data for 1630 children (mean age [SD] 11.8 [3.4]; 624 [38%] female). Of these children, 875 (53.7%) were classified as having an early return to school. The mean (SD) number of days missed increased across age groups (5-7 years, 2.61 [5.2]; 8-12 years, 3.26 [4.9]; 13-18 years, 4.71 [6.1]). An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group. The association between early return and lower symptom burden was stronger in individuals with a higher symptom burden at the time of injury, except those aged 5 to 7 years.

Conclusions and Relevance

In this cohort study of youth aged 5 to 18 years, these results supported the growing belief that prolonged absences from school and other life activities after a concussion may be detrimental to recovery. An early return to school may be associated with a lower symptom burden and, ultimately, faster recovery.

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η²=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Early analgesic administration and headache presence 7 days post-concussion in children

OBJECTIVE

This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth.

METHODS

A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models.

RESULTS

2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)].

CONCLUSIONS

Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in Adolescents

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in adolescent student athletes. We hypothesized that there would be an association between the severity of acute symptoms experienced in the first 72 hours and functional recovery such that adolescents with the lowest burden of acute symptoms would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 375 adolescent student athletes aged 14-19 years who sustained a sport-related concussion between 2014 and 2020. Athletic trainers documented time to return to school and to sports. A greater proportion of adolescents with the highest acute symptoms remained out of school at 3 (odds ratio [OR] = 2.5, 95% confidence interval [CI] 1.5-4.4), 5 (OR = 2.4, 95% CI 1.4-4.0), 7 (OR = 2.6, 95% CI 1.5-4.3), and 10 days (OR = 2.3, 95% CI 1.3-3.9) compared to those with the lowest acute symptoms. Similarly, a greater proportion of athletes with the highest acute symptoms remained out of sports at 7 (OR = 3.5, 95% CI 1.5-8.1), 10 (OR = 3.1, 95% CI 1.8-5.6), 14 (OR = 1.8, 95% CI 1.1-3.0), and 21 days (OR = 1.9, 95% CI 1.0-3.6) compared to those with the lowest acute symptoms. This study underscores the adverse effect of high acute symptom burden following concussion on return to school and to sports among adolescent student athletes. Conversely, student athletes with a low burden of acute symptoms have a faster return to school and to sports.

A Pilot Prospective Observational Study of Cerebral Autoregulation and 12-Month Outcomes in Children With Complex Mild Traumatic Brain Injury: The Argument for Sufficiency Conditions Affecting TBI Outcomes

BACKGROUND

The relationship between cerebral autoregulation and outcomes in pediatric complex mild traumatic brain injury (TBI) is unknown, and explored in this study.

METHODS

We conducted a prospective observational study of patients aged 0 to 18 years hospitalized with complex mild TBI (admission Glasgow Coma Scale score 13 to 15 with either abnormal computerized tomogram of the head or history of loss of consciousness). Cerebral autoregulation was tested using transcranial Doppler ultrasonography, and impaired autoregulation defined as autoregulation index<0.4. We collected Glasgow Outcome Scale Extended-Pediatrics score and health-related quality of life data at 3, 6, and 12 months after discharge.

RESULTS

Twenty-four patients aged 1.8 to 16.6 years (58.3% male) with complete 12-month outcome data were included in the analysis. Median admission Glasgow Coma Scale score was 15 (range: 13 to 15), median injury severity score was 12 (range: 4 to 29) and 23 patients (96%) had isolated TBI. Overall, 10 (41.7%) patients had impaired cerebral autoregulation. Complete recovery was observed in 6 of 21 (28.6%) children at 3 months, in 4 of 16 (25%) children at 6 months, and in 8 of 24 (33.3%) children at 12 months. There was no difference in median (interquartile range) Glasgow Outcome Scale Extended-Pediatrics score (2 [2.3] vs. 2 [interquartile range 1.3]) or health-related quality of life scores (91.5 [21.1] vs. 90.8 [21.6]) at 12 months between those with intact and impaired autoregulation, respectively. Age-adjusted hypotension occurred in 2/24 (8.3%) patients.

CONCLUSION

Two-thirds of children with complex mild TBI experienced incomplete functional recovery at 1 year. The co-occurrence of hypotension and cerebral autoregulation may be a sufficiency condition needed to affect TBI outcomes.

Adolescents with a concussion have altered brain network functional connectivity one month following injury when compared to adolescents with orthopedic injuries

Concussion is a mild traumatic brain injury (mTBI) with increasing prevalence among children and adolescents. Functional connectivity (FC) within and between the default mode network (DMN), central executive network (CEN) and salience network (SN) has been shown to be altered post-concussion. Few studies have investigated connectivity within and between these 3 networks following a pediatric concussion. The present study explored whether within and between-network FC differs between a pediatric concussion and orthopedic injury (OI) group aged 10-18. Participants underwent a resting-state functional magnetic resonance imaging (rs-fMRI) scan at 4 weeks post-injury. One-way ANCOVA analyses were conducted between groups with the seed-based FC of the 3 networks. A total of 55 concussion and 27 OI participants were included in the analyses. Increased within-network FC of the CEN and decreased between-network FC of the DMN-CEN was found in the concussion group when compared to the OI group. Secondary analyses using spherical SN regions of interest revealed increased within-network FC of the SN and increased between-network FC of the DMN-SN and CEN-SN in the concussion group when compared to the OI group. This study identified differential connectivity patterns following a pediatric concussion as compared to an OI 4 weeks post-injury. These differences indicate potential adaptive brain mechanisms that may provide insight into recovery trajectories and appropriate timing of treatment within the first month following a concussion.